The Effect of Brief Cognitive-Behavioral
Therapy for PTCA Patients

Background and Summary of Study Findings

by
William Stone RN MSN CNS

Abstract

     Percutaneous Transluminal Coronary Angioplasty (PTCA) has become a major treatment modality for patients with coronary artery disease (CAD). Recurrent disease (myocardial infarction, restenois, recurrent pain, etc.) following PTCA remains a significant problem. Psychological interventions have been shown to reduce risk for recurrent events, but results have been inconsistent. This study was designed to evaluate the effectiveness of brief counseling (2 or 3 outpatient sessions of 90 minutes each) in reducing factors associated with coronary disease. Data analysis revealed that the treatment group (n=11) achieved a significant reduction in distress (measured by GHQ-20, p =.012) and a small but significant reduction in anger (MMPI-2 anger content scale, p=.046). The treatment group also had significant changes in heart rate variability patterns (increase in total entrainment score, p=.008), indicating beneficial improvements in autonomic balance. No significant changes were seen in the comparison group (n=5). These results suggest that brief counseling can be effective in reducing risk for recurrent coronary events.

Background

     A number of studies have shown that well-designed psychological interventions can be very effective in reducing risk for recurrent coronary disease. But other studies have shown similar interventions to have little effect. Whether the interventions were successful or not, all of these studies invested a substantial amount of time treating subjects (from 14 to 57 hours per patient). The intervention reported here involved an average of 5 hours per patient.
     The Recurrent Coronary Prevention Project (Freidman et al, 1986) targeted Type A behavior in patients after myocardial infarction (post MI). The experimental group (n=592) had a cumulative recurrence rate of roughly half that of the comparison groups over a 4.5 year study period. More recently, Appels and colleagues (1997) studied stress management for PTCA patients (n=95), and with their intervention achieved a 50% reduction of recurrence over an 18 month period. Blumenthal and colleagues (1997) designed their study to evaluate two interventions, stress management and exercise. Results were gathered after 5 years, following an intensive 4-month training program. There were 3 (9.1% of 33 subjects) cardiac events in the stress management group, 7 (20.6% of 34) in the exercise group, and 12 (30.0% of 40) in the usual care group.
     However, stress management has not been an effective intervention in all studies. In two large studies, it had little effect on outcome (Jones and West, 1996; Frasure-Smith et al, 1997). Full analysis of the problems that limited the effectiveness of these interventions is beyond the scope of this summary, but there is evidence that a specifically targeted approach is more likely to have a significant impact. For example, treating identified issues that are troubling the client (such as depression, or anger and hostility) may be better than a generalized program of relaxation techniques that are assumed to be helpful for everyone. Utilization of a therapist with specialized training and expertise may also improve the chance for success.

Study Design

     Subjects were recruited while in the hospital, following PTCA. Patients were given an overview of the study, and introduced to the harmful effects of hostility and the benefits of social connection. Informed consent was obtained. Pretests to measure distress (General Health Questionnaire, GHQ-20;Goldberg, 1972) , hostility (cynical distrust scale; Greenglass and Julkunen, 1989), and perception of control (control attitudes scale; Moser and Dracup, 1995) were given at intake. These measures were repeated at the conclusion of study. Subjects who were willing to take the pre and post tests, but did not wish to take part in the intervention (because of time commitment, travel distance, or other personal reasons) were included in the comparison group. The anger scale was added to the study after some subjects had already enrolled, and was not administered to the comparison group (MMPI?2 anger content scale, Kawachi et al, 1996). Subjects in the treatment group took the anger scale prior to their first outpatient session, and at the conclusion of study. The treatment group also had a 5-minute heart rate variability (HRV) baseline recording, and another 5-minute recording while practicing the Freeze-Frame technique. Total entrainment scores were calculated using these recordings (Tiller, et al, 1996).
     Subjects were asked to keep an anger log for the first week or two following PTCA. The log is a record of the frequency, intensity, and circumstances surrounding experienced anger, serving to increase awareness of the individual's anger responses. Subjects were also asked to complete Pennebaker's 20 minute writing exercise at least 2 times (Pennebaker, 1995). This exercise is designed to facilitate the release of emotional energy and helps to give perspective and shed some light on the dynamics behind the episodes.
     An attempt was made to schedule the first outpatient session one to two weeks after discharge from the hospital. This allowed for a timely review of the anger log and written exercises. The Freeze-Frame technique (Tiller et al, 1996) was introduced in this session. This technique is a 5-step method designed to transform the habitual anger response, replacing it with a positive mental state. The exercise helps to develop an emotional space for consideration of alternative responses and solutions. The following sessions were used to address any issues of concern to the subjects, and for review and practice of the skills that were taught in the earlier sessions.
     The initial design for this study excluded those with low hostility (a score of less than 10 on the cynical distrust scale). It was thought that subjects with more hostility would have a greater benefit from the intervention. This design had to be modified because of difficulty in recruitment of high hostility subjects. Most of those who were willing to take the cynical distrust scale had relatively low scores, and those that didn't want to participate often seemed more irritable and distrustful. It was necessary to redesign the study to include all consenting subjects, regardless of hostility score.

Results and Implications

     A short course of 2 or 3 outpatient sessions achieved statistically significant decreases in distress levels in this small study of 11 subjects (measured by GHQ-20, p =.012). No significant changes were seen in the comparison group (n=5). High distress levels have been associated with a threefold increase in cardiac mortality (Frasure-Smith, 1991). A small but significant reduction in anger was also achieved (MMPI-2 anger content scale, p=.046). High anger has been associated with three times the risk for recurrent events among males after PTCA (Mendes de Leon et al, 1996). In this study, counseling and coaching was effective in producing beneficial autonomic changes as documented by heart rate variability (HRV) recordings (increases in total entrainment score, p=.008). Evidence that suggests that these improvements will reduce risk for CAD has been outlined (Tiller et al, 1996). The importance of HRV patterns for coronary patients was demonstrated in a study (n=808) by Kleiger and colleagues (1987) who found that low HRV was associated with 5.3 times the mortality of high HRV. Brief cognitive-behavioral therapy is a powerful intervention that has a measurable impact upon mental factors that contribute to coronary disease. These findings extend the mounting evidence that psychological interventions, when properly designed, can reduce the risk of recurrent coronary events.

References

Appels, A., Bar, F., Lasker, J, Flamm, U. and Kop, W. (1997). The effect of a psychological intervention program on the risk of a new coronary event after angioplasty: a feasibility study. Journal of Psychosomatic Research 43(2):209-17.

Blumenthal, J., Jiang, W., Babyak, M., Krantz, D., Frid, D., Coleman, R., Waugh, R., Hanson, M., Appelbaum, M., O'Connor, C., and Morris, J. (1997). Stress management and exercise training in cardiac patients with myocardial ischemia. Archives of Internal Medicine 157:2213-23.

Frasure-Smith, N. (1991). In-Hospital Symptoms of Psychological Stress as Predictors of Long-Term Outcome After Acute Myocardial Infarction in Men. The American Journal of Cardiology 67: 121-7.

Frasure-Smith, N., Lesperance, F., Prince, R., Verrier, P., Garber, R., Juneau, M., Wolfson, C., and Bourassa, M. (1997). Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction. Lancet 350: 473-9.

Freidman, M., et al. (1986). Alteration of Type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: Summary results of the Recurrent Coronary Prevention Project. American Heart Journal 112:653-65.

Goldberg, D. (1972). The Detection of Psychiatric Illness by Questionnaire. London. Oxford University Press.

Greenglass, E. and Julkunen, J. (1989). Construct Validity and Sex Differences in Cook-Medley Hostility. Personality and Individual Differences 10(2): 209-18.

Jones, D. and West, R. (1996). Psychological rehabilitation after myocardial infarction: multicentre randomized controlled trial. British Medical Journal 313: 1517-21.

Kawachi, I., Sparrow, D., Spiro, A., Vokonas, P., and Weiss, S. (1996). A prospective study of anger and coronary heart disease: The Normative Aging Study. Circulation 94:2090-2095.

Kleiger, R., Miller, P., Bigger, T., Moss, A., and the Multicenter Post-infarction Research Group. (1987). Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. The American Journal of Cardiology 59:256-262.

Mendes de Leon, C., Kop, W. de Swart, H., Bar, F. and Appels, A. (1996). Psychosocial characteristics and recurrent events after percutaneous transluminal coronary angioplasty. The American Journal of Cardiology 77(4):252-5.

Moser, D., and Dracup, K. (1995). Psychosocial recovery from a cardiac event: The influence of perceived control. Heart and Lung 24:273-80.

Pennebaker, J. (1995). Emotion, Disclosure, and Health. Washington, DC: American Psychological Association.

Tiller, W., McCraty, R., and Atkinson, M. (1996). Cardiac coherence: a new, noninvasive measure of autonomic nervous system order. Alternative Therapies in Health and Medicine 2(1):52-65.