International Journal of Behavioral Medicine

, Volume 16, Issue 3, pp 227–235 | Cite as

Daily Stress and Social Support among Women with CAD: Results from a 1-year Randomized Controlled Stress Management Intervention Study

  • May Blom
  • Anastasia Georgiades
  • Imre Janszky
  • Hassan Alinaghizadeh
  • Birgitta Lindvall
  • Staffan AhnveEmail author



Psychosocial stress may play a causative role in development and progression of coronary artery disease (CAD).


We investigated the effects of a 1-year stress management program on daily stress behavior and social support among female CAD patients.


Women, 247 (≤75 years), hospitalized for a cardiac event were randomized to either a control or an intervention group. Controls obtained usual health care; intervention patients participated in 20 2-h group sessions of stress management therapy and obtained health care by a cardiologist. Measurements were at baseline, 10 weeks (after ten sessions), 1-year (end of intervention), and at a 1- to 2-year follow-up.


Daily stress scores for the intervention and control groups were at baseline 39.5 ± 8.1 vs. 37.2 ± 9.1 (p = 0.06), 10 weeks 37.2 ± 8.0 vs. 35.5 ± 9.4 (p = 0.20), 1-year 36.1 ± 7.2 vs. 35.9 ± 8.5 (p = 0.85), and at 1–2 year follow-up 34.0 ± 7.8 vs. 35.3 ± 8.7 (p = 0.32), respectively. Intention to treat analyses showed interaction between treatment and time [F(3,213) = 2.72; p = 0.01] reflecting that the decrease was more pronounced in the intervention group. There was no evidence for a difference in change concerning social support.


CAD women in the intervention group had a more pronounced reduction of self-rated daily stress behavior over time compared to controls. However, as the intervention group had higher baseline values, due to regression toward the mean, we have no evidence that the difference in decrease of daily stress was due to the intervention.


Stress management intervention Social support CAD Women 



We thank Gunilla Burell, PhD, for sharing her experiences in performing and developing stress management programs for men and women with CAD. Special thanks also to research nurses: Gun Wesley, Diana Karlsson, Gunilla Gabriel, Gunilla Levin, Åsa Hemberg, Birgitta Welin at Karolinska University Hospital, Huddinge and Charlotta Cronsten-Engberg, Anna Johannesen, Christina Walldin at St Görans Hospital for very skillful assistance.

We also thank cardiologists Jan-Olof Magnusson MD, PhD, Staffan Hederoth, MD, Barbro Kedinge Cyrus, MD, and Gunilla Wennersten, MD, who were responsible for the treatment of patients in the intervention group at St Görans Hospital.

This study was supported by grants from the Ansgarius Foundation, the Belven Foundation, the Swedish Heart and Lung Foundation, the Public Health Committee, as well as EXPO-95 of Stockholm County Council, the Swedish Medical Research Council (project 19X-11629), the Vardal Foundation, all in Stockholm, Sweden.


  1. 1.
    Krantz DS, Kop WJ, Santiago HT, Gottdiener JS. Mental stress as a trigger of myocardial ischemia and infarction. Cardiol Clin 1996;14(2):271–87.PubMedGoogle Scholar
  2. 2.
    Krantz DS, Quigley JF, O’Callahan M. Mental stress as a trigger of acute cardiac events: the role of laboratory studies. Ital Heart J 2001;2(12):895–9.PubMedGoogle Scholar
  3. 3.
    Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999;99(16):2192–217.PubMedGoogle Scholar
  4. 4.
    Tennant C. Life stress, social support and coronary heart disease. Aust N Z J Psychiatry 1999;33(5):636–41.PubMedCrossRefGoogle Scholar
  5. 5.
    Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:937–52.PubMedCrossRefGoogle Scholar
  6. 6.
    Leor J, Poole WK, Kloner RA. Sudden cardiac death triggered by an earthquake. N Engl J Med 1996;334(7):413–19.PubMedCrossRefGoogle Scholar
  7. 7.
    Meisel SR, Kutz I, Dayan KI, Pauzner H, Chetboun I, Arbel Y, et al. Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians. Lancet 1991;338(8768):660–1.PubMedCrossRefGoogle Scholar
  8. 8.
    Feng J, Lenihan DJ, Johnson MM, Karri V, Reddy CV. Cardiac sequelae in Brooklyn after the September 11 terrorist attacks. Clin Cardiol 2006;29:13–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Wilbert-Lampen U, Leistner D, Greven S, Pohl T, Sper S, Volker C, et al. Cardiovascular events during World Cup soccer. N Engl J Med 2008;358:475–83.PubMedCrossRefGoogle Scholar
  10. 10.
    Hemingway H, Marmot M. Evidence based cardiology: psychosocial factors in the aetiology and prognosis of coronary heart disease. Systematic review of prospective cohort studies. Br Med J 1999;318(7196):1460–7.Google Scholar
  11. 11.
    Blumenthal JA, Babyak M, Wei J, O’Connor C, Waugh R, Eisenstein E, et al. Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men. Am J Cardiol 2002;89(2):164–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Friedman M, Thoresen CE, Gill JJ, Ulmer D, Powell LH, Price VA, et al. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project. Am Heart J 1986;112(4):653–65.PubMedCrossRefGoogle Scholar
  13. 13.
    Linden W. Psychological treatments in cardiac rehabilitation: review of rationales and outcomes. J Psychosom Res 2000;48(4–5):443–54.PubMedCrossRefGoogle Scholar
  14. 14.
    Hallman T, Burell G, Setterlind S, Oden A, Lisspers J. Psychosocial risk factors for coronary heart disease, their importance compared with other risk factors and gender differences in sensitivity. J Cardiovasc Risk 2001;8(1):39–49.PubMedCrossRefGoogle Scholar
  15. 15.
    Falger PRJ. Why do women fare worse than men after acute coronary syndromes? Eur J Intern Med 2002;13(8):471–3.PubMedCrossRefGoogle Scholar
  16. 16.
    Burell G, Granlund B. Women’s hearts need special treatment. Int J Behav Med 2002;9(3):228–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Bunker SJ, Colquhoun DM, Esler MD, Hickie IB, Hunt D, Jelinek V, et al. “Stress” and coronary heart disease: psychosocial risk factors. Med J Aust 2003;178(6):272–6.PubMedGoogle Scholar
  18. 18.
    Greenwood DC, Muir KR, Packham CJ, Madeley RJ. Coronary heart disease: a review of the role of psychosocial stress and social support. J Pub Health Med 1996;18(2):221–31.Google Scholar
  19. 19.
    Horsten M, Mittleman MA, Wamala SP, Schenck-Gustafsson K, Orth-Gomer K. Depressive symptoms and lack of social integration in relation to prognosis of CHD in middle-aged women. The Stockholm Female Coronary Risk Study. Eur Heart J 2000;21(13):1072–80.PubMedCrossRefGoogle Scholar
  20. 20.
    Claesson M, Burell G, Birgander LS, Lindahl B, Asplund K. Psychosocial distress and impaired quality of life-targets neglected in the secondary prevention in women with ischaemic heart disease. Eur J Cardiovasc Prev Rehabil 2003;10(4):258–66.PubMedCrossRefGoogle Scholar
  21. 21.
    Burell G. Group psychotherapy in project New Life: Treatment of coronary prone behavior in coronary bypass graft surgery patients. In: Allan R, Scheidt S, editors. Heart & mind. Washington DC: American Psychological Association; 1996.Google Scholar
  22. 22.
    Lindahl BG, Asplund B-M, Burell G. Gender differences in psychosocial well-being in a healthy population. Department of behavioral Medicine, University of North Sweden, Umeå,Sweden. Submitted; 2003.Google Scholar
  23. 23.
    Öhman A, Burell G, Ramund B, Fleischmann N. Decomposing coronary-prone behavior: assessment of Type A behavior by the videotaped structured interview. J Psychopathol Behav Assess 1992;14:21–54.CrossRefGoogle Scholar
  24. 24.
    Henderson S, Duncan-Jones P, Byrne DG, Scott R. Measuring social relationships. The interview schedule for social interaction. Psychol Med 1980;10(4):723–34.PubMedCrossRefGoogle Scholar
  25. 25.
    Unden AL, Orth-Gomer K. Development of a social support instrument for use in population surveys. Soc Sci Med 1989;29(12):1387–92.PubMedCrossRefGoogle Scholar
  26. 26.
    Beck AT, Steer RA, Ball R, Ranieri W. Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. J Pers Assess 1996;67(3):588–97.PubMedCrossRefGoogle Scholar
  27. 27.
    Little RJ, Raghunathan T. On summary measures analysis of the linear mixed effects model for repeated measures when data are not missing completely at random. Stat Med 1999;18(17–18):2465–78. 2462 [pii].PubMedCrossRefGoogle Scholar
  28. 28.
    Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, Brutsaert DL. Personality as independent predictor of long-term mortality in patients with coronary heart disease. Lancet 1996;347(8999):417–21.PubMedCrossRefGoogle Scholar
  29. 29.
    Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation 1995a;91(4):999–1005.PubMedGoogle Scholar
  30. 30.
    Januzzi JL, Pasternak RC. Depression, hostility, and social isolation in patients with coronary artery disease. Curr Treatm Opt Cardiovasc Med 2002;4(1):77–85.CrossRefGoogle Scholar
  31. 31.
    Janszky I, Ahlbom A, Hallqvist J, Ahnve S. Hospitalization for depression is associated with an increased risk for myocardial infarction not explained by lifestyle, lipids, coagulation, and inflammation: the SHEEP Study. Biol Psychiatry 2007;62:25–32.PubMedCrossRefGoogle Scholar
  32. 32.
    Rosengren A, Haweken S, Öunpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:953–62.PubMedCrossRefGoogle Scholar
  33. 33.
    Blumenthal JA, Sherwood A, Babyak MA, Watkins LL, Waugh R, Georgiades A, et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease. J Am Med Assoc 2005;293(13):1626–34.CrossRefGoogle Scholar
  34. 34.
    Claesson M, Slunga-Brigander L, Lindahl B, Nasic S, Åström M, Asplund K, Burell G. Women’s hearts—stress management for women with ichemic heart disease. J Cardiopulm Rehabil 2005;(25):93–102.Google Scholar
  35. 35.
    Karlberg L, Krakau I, Unden AL. Type A behavior intervention in primary health care reduces hostility and time pressure: a study in Sweden. Soc Sci Med 1998;46(3):397–402.PubMedCrossRefGoogle Scholar
  36. 36.
    Arnold E. The stress connection. Women and coronary heart disease. Crit Care Nurs Clin North Am 1997;9(4):565–75.PubMedGoogle Scholar
  37. 37.
    Dusseldorp E, van Elderen T, Maes S, Meulman J, Kraaij V. A meta-analysis of psychoeduational programs for coronary heart disease patients. Health Psychol 1999;18(5):506–19.PubMedCrossRefGoogle Scholar
  38. 38.
    Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med 1996;156(7):745–52.PubMedCrossRefGoogle Scholar
  39. 39.
    Oldenburg B, Perkins RJ, Andrews G. Controlled trial of psychological intervention in myocardial infarction. J Consult Clin Psychol 1985;53(6):852–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Rugulies R, Scherwitz L, Siegrist J, Hertel L, Benesch L. Comprehensive life style changes by coronary patients—an intervention study. Gesundheitswesen 1996;58(Suppl 2):149–51.PubMedGoogle Scholar
  41. 41.
    Barefoot JC, Brummett BH, Helms MJ, Mark DB, Siegler IC, Williams RB. Depressive symptoms and survival of patients with coronary artery disease. Psychosom Med 2000;62(6):790–5.PubMedGoogle Scholar
  42. 42.
    Blumenthal JA, Lett HS, Babyak MA, White W, Smith PK, Mark DB, et al. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet 2003;362(9384):604–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Frasure-Smith N, Lesperance F. Depression and other psychological risks following myocardial infarction. Arch Gen Psychiatry 2003;60(6):627–36.PubMedCrossRefGoogle Scholar
  44. 44.
    Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. J Am Med Assoc 1993;270(15):1819–25.CrossRefGoogle Scholar
  45. 45.
    Frasure-Smith N, Lesperance F, Talajic M. The impact of negative emotions on prognosis following myocardial infarction: is it more than depression? Health Psychol 1995b;14(5):388–98.PubMedCrossRefGoogle Scholar
  46. 46.
    Linden W, Leung D, Chawla A, Stossel C, Rutledge T, Tanco SA. Social determinants of experienced anger. J Behav Med 1997;20(5):415–32.PubMedCrossRefGoogle Scholar
  47. 47.
    Kaplan BH, Cassel JC, Gore S. Social support and health. Med Care 1977;15(5 SUPPL):47–58.PubMedCrossRefGoogle Scholar
  48. 48.
    Fridlund B. Social network and social support among MI-women during the three month following upon a first myocardial infarction. Vård Nord 1997;17(2):9–14.Google Scholar
  49. 49.
    Twisk JW, Snel J, Kemper HC, van Mechelen W. Changes in daily hassles and life events and the relationship with coronary heart disease risk factors: a 2-year longitudinal study in 27–29-year-old males and females. J Psychosom Res 1999;46(3):229–40.PubMedCrossRefGoogle Scholar
  50. 50.
    Fredrikson M, Blumenthal JA. Serum lipids, neuroendocrine and cardiovascular responses to stress in healthy Type A men. Biol Psychol 1992;34(1):45–58.PubMedCrossRefGoogle Scholar
  51. 51.
    Mamalakis G, Kafatos A, Board S. Type A behavior and adipose tissue linoleic acid: implications for stress management. J Am Coll Nutr 1994;13(3):292–7.PubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2009

Authors and Affiliations

  • May Blom
    • 1
  • Anastasia Georgiades
    • 1
  • Imre Janszky
    • 1
  • Hassan Alinaghizadeh
    • 1
  • Birgitta Lindvall
    • 1
  • Staffan Ahnve
    • 1
    • 2
    Email author
  1. 1.Preventive Medicine, Social Medicine, Department of Public Health SciencesKarolinska Institutet, and Center of Public HealthStockholmSweden
  2. 2.Preventive Medicine, Norrbacka 6th floorKarolinska University HospitalStockholmSweden

Personalised recommendations