Am Coll Cardiol, 2006; 47:212-213, doi:10.1016/j.jacc.2005.10.

003 (Published online 13 December

2005).
2005 by the American College of Cardiology Foundation

LETTERS TO THE EDITOR

Cardiac Rehabilitation, Exercise Training, and

Psychosocial Risk Factors: REPLY
Alan Rozanski, MD* and James Blumenthal, PhD
St. Luke's/Roosevelt Hospital, Department of Medicine, 1111 Amsterdam Avenue,
New York, New York 10025-1716 (Email: ar77@columbia.edu
).
*

We agree with Drs. Lavie and Milani that exercise is a well-established intervention
for the secondary prevention of coronary heart disease (CHD), and is a major
component of cardiac rehabilitation programs (1,2). We also are aware that cardiac
rehabilitation services are seriously underutilized. For example, according to a recent
position paper from the American Heart Association (3) only 10% to 20% of eligible
patients actually participate in cardiac rehabilitation. A meta-analysis (4) reported
results from 32 studies with 16,804 patients eligible for cardiac rehabilitation and
reported that only 25% to 31% of eligible men and 11% to 20% of eligible women
participated. It is evident that many physicians do not refer patients to cardiac
rehabilitation, and this reluctance is especially true for women and minorities (5).
As alluded to by Drs. Lavie and Milani, exercise cannot only induce beneficial
physiological adaptations, but can also improve psychological functioning. For
example, in a recent randomized trial, exercise training decreased depressive
symptoms as effectively as antidepressant medication in patients with clinical
depression (6,7). Other work by Thayer et al. (8) has demonstrated that even short
bursts of exercise activity can effectively increase energy or decrease tension for twohour periods. Recent data also emphasize the beneficial effects of exercise on
cognitive function and brain plasticity (9). However, because poor adherence to
exercise training is relatively common, effective strategies for optimizing patient
adherence are needed (10).
It also should be noted that, though there is an extensive literature documenting the
value of exercise in patients with coronary artery disease (CAD), data regarding the
significance of stress-management training in improving clinical outcomes are limited.
A nonrandomized trial of patients with stable CHD showed that stress-management
training was associated with reduced ischemia, fewer cardiac events, and lower
medical costs compared to usual care controls (11,12). In the absence of data from
large multicenter randomized clinical trials with "hard" clinical end points, we
advocate for smaller studies using intermediate biomarkers of cardiovascular risk (13).
For example, in a recent study (14) both exercise and stress-management training were
found to reduce myocardial ischemia and improve vascular endothelial function,
compared to usual care. Furthermore, stress management was actually superior to

exercise training in improving measures of heart rate variability and baroreflex

sensitivity. These data would strongly support the potential clinical benefits of both
exercise and stress management in the routine care of patients with CHD.

References
Top
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