{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T15:38:16Z","timestamp":1791214696538,"version":"4.1.0"},"reference-count":48,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"14","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circulation"],"published-print":{"date-parts":[[2016,4,5]]},"abstract":"<jats:sec>\n                    <jats:title>Background\u2014<\/jats:title>\n                    <jats:p>Cardiac rehabilitation (CR) is the standard of care for patients with coronary heart disease. Despite considerable epidemiological evidence that high stress is associated with worse health outcomes, stress management training (SMT) is not included routinely as a component of CR.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and Results\u2014<\/jats:title>\n                    <jats:p>\n                      One hundred fifty-one outpatients with coronary heart disease who were 36 to 84 years of age were randomized to 12 weeks of comprehensive CR or comprehensive CR combined with SMT (CR+SMT), with assessments of stress and coronary heart disease biomarkers obtained before and after treatment. A matched sample of CR-eligible patients who did not receive CR made up the no-CR comparison group. All participants were followed up for up to 5.3 years (median, 3.2 years) for clinical events. Patients randomized to CR+SMT exhibited greater reductions in composite stress levels compared with those randomized to CR alone (\n                      <jats:italic>P<\/jats:italic>\n                      =0.022), an effect that was driven primarily by improvements in anxiety, distress, and perceived stress. Both CR groups achieved significant, and comparable, improvements in coronary heart disease biomarkers. Participants in the CR+SMT group exhibited lower rates of clinical events compared with those in the CR-alone group (18% versus 33%; hazard ratio=0.49; 95% confidence interval, 0.25\u20130.95;\n                      <jats:italic>P<\/jats:italic>\n                      =0.035), and both CR groups had lower event rates compared with the no-CR group (47%; hazard ratio=0.44; 95% confidence interval, 0.27\u20130.71;\n                      <jats:italic>P<\/jats:italic>\n                      &lt;0.001).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions\u2014<\/jats:title>\n                    <jats:p>CR enhanced by SMT produced significant reductions in stress and greater improvements in medical outcomes compared with standard CR. Our findings indicate that SMT may provide incremental benefit when combined with comprehensive CR and suggest that SMT should be incorporated routinely into CR.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Clinical Trial Registration\u2014<\/jats:title>\n                    <jats:p>\n                      URL:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"http:\/\/www.clinicaltrials.gov\">http:\/\/www.clinicaltrials.gov<\/jats:ext-link>\n                      . Unique identifier: NCT00981253.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circulationaha.115.018926","type":"journal-article","created":{"date-parts":[[2016,3,21]],"date-time":"2016-03-21T23:55:16Z","timestamp":1458604516000},"page":"1341-1350","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":234,"title":["Enhancing Cardiac Rehabilitation With Stress Management Training"],"prefix":"10.1161","volume":"133","author":[{"given":"James A.","family":"Blumenthal","sequence":"first","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Sherwood","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick J.","family":"Smith","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lana","family":"Watkins","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephanie","family":"Mabe","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William E.","family":"Kraus","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krista","family":"Ingle","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paula","family":"Miller","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alan","family":"Hinderliter","sequence":"additional","affiliation":[{"name":"From the Departments of Psychiatry and Behavioral Sciences (J.A.B., A.S., P.J.S., L.W., S.M., K.I.) and Medicine (W.E.K.), Duke University Medical Center, Durham, NC; and Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (P.M., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.106.180945"},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra001529"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2015.10.044"},{"key":"e_1_3_4_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2004.12.005"},{"key":"e_1_3_4_6_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(04)17018-9"},{"key":"e_1_3_4_7_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(04)17019-0"},{"key":"e_1_3_4_8_2","first-page":"CD002902","article-title":"Psychological interventions for coronary heart disease.","author":"Rees K","year":"2004","unstructured":"Rees K, Bennett P, West R, Davey SG, Ebrahim S. Psychological interventions for coronary heart disease. Cochrane Database Syst Rev. 2004:CD002902.","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_3_4_9_2","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.1997.00440400063008"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.293.13.1626"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.2307\/2531158"},{"key":"e_1_3_4_12_2","volume-title":"Beck Depression Inventory Manual","author":"Beck AT","year":"1996","unstructured":"Beck AT, Steer RA, Brown GK. Beck Depression Inventory Manual. San Antonio, TX: The Psychological Corp; 1996."},{"key":"e_1_3_4_13_2","volume-title":"Manual For the State-Trait Anxiety Inventory","author":"Spielberger CE","year":"1970","unstructured":"Spielberger CE, Gorsuch RL. Manual For the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1970."},{"key":"e_1_3_4_14_2","doi-asserted-by":"publisher","DOI":"10.1186\/1477-7525-11-37"},{"key":"e_1_3_4_15_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2010.04.011"},{"key":"e_1_3_4_16_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(91)90432-K"},{"key":"e_1_3_4_17_2","doi-asserted-by":"publisher","DOI":"10.2307\/2136404"},{"key":"e_1_3_4_18_2","doi-asserted-by":"publisher","DOI":"10.1097\/00008483-199811000-00006"},{"key":"e_1_3_4_19_2","first-page":"141","article-title":"A simple method to assess exercise behavior in the community.","volume":"10","author":"Godin G","year":"1985","unstructured":"Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985;10:141\u2013146.","journal-title":"Can J Appl Sport Sci"},{"key":"e_1_3_4_20_2","first-page":"1294","article-title":"Validation study of Nexfin\u00ae continuous non-invasive blood pressure monitoring in critically ill adult patients.","volume":"80","author":"Ameloot K","year":"2014","unstructured":"Ameloot K, Van De Vijver K, Van Regenmortel N, De Laet I, Schoonheydt K, Dits H, Broch O, Bein B, Malbrain ML. Validation study of Nexfin\u00ae continuous non-invasive blood pressure monitoring in critically ill adult patients. Minerva Anestesiol. 2014;80:1294\u20131301.","journal-title":"Minerva Anestesiol"},{"key":"e_1_3_4_21_2","doi-asserted-by":"publisher","DOI":"10.1109\/TAU.1967.1161901"},{"key":"e_1_3_4_22_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2014.12.018"},{"key":"e_1_3_4_23_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.STR.27.11.2136"},{"key":"e_1_3_4_24_2","doi-asserted-by":"publisher","DOI":"10.1002\/sim.4780090711"},{"key":"e_1_3_4_25_2","doi-asserted-by":"publisher","DOI":"10.1097\/00005650-198601000-00007"},{"key":"e_1_3_4_26_2","doi-asserted-by":"publisher","DOI":"10.1097\/00006842-200207000-00003"},{"key":"e_1_3_4_27_2","doi-asserted-by":"publisher","DOI":"10.1136\/heartjnl-2011-300302"},{"key":"e_1_3_4_28_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.313.7071.1517"},{"key":"e_1_3_4_29_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(97)02142-9"},{"key":"e_1_3_4_30_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.289.23.3106"},{"key":"e_1_3_4_31_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12529-012-9282-x"},{"key":"e_1_3_4_32_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2007.03.026"},{"key":"e_1_3_4_33_2","first-page":"CD004366","article-title":"Exercise for depression.","author":"Mead GE","year":"2009","unstructured":"Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database Syst Rev. 2009:CD004366.","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_3_4_34_2","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.166.17.1878"},{"key":"e_1_3_4_35_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2012.8720"},{"key":"e_1_3_4_36_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2013.5566"},{"key":"e_1_3_4_37_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.288.6.701"},{"key":"e_1_3_4_38_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2010.03.068"},{"key":"e_1_3_4_39_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2007.12.024"},{"key":"e_1_3_4_40_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1993.03510150053029"},{"key":"e_1_3_4_41_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.91.4.999"},{"key":"e_1_3_4_42_2","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.160.9.1354"},{"key":"e_1_3_4_43_2","doi-asserted-by":"publisher","DOI":"10.1161\/hc0902.104707"},{"key":"e_1_3_4_44_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000019"},{"key":"e_1_3_4_45_2","doi-asserted-by":"publisher","DOI":"10.1001\/archgenpsychiatry.2010.74"},{"key":"e_1_3_4_46_2","doi-asserted-by":"publisher","DOI":"10.1097\/HJR.0b013e3280142a02"},{"key":"e_1_3_4_47_2","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.112.000068"},{"key":"e_1_3_4_48_2","doi-asserted-by":"publisher","DOI":"10.1097\/00006842-198011000-00002"},{"key":"e_1_3_4_49_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.92.7.1720"}],"container-title":["Circulation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/CIRCULATIONAHA.115.018926","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,13]],"date-time":"2024-05-13T03:00:51Z","timestamp":1715569251000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ahajournals.org\/doi\/10.1161\/CIRCULATIONAHA.115.018926"}},"subtitle":["A Randomized, Clinical Efficacy Trial"],"short-title":[],"issued":{"date-parts":[[2016,4,5]]},"references-count":48,"journal-issue":{"issue":"14","published-print":{"date-parts":[[2016,4,5]]}},"alternative-id":["10.1161\/CIRCULATIONAHA.115.018926"],"URL":"https:\/\/doi.org\/10.1161\/circulationaha.115.018926","relation":{"has-review":[{"id-type":"doi","id":"10.3410\/f.726265723.793518607","asserted-by":"object"}]},"ISSN":["0009-7322","1524-4539"],"issn-type":[{"value":"0009-7322","type":"print"},{"value":"1524-4539","type":"electronic"}],"subject":[],"published":{"date-parts":[[2016,4,5]]},"assertion":[{"value":"2015-08-10","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2016-02-12","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2016-03-21","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}