RESEARCH FINDINGS USING GUIDED
IMAGERY FOR
CORONARY HEART DISEASE
July, 2006
Definition
of the Problem
Coronary heart disease (CHD) results when deposits called
plaques build up in arteries. This leads to
atherosclerosis, a condition that reduces blood flow and
oxygen. CHD, also called coronary artery disease (CAD),
develops over time, and leads to partial or complete
blockage of the arteries involved. One major cause of
atherosclerosis is having high lipids (fats) such as
cholesterol and triglycerides in the blood. Other major
causes are hypertension, and smoking. Stress, obesity, and
a sedentary lifestyle also contribute to the development of
CHD. Other risk factors are heredity, race, age, diabetes,
depression, low socioeconomic status, social isolation, and
male gender.
CHD can be “silent,” producing no symptoms, or patients can
experience shortness of breath, dizziness, chest pain
(angina), or a heart attack.
Scope and Cost of the Problem
According to the National Heart, Lung, and Blood Institute,
American Heart Association, as of 1999approximately 13 12.6
million Americans haved CHD. The direct and indirect costs
of CHD to the U.S. economy exceed $351.8129.9 billion
annually (AHA, 2002).2 Medicare alone spends more than
$10.6 billion annually in its treatment (AHA,
2001).3 The most common form of heart
disease, CHD is the leading cause of permanent disability
in the U.S, and is the primary cause of death
in Americans, both male and female -- over 500725,000
deaths annually (NHLBI).4
Medical
Treatment
Treatment for CHD depends on many factors, including the
severity of the disease and any comorbid conditions.
Frequent treatments include aspirin, beta-blockers,
nitrates, lipid-lowering medications, and ACE inhibitors.
Surgical procedures include coronary artery bypass, and
angioplasty. Recommended lifestyle changes include quitting
smoking, maintaining correct weight, regular exercise, and
following a diet low in fat and cholesterol (Bass,
2001).5
Lifestyle
Changes, Emotions, and Well-Being
A landmark 1998 study by Dean Ornish and associates
demonstrated that lifestyle changes (diet, exercise,
relaxation, and social support) can dramatically reverse
CHD (Ornish, Scherwitz, et al, 1998).6 Other studies have shown that
emotions play a major role in CHD. Fear, grief, and anxiety
can trigger cardiac events (Ornish, 1998; Verrier and
Mittleman, 1997; Williams, Kiecolt-Glaser, et al,
1999).7-9 Anger can be a trigger
(Boltwood, Taylor, et al, 1993; Ironson, Taylor, et al,
1993; Verrier, Hagestad and Lown, 1987; Verrier, Mittelman,
et al, 1995)7,10-13,
and depression can
affect the outcome of long-term survival (Barefoot,
Brummett, et al, 2000).14 The role of stress in the
development and progression of CHD both in men and women is
also well documented (Allison, Williams, et al, 1995;
Bairey, Krantz and Rozanski, 1990; Nordstrom, Kwyer, et al,
2001; Orth-Gomer, Wamala, et al, 2000; Sheps, McMahn, et
al, 2002).15-19
Mind-Body
Approaches Including Guided Imagery
Relaxation, and guided imagery, and other mind-body
intervensions can reduce the impact of CHD both
psychologically and physiologicallyin several ways.
Anger and other possibly harmful emotional states are
reduced by the inner-focused, relaxed state induced by
guided imagery and other mind-body modalities.
Additionally, a sense of emotional well-being can be
improved by the use of these therapies. Guided imagery and
relaxation can reduce stress, and lower heart rate and
blood pressure Hermann, 2002; .20-23 (Crowther, 1983; Hermann, 2002;
Pender, 1985; Sharpley, 1994; Taylor, Farquhar, et al,
1977). Meditation produces similar physiological
results Barnes, Treiber, et al, 2004; Castillo-Richmond,
Schneider, et al, 2000; Zamarra, Schneider, et al, 1996;
Lin, Nahin, et al, 2001), as does biofeedback, with or
without imagery (Nakao, Yano, et al,
2003).24-25 Yoga that combined both
postures and yogic breathing produced significant positive
levels of blood lipids in those patients who participated
in the program (Bijlani,Vempati, et al, 2005). Raja yoga
improved respiratory functions, cardiovascular parameters
and lipid profile (Vyas & Dikshit, 2002).
According to a review of 23 major heart disease studies,
when psychosocial approaches were added to standard medical
treatments, survival and further cardiac event rates
improved significantly (Linden, Stossel and Maurice,
1996).26 A more recent review also
confirmed that relaxation training can help patient recover
from a cardiac events, reduce future angina and
arrhythmias, and speed the time it takes to return to work
(van Dixhoorn and White, 2005). Complementary approaches
like relaxation training and imagery are so effective that
they are routinely done at prestigious facilities such as
Columbia Presbyterian Hospital’s Department of Surgery (Oz,
Lemole et al, 1996).27 Relaxation, imagery, and
education are important parts of Stanford’s Chronic Disease
Self-Management Program (Lorig, Sobel et al, 1999). Use of
guided imagery in cardiac patients 28 has led to shorter hospital
stays, lower pharmacy costs, and lower use of pain
medication (Halpin, Speir, et al, 2002).
The results of a lifestyle study showed that 80% of people
who used complementary approaches were able to avoid
cardiac surgery – a savings of almost $30,000 per patient
(Ornish, 1998).29 Quality of life can also
improve (Chang, Hendricks, 2005). Self-management of
chronic conditions including CHD improves symptom
management and reduces medical costs (Lorig, Sobel et al,
1999).28 In assessing the its
importance, researchers van Dixhoorn and White deemed
relaxation training “an important ingredient of cardiac
rehabilitation” (2005).
Conclusion
A
low-cost guided imagery-based program can help to lower
stress and blood pressure, enhance an overall sense of
emotional well-being, and improve compliance with lifestyle
changes. Each of these factors, in turn, can aid in
slowing, halting or reversing the progression of CHD and in
reducing the number of further coronary events,
re-hospitalizations, and surgeries.
References:
1.
American Heart Association. (2002). 2003 Heart and Stroke
Statistical Update. Dallas, Texas. Pg. 4.
www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf
Accessed: September, 2003.
2.
American Heart Association. (2002). 2003 Heart and Stroke
Statistical Update. Dallas, Texas. Pg. 11.
www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf
Accessed: September, 2003.
3. American Heart Association. (2001). 2002 Heart and
Stroke Statistical Update. Dallas, Texas: American Heart
Association.
www.americanheart.org/downloadable/heart/10148328094661013190990123HS_State_02.pdf.
Pg. 12.
Accessed: September, 2003.
4.
www.nhlbi.nih.gov/health/public/heart/other/chdfacts.htm)
5. Baas, A. MD (2001). Chronic Ischemic Heart Disease
in Best
Practice of Medicine. Accessed at Merck Praxis
MD http://merck.praxis.md/bpm/bpm.asp?page=BPM01CA05
6. Ornish, D., Scherwitz, L.W., Billings, J.H., Brown,
S.E., Gould, K.L., Merritt, T.A., Sparler, S., Armstrong,
W.T., Ports, T.A., Kirkeeide, R.L., Hogeboom, C, Brand,
R.J. (1998). Intensive lifestyle changes for reversal of
coronary heart disease. JAMA,
Dec
16;280(23):2001-7.
7. Verrier, R.L., Mittelman, M.A. (1997). Cardiovascular
consequences of anger and other stress states.
Baillieres Clin
Neurol, Jul;6(2):245-59.
8. Williams, R., Kiecolt-Glaser, J., Legato, M.J., Ornish,
D., Powell, L.H., Syme, S.L., Williams, V. (1999). The
impact of emotions on cardiovascular health.
The Journal of
Gender-Specific Medicine, 2[5]:52-58.
9. Ornish, D. (1998). Love & Survival: The Scientific
Basis for the Healing Power of Intimacy. New York, NY:
HarperCollins.
10. Mittleman, M.A., Maclure, M., Sherwood, J.B., et
al.(1995). Triggering of acute myocardial infarction onset
by episodes of anger. Circulation,
92:1720-1725.
11. Ironson, G., Taylor, C.B., Boltwood, M., et al. (1993).
Effects of anger on left ventricular ejection fraction in
coronary artery disease. Am J Cardiol,
70:281-285.
12. Boltwood, M.D., Taylor, C.B., Boutte Burke, M., et al.
(1993). Anger report predicts coronary artery vasomotor
response to mental stress in atherosclerotic
segments. Am J
Cardiol, 72:1361-1365.
13. Verrier, R.L., Hagestad, E.L., Lown, B. (1987). Delayed
myocardial ischemia induced by anger. Circulation,
5:249-254.
14. Barefoot, J.C, Brummett, B.H., Helms, M.J., Mark, D.B.,
Siegler, I.C., Williams, R.B. (2000). Depressive Symptoms
and Survival of Patients with Coronary Artery
Disease. Journal of Psychosomatic
Medicine, Nov-Dec; 62(6): pp790-5.
15. Orth-Gomer, K., Wamala, S.P., Horsten, M.,
Schenck-Gustafsson, K., Schneiderman, N., Mittleman, M.A.
(2000). Marital Stress worsens prognosis in women with
coronary heart disease: The Stockholm Female
Coronary Risk Study. JAMA,
Dec 20; 284 (23):
pp. 3008-3014.
16. Sheps, D.S, McMahon, R.P., Becker, L., Carney, R.M.,
Freedland, K.E., Cohen, J.D., Sheffield, D., Goldberg,
A.D., Ketterer, M.W., Pepine, C.J., Raczynski, J.M., Light,
K., Krantz, D.S., Stone, P.H., Knatterud, G.L., Kaufmann,
P.G. (2002). Mental stress-induced ischemia and all-cause
mortality in patients with coronary artery disease: Results
from the Psychophysiological Investigations of Myocardial
Ischemia study. Circulation,
Apr 16;105:1780–1784.
17. Bairey, C.N., Krantz, D.S., Rozanski, A. (1990). Mental
stress as an acute trigger of ischemic left ventricular
dysfunction and blood pressure elevation in coronary artery
disease. Am J Cardiol,
Nov
6;66(16):28G-31G.
18. Nordstrom, C.K., Dwyer, K.M., Merz, C.N., Shircore, A,
Dwyer, J.H. (2001). Work-related stress and early
atherosclerosis. Epidemiolog,
Mar;12(2): 180-5.
19. Allison, T.G., Williams, D.E., Miller, T.D., Patten,
C.A., Bailey, K.R., Squires, R.W., Gau, G.T. (1995).
Medical and economic costs of psychologic distress in
patients with coronary artery disease. Mayo Clin Proc,
Aug;70(8):734-42.
20. Pender NJ. (1985). Effects of progressive muscle
relaxation training on anxiety and health locus of control
among hypertensive adults. Res Nurs
Health, Mar;8(1) :67-72
21. Sharpley, C.F. (1994). Maintenance and generalizability
of laboratory-based heart rate reactivity control
training. Journal of Behavioral
Medicine,17(3): 309-329).
22. Crowther, J.H. (1983). Stress management training and
relaxation imagery in the treatment of essential
hypertension. J Behav
Med,
Jun;6(2):169-87.
23. Taylor, C.B., Farquhar, J.W., Nelson, E. & Agras,
S.(1977). Relaxation therapy and high blood
pressure. Archives of General
Psychiatry, 34: 339-42.
24. Zamarra, J.W., Schneider, R.H., Besseghini, I.,
Robinson, D.K., Salerno, J.W. (1996). Usefulness of the
transcendental meditation program in the treatment of
patients with coronary artery disease. Am J
Cardiol, Apr 15;77(10):867-70.
25. Castillo-Richmond, A., Schneider, R.H., Alexander,
C.N., Cook, R., Myers, H., Nidich, S., Haney, C.,
Rainforth, M., Salerno, J. (2000). Effects of stress
reduction on carotid atherosclerosis in hypertensive
African Americans. Stroke.
Mar;31(3):568-73.
26. Linden, W., Stossel, C., Maurice, J. (1996).
Psychosocial interventions for patients with coronary
artery disease: a meta-analysis. Arch Intern
Med,
Apr 8;156(7):745-52.
27. Oz, M.C., Lemole, E.J., Oz, L.L., Whitworth, G.C.,
Lemole, G.M. (1996). Treating CHD with Cardiac Surgery
Combined with Complementary Therapy. Medscape Womens
Health, Oct;1(10):7.
28. Lorig, K.R., Sobel, D.S., Stewart, A.L., Brown, Jr
B.W., Ritter, P.L., Gonzalez, V.M., Laurent, D.D., Holman,
H.R. (1999). Evidence suggesting that a chronic disease
self-management program can improve health status while
reducing utilization and costs: A randomized trial.
Medical
Care,
37(1): 5-14.
29. Ornish, D. (1998) Avoiding revascularization with
lifestyle changes: The Multicenter Lifestyle Demonstration
Project. Am J
Cardiol, 82:72T-76T.
Allison TG, Williams DE, Miller TD, Patten CA, Bailey KR,
Squires RW, Gau GT. Medical and economic costs of
psychologic distress in patients with coronary artery
disease. Mayo Clin
Proc.
1995 Aug;70(8):734-42.
American Heart Association. (2002). 2003 Heart and Stroke
Statistics -- 2003 Update. Dallas, TX. American Heart
Associatin. 2002. Pg. 12, 40.
www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf
Accessed: June, 2006.
Baas A. MD. Chronic Ischemic Heart Disease in Best Practice
of Medicine. 2001. Modified March 25, 2003. Accessed at
Merck Praxis MD. http://merck.micromedex.com/index.asp?page=bpm_brief&article_id=BPM01CA05.
Accessed June, 2006.
Bairey CN, Krantz DS, Rozanski A. Mental stress as an acute
trigger of ischemic left ventricular dysfunction and blood
pressure elevation in coronary artery disease.
Am J
Cardiol. 1990. Nov 6;66(16):28G-31G.
Barefoot JC, Brummett BH, Helms MJ, Mark DB, Siegler IC,
Williams RB. Depressive Symptoms and Survival of Patients
with Coronary Artery Disease. Journal of Psychosomatic
Medicine. 2000 Nov-Dec; 62(6): pp790-5.
Barnes VA, Treiber FA, Johnson
MH. Impact of transcendental meditation on ambulatory blood
pressure in African-American adolescents.
American
Journal of Hypertension. 2004 Apr; 17(4): pages 366-9.
Bijlani RL, Vempati RP, Yadav
RK, Ray RB, Gupta V, Sharma R, Mehta N, Mahapatra SC. A
brief but comprehensive lifestyle education program based
on yoga reduces risk factors for cardiovascular disease and
diabetes mellitus. J Altern Complement
Med.
2005 Apr;11(2):267-74.
Boltwood MD, Taylor CB, Burke
MB, Grogin H, Giacomini J. Anger report predicts coronary
artery vasomotor response to mental stress in
atherosclerotic segments. Am J Cardiol.
1993 72:1361-1365.
Castillo-Richmond A, Schneider RH, Alexander CN, Cook R,
Myers H, Nidich S, Haney C, Rainforth M, Salerno J. Effects
of stress reduction on carotid atherosclerosis in
hypertensive African Americans. Stroke.
2000 Mar;31(3):568-73.
Chang BH, Hendricks A, Zhao Y,
Rothendler JA, LoCastro JS, Slawsky MT. A relaxation
response randomized trial on patients with chronic heart
failure. Journal of
Cardiopulmonology and Rehabilitation.
2005 May-Jun; 25
(3): 149-57.
Crowther JH. Stress management training and relaxation
imagery in the treatment of essential hypertension.
J Behav
Med. 1983 Jun;6(2):169-87.
Halpin LS, Speir AM, CapoBianco
P, Barnett SD. Guided imagery in cardiac surgery.
Outcomes in
Management & Nursing Practice. 2002 Jul-Sep;6(3):132-7.
Herrmann JM. Essential
hypertension and stress. When do yoga, psychotherapy and
autogenic training help?] [Article in German]
MMW Fortschr
Med.
2002 May 9;144(19):38-41.
.
Ironson G, Taylor CB, Boltwood M. Bartzokis T, Dennis C,
Chesney M, Spitzer S, Segall GM. Effects of anger on left
ventricular ejection fraction in coronary artery
disease. Am J Cardiol.
1993 70:281-285.
Lin MC, Nahin R, Gershwin ME,
Longhurst JC, Wu KK. State of complementary and alternative
medicine in cardiovascular, lung, and blood research:
executive summary of a workshop. Circulation.
2001 Apr 24;103(16):2038-41.
Linden W, Stossel C, Maurice J.
Psychosocial interventions for patients with coronary
artery disease: a meta-analysis. Arch Intern
Med. 1996 Apr 8;156(7):745-52.
Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL,
Gonzalez VM, Laurent DD, Holman HR. Evidence suggesting
that a chronic disease self-management program can improve
health status while reducing utilization and costs: A
randomized trial. Medical Care.
1999 37(1): 5-14.
Mittleman MA, Maclure M, Sherwood JB, Mulry RP, Tofler GH,
Jacobs SC, Friedman R, Benson H, Muller JE. Triggering of
acute myocardial infarction onset by episodes of
anger. Circulation.
1995 92:1720-1725.
Nakao M, Yano E, Nomura S,
Kuboki T. Blood pressure-lowering effects of biofeedback
treatment in hypertension: a meta-analysis of randomized
controlled trials. Hypertension
Research. 2003 Jan; 26(1): pages 37-46.
National Heart Blood and Lung Institute
http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_Summary.html.
Accessed June, 2006.
Nordstrom CK, Dwyer KM, Merz CN, Shircore A, Dwyer JH.
Work-related stress and early atherosclerosis.
Epidemiolog.
2001 Mar;12(2):
180-5.
Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL,
Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide
RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for
reversal of coronary heart disease. JAMA.
1998 Dec 16;280(23):2001-7.
Ornish D. (1998). Love & Survival: The
Scientific Basis for the Healing Power of
Intimacy. New York, NY:
HarperCollins.
Ornish D. Avoiding revascularization with lifestyle
changes: The Multicenter Lifestyle Demonstration
Project. Am J Cardiol.
1998c 82:72T-76T.
Orth-Gomer K, Wamala SP, Horsten M, Schenck-Gustafsson K,
Shneiderman N, Mittleman MA. Marital stress worsens
prognosis in women with coronary heart disease: The Stockholm Female
Coronary Risk Study. JAMA.
2000 Dec 20; 284
(23): pp. 3008-3014.
Oz MC, Lemole EJ, Oz LL, Whitworth, GC, Lemole GM. Treating
CHD with cardiac surgery combined with complementary
therapy. Medscape Womens
Health. 1996 Oct;1(10):7.
Pender NJ. Effects of progressive muscle relaxation
training on anxiety and health locus of control among
hypertensive adults. Res Nurs
Health. 1985 Mar;8(1) :67-72.
Sharpley CF. Maintenance and generalizability of
laboratory-based heart rate reactivity control
training. Journal of Behavioral
Medicine.1994 17(3): 309-329).
Sheps DS, McMahon RP, Becker L, Carney RM, Freedland KE,
Cohen JD, Sheffield D, Goldberg AD, Ketterer MW, Pepine CJ,
Raczynski JM, Light K, Krantz DS, Stone PH, Knatterud GL,
Kaufmann PG. Mental stress-induced ischemia and all-cause
mortality in patients with coronary artery disease: Results
from the Psychophysiological Investigations of Myocardial
Ischemia study. Circulation.
2002 Apr
16;105:1780–1784.
Taylor CB, Farquhar JW, Nelson E & Agras S. Relaxation
therapy and high blood pressure. Archives of General
Psychiatry. 1977 34: 339-42.
Van Dixhoorn J, White A. Relaxation therapy for
rehabilitation and prevention in ischaemic heart disease: a
systematic review and meta-analysis. Eur J Cardiovasc Prev
Rehabil. 2005; June;12(3):193-202.
Vyas R, Dikshit N. Effect of
meditation on respiratory system, cardiovascular system and
lipid profile. Indian J Physiol
Pharmacol. 2002 Oct;46(4):487-91.
Verrier RL, Hagestad EL, Lown
B. Delayed myocardial ischemia induced by anger.
Circulation.
1987 5:249-254.
Verrier, RL, Mittelman MA. Cardiovascular consequences of
anger and other stress states. Baillieres Clin
Neurol. 1997 Jul;6(2):245-59.
Williams R, Kiecolt-Glaser J, Legato, MJ, Ornish D, Powell
LH, Syme SL, Williams V. The impact of emotions on
cardiovascular health. The Journal of
Gender-Specific Medicine. 1999 2[5]:52-58.
Zamarra JW, Schneider RH, Besseghini I, Robinson DK,
Salerno JW Usefulness of the transcendental meditation
program in the treatment of patients with coronary artery
disease. Am J Cardiol.
1996 Apr
15;77(10):867-70.