Abstract
Patients with coronary artery disease (CAD) often experience anger events before cardiovascular events. Anger is a psychological risk factor and causes underlying psychophysiological mechanisms to lose balance of the autonomic nervous system (ANS). The heart rate variability (HRV) was the common index for ANS regulation. It has been confirmed that heart rate variability biofeedback (HRV-BF) restored ANS balance in patients with CAD during the resting state. However, the effects of HRV-BF during and after the anger event remain unknown. This study aimed to examine the effects of HRV-BF on ANS reactivity and recovery during the anger recall task in patients with CAD. This study was a randomized control trial with a wait-list control group design, with forty patients in the HRV-BF group (for six sessions) and 44 patients in the control group. All patients received five stages of an anger recall task, including baseline, neutral recall task, neutral recovery, anger recall task, and anger recovery. HRV reactivity in the HRV-BF group at the post-test was lower than that in the control group. HRV recovery at the post-test in the HRV-BF group was higher than that in the control group. The HRV-BF reduced ANS reactivity during anger events and increased ANS recovery after anger events for CAD patients. The possible mechanisms of HRV-BF may increase total HRV, ANS regulation, and baroreflex activation at anger events for patients with CAD, and may be a suitable program for cardiac rehabilitation.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Change history
17 March 2022
The numbers generated near to Fig. 2 and Fig. 3 during proof preparation is removed.
References
Billman, G. E. (2013). The effect of heart rate of the heart rate variability response to autonomic interventions. Frontiers in Physiology, 4(222), 1–9. https://doi.org/10.3389/fphys.2013.00222
Brosschot, J. F., & Thayer, J. F. (1998). Anger inhibition, cardiovascular recovery, and vagal function: A model of the link between hostility and cardiovascular disease. Annals of Behavioral Medicine, 20(4), 326–332. https://doi.org/10.1007/BF02886382
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Erlbaum.
Del Pozo, J. M., Gevirtz, R. N., Scher, B., & Guarneri, E. (2004). Biofeedback treatment increases heart rate variability in patients with known coronary artery disease. American Heart Journal, 147(3), 545. https://doi.org/10.1016/j.ahj.2003.08.013
Francis, H. M., Penglis, K. M., & McDonald, S. (2015). Manipulation of heart rate variability can modify response to anger-inducing stimuli. Social Neuroscience, 11(5), 545–552. https://doi.org/10.1080/17470919.2015.1115777
Hallman, D. M., Olsson, E. M., Von Schéele, B., Melin, L., & Lyskov, E. (2011). Effects of heart rate variability biofeedback in subjects with stress-related chronic neck pain: a pilot study. Applied Psychophysiology and Biofeedback, 36(2), 71–80.
Herrero, N., Gadea, M., Rodríguez-Alarcón, G., Espert, R., & Salvador, A. (2010). What happens when we get angry? Hormonal, cardiovascular and asymmetrical brain responses. Hormones and Behavior, 57(3), 276–283. https://doi.org/10.1016/j.yhbeh.2009.12.008
Hottenrott, L., Ketelhut, S., & Hottenrott, K. (2019). Commentary: Vagal tank theory: The three Rs of cardiac vagal control functioning–resting, reactivity, and recovery. Frontiers in Neuroscience, 13, 1300. https://doi.org/10.3389/fnins.2019.01300
Karavidas, M. K., Lehrer, P. M., Vaschillo, E., Vaschillo, B., Marin, H., Buyske, S., Malinovsky, I., Radvanski, D., & Hassett, A. (2007). Preliminary results of an open label study of heart rate variability biofeedback for the treatment of major depression. Applied Psychophysiology and Biofeedback, 32(1), 19–30. https://doi.org/10.1007/s10484-006-9029-z
Kop, W. J. (1999). Chronic and acute psychological risk factors for clinical manifestations of coronary artery disease. Psychosomatic Medicine, 61(4), 476–487. https://doi.org/10.1097/00006842-199907000-00012
Krantz, D. S., & Manuck, S. B. (1984). Acute psychophysiologic reactivity and risk of cardiovascular disease: A review and methodologic critique. Psychological Bulletin, 96(3), 435–464. https://doi.org/10.1037//0033-2909.96.3.435
Laborde, S., Mosley, E., & Mertgen, A. (2018). Vagal tank theory: The three rs of cardiac vagal control functioning–resting, reactivity, and recovery. Frontiers in Neuroscience, 12, 458. https://doi.org/10.3389/fnins.2018.00458
Laborde, S., Mosley, E., & Thayer, J. F. (2017). Heart rate variability and cardiac vagal tone in psychophysiological research- Recommendations for experiment planning, data analysis and data reporting. Frontiers in Psychology, 8, 213. https://doi.org/10.3389/fpsyg.2017.00213
Larsen, B. A., & Christenfeld, N. J. (2011). Cognitive distancing, cognitive restructuring, and cardiovascular recovery from stress. Biological Psychology, 86(2), 143–148. https://doi.org/10.1016/j.biopsycho.2010.02.011
Lehrer, P., Vaschillo, E., Lu, S. E., Eckberg, D., Vaschillo, B., Scardella, A., & Habib, R. (2006). Heart rate variability biofeedback: Effects of age on heart rate variability, baroreflex gain, and asthma. Chest, 129(2), 278–284. https://doi.org/10.1378/chest.129.2.278
Lehrer, P., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology and Biofeedback, 25(3), 177–191. https://doi.org/10.1023/A:1009554825745
Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 1–9. https://doi.org/10.3389/fpsyg.2014.00756
Lin, I. M., Fan, S. Y., Lu, H. C., Lin, T. H., Chu, C. S., Kuo, H. F., Lee, C. S., & Lu, Y. H. (2015a). Randomized controlled trial of heart rate variability biofeedback in cardiac autonomic and hostility among patients with coronary artery disease. Behaviour Research and Therapy, 70, 38–46. https://doi.org/10.1016/j.brat.2015.05.001
Lin, I. M., Weng, C. Y., Lin, T. K., & Lin, C. L. (2015b). The relationship between expressive/suppressive hostility behavior and autonomic nervous activations in coronary artery disease patients. Acta Cardiologica Sinica, 31(4), 308–316. https://doi.org/10.6515/ACS20141027B
Lin, P. Y., Lu, H. C., Chang, C. J., & Lin, I. M. (2018). The effects of heart rate variabity biofeedback on patients with coronary artery disease and premature ventricular contractions. Taiwan Journal of Family Medicine, 28(3), 129–141.
Ministry of Health and Welfare. (2021, Jane 22). 2020 cause of death statistics. Ministry of Health and Welfare. https://dep.mohw.gov.tw/dos/cp-5202-61532-113.html
Mostofsky, E., Maclure, M., Tofler, G. H., Muller, J. E., & Mittleman, M. A. (2013). Relation of outbursts of anger and risk of acute myocardial infarction. The American Journal of Cardiology, 112(3), 343–348. https://doi.org/10.1016/j.amjcard.2013.03.035
Mostofsky, E., Penner, E. A., & Mittleman, M. A. (2014). Outbursts of anger as a trigger of acute cardiovascular events: A systematic review and meta-analysis. European Heart Journal, 35(21), 1404–1410. https://doi.org/10.1093/eurheartj/ehu033
National Center for Chronic Disease Prevention and Health Promotion (2020, June 18). Heart disease facts. https://www.cdc.gov/hear
Neumann, S. A., Waldstein, S. R., Sellers, J. J., III., Thayer, J. F., & Sorkin, J. D. (2004). Hostility and distraction have differential influences on cardiovascular recovery from anger recall in women. Health Psychology, 23(6), 631–640. https://doi.org/10.1037/0278-6133.23.6.631
Nolan, R. P., Kamath, M. V., Floras, J. S., Stanley, J., Pang, C., Picton, P., & Young, Q. R. (2005). Heart rate variability biofeedback as a behavioral neurocardiac intervention to enhance vagal heart rate control. American Heart Journal, 149(6), 1137.e1-1137.e7. https://doi.org/10.1016/j.ahj.2005.03.015
Ottaviani, C., & Shapiro, D. (2011). Do we need a stressor to be stressed? Insights from cardiac regulation. Japanese Psychological Research, 53(2), 155–162. https://doi.org/10.1111/j.1468-5884.2011.00462.x
Ottaviani, C., Shapiro, D., & Fitzgerald, L. (2011). Rumination in the laboratory: What happens when you go back to everyday life. Psychophysiology, 48(4), 453–461. https://doi.org/10.1111/j.1469-8986.2010.01122.x
Panaite, V., Salomon, K., Jin, A., & Rottenberg, J. (2015). Cardiovascular recovery from psychological and physiological challenge and risk for adverse cardiovascular outcomes and all-cause mortality. Psychosomatic Medicine, 77(3), 215–226. https://doi.org/10.1097/PSY.0000000000000171
Pfeifer, M. A., Weinberg, C. R., Cook, D., Best, J. D., Reenan, A., & Halter, J. B. (1983). Differential changes of autonomic nervous system function with age in man. The American Journal of Medicine, 75(2), 249–258. https://doi.org/10.1016/0002-9343(83)91201-9
Porges, S. W. (2003). The polyvagal theory: Phylogenetic contributions to social behavior. Physiology & Behavior, 79(3), 503–513. https://doi.org/10.1016/s0031-9384(03)00156-2
Shaffer, F. (2020). Resonance frequency assessment: The challenge of standardizing heart rate variability biofeedback research. Biofeedback, 48(1), 7–15. https://doi.org/10.5298/1081-5937-48.01.06
Shaffer, F., & Ginsberg, J. P. (2017). An overview of heart rate variability metrics and norms. Frontiers in Public Health, 5, 258. https://doi.org/10.3389/fpubh.2017.00258
Shaffer, F., McCraty, R., & Zerr, C. L. (2014). A healthy heart is not a metronome: An integrative review of the heart’s anatomy and heart rate variability. Frontiers in Psychology, 5, 1040. https://doi.org/10.3389/fpsyg.2014.01040
Shaffer, F., & Meehan, Z. M. (2020). A practical guide to resonance frequency assessment for heart rate vriability biofeedback. Frontiers in Neuroscience, 14, 570400. https://doi.org/10.3389/fnins.2020.570400
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, 105(15), 1780–1784. https://doi.org/10.1161/01.CIR.0000014491.90666.06
Smeijers, L., Szabó, B. M., van Dammen, L., Wonnink, W., Jakobs, B. S., Bosch, J. A., & Kop, W. J. (2015). Emotional, neurohormonal, and hemodynamic responses to mental stress in Tako-Tsubo cardiomyopathy. The American Journal of Cardiology, 115(11), 1580–1586. https://doi.org/10.1016/j.amjcard.2015.02.064
Suchday, S., Carter, M. M., Ewart, C. K., Larkin, K. T., & Desiderato, O. (2004). Anger cognitions and cardiovascular recovery following provocation. Journal of Behavioral Medicine, 27(4), 319–341. https://doi.org/10.1023/B:JOBM.0000042408.80551.e1
Tan, G., Dao, T. K., Farmer, L., Sutherland, R. J., & Gevirtz, R. (2011). Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): A pilot study. Applied Psychophysiology and Biofeedback, 36(1), 27–35. https://doi.org/10.1007/s10484-010-9141-y
Task Force of the European Society of Cardiology the North American Society of Pacing Electrophysiology. (1996). Heart rate variability: Standards of measurement, physiological interpretation, and clinical use. Circulation, 93(5), 1043–1065. https://doi.org/10.1161/01.CIR.93.5.1043
Thayer, J. F., & Lane, R. D. (2009). Claude Bernard and the heart–brain connection: Further elaboration of a model of neurovisceral integration. Neuroscience & Biobehavioral Reviews, 33(2), 81–88. https://doi.org/10.1016/j.neubiorev.2008.08.004
van Dixhoorn, J. J., & Duivenvoorden, H. J. (1999). Effect of relaxation therapy on cardiac events after myocardial infarction: A 5-year follow-up study. Journal of Cardiopulmonary Rehabilitation and Prevention, 19(3), 178–185.
Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2020). Heart disease and stroke statistics—2020 update: A report from the American Heart Associationexternal icon. Circulation, 141(9), e139–e596. https://doi.org/10.1161/CIR.0000000000000757
Young, H. A., & Benton, D. (2018). Heart-rate variability: A biomarker to study the influence of nutrition on physiological and psychological health? Behavioural Pharmacology, 29(2-), 140–151. https://doi.org/10.1097/FBP.0000000000000383
Yu, L. C., Lin, I. M., Fan, S. Y., Chien, C. L., & Lin, T. H. (2018). One-year cardiovascular prognosis of the randomized, controlled, short-term heart rate variability biofeedback among patients with coronary artery disease. International Journal of Behavioral Medicine, 25(3), 271–282. https://doi.org/10.1007/s12529-017-9707-7
Acknowledgements
This study was supported by the Ministry of Science and Technology, Taiwan (MOST 100-2410-H-037-002 and MOST 102-2410-H-037-003). The article was adapted from the master's thesis of Pei-Yun Lin, Department of Psychology, Kaohsiung Medical University. Thank you for Dr. Chee-Siong Lee, Dr. Ye-Hsu Lu, Dr. Tsung-Hsien Lin, Dr. Chih-Sheng Chu, and Dr. Hsuan-Fu Kuo from the Cardiology Department of Kaohsiung Medical University Hospital and Kaohsiung Datong Hospital for referring CAD patients to participate in this study. Thank you for Te-Lun Hu, Lin-Yuan Tai, Hsueh-Chen Lu, Li-Ching, Yu and Yu-Chiao Huang from the Department of Psychology, Kaohsiung Medical University for data collection.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All authors state that they have no conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Lin, IM., Lin, PY. & Fan, SY. The Effects of Heart Rate Variability (HRV) Biofeedback on HRV Reactivity and Recovery During and After Anger Recall Task for Patients with Coronary Artery Disease. Appl Psychophysiol Biofeedback 47, 131–142 (2022). https://doi.org/10.1007/s10484-022-09539-1
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10484-022-09539-1