HEART DISEASE, MINDFULNESS AND MEDITATION
A Literature Review
Dr Ian Gawler OAM, BVSc, MCounsHS March 2021
What evidence is there mindfulness and meditation can have therapeutic benefits for those affected by heart disease?
Can mindfulness and meditation prevent heart disease? Does mindfulness and meditation offset the ongoing risks for people who have already experienced heart disease? Can mindfulness and meditation play a part in helping people to actually recover from heart disease?
This literature review aims to bring together the research evidence around heart disease, mindfulness and meditation. And given the times we are in, this review also examines the evidence base for online programs.
Quite a large body of research has been published in this field, but not surprisingly, it varies in quality. Therefore, while not exhaustive, this review aims to reproduce key research (using many direct quotes) that investigates the efficacy of mindfulness and meditation for people affected by heart disease.
This review includes direct hyper-links to the original articles as published. The review is in three parts –the role of mindfulness and meditation in the prevention of heart disease, in the management of heart disease and evidence for online programs. On prevention, just the one major review of recent research is quoted.
THE BACKGROUND of TRAGEDY
Heart disease remains the leading non-communicable lifestyle related illness in Australia and the US Heart disease, leading to 1 in 4 deaths in both countries. Consider how many lives this directly and indirectly affects. Tragic.
Yet heart disease is highly preventable, and much can be done for people diagnosed with heart disease.
CONTEXT – THE ORNISH STUDIES
For more than 35 years, Dr. Ornish has championed lifestyle modification as a proven approach for reversing heart disease in patients with pre-existing coronary artery disease. The program Ornish developed has much in common with those developed at the Gawler Foundation for people affected by cancer and multiple sclerosis (See Ian Gawler’s You Can Conquer Cancer and George Jelinek’s Overcoming MS).
Based on indepth scientific research, Dr. Ornish’s approach actually reverses the progression of cardiovascular disease and reduces the need for interventional revascularizations and costly medications for patients with one of several risk indicators, including a prior acute myocardial infarction, CABG surgery, a PCI procedure or stable angina.
Recognizing the extraordinary results that Dr. Ornish achieved in reversing heart disease, Congress and the Centers for Medicare and Medicaid Services (CMS) in 2010 provided for Medicare reimbursement for individuals enrolled in The Ornish Program for Reversing Heart Disease. Dr. Ornish and Healthways are now deploying a scalable solution that is unmatched in its impact on outcomes and costs.
The Ornish program uses the following four core elements equally
1. A very low-fat, whole foods diet
2. Moderate aerobic exercise
3. Stress management techniques
4. Support groups
The program has proven results documented in peer-reviewed research journals. In these published studies, CHD patients showed greater changes in diet and lifestyle and better clinical outcomes than have ever before been reported for various lifestyle change interventions. These studies showed, for the first time, that the progression of coronary atherosclerosis could be stopped or reversed by making comprehensive lifestyle changes.
Specifically, these studies demonstrated the following benefits of the lifestyle modification program
• Regression of coronary artery stenosis using quantitative coronary arteriography
• Decreased size and severity of ischemic myocardial perfusion abnormalities (blood flow to the heart) using cardiac positron emission tomography (PET), exercise thallium scintigraphy, and exercise radionuclide ventriculography
• Safe avoidance of revascularization procedures such as coronary bypass surgery, angioplasty, and intracoronary stents in almost 80% of those who were eligible for these procedures, with comparable clinical outcomes
• Significantly greater exercise capacity
• Substantial cardiac risk factor improvements, e.g., reductions in LDL-cholesterol comparable to what can be achieved with statin drugs without the costs and potential side-effects as well as significant reductions in weight, BMI, blood pressure and fasting blood glucose
• Marked, rapid, and often dramatic decreases in the frequency and severity of angina
• Substantial improvements in quality of life by a variety of measures (including decreased emotional stress and depression and increased vitality, physical function, and well-being)
• 2.5 times fewer cardiac events. In addition, we measured significant improvements in other chronic diseases prevalent in the population, including obesity, diabetes, hypertension, hypercholesterolemia, depression, arthritis, prostate cancer, and related illnesses.
Follow-up analyses revealed even more reversal after five years than after one year. In contrast, patients in the usual-care randomized control group showed worsening (progression) of coronary atherosclerosis after one year and even more worsening after five years. Also, there was a direct correlation between degree of adherence to this lifestyle 5 modification program and changes in coronary atherosclerosis after one year and also after five years.
Given the success of the Ornish program, and given it has stress management based upon meditation and yoga as a key element, all the more the question – what does the research have to say regarding heart disease, mindfulness and meditation?
PART 1 – MINDFULNESS AND MEDITATION IN THE PREVENTION OF HEART DISEASE
The American Heart Association’s major review from 2017
This review was compiled by a large group of leading researchers under the auspices of the AMA. It systematically reviewed the data on the potential benefits of meditation on cardiovascular risk.
Neurophysiological and neuroanatomical studies demonstrate that meditation can have long‐standing effects on the brain, which provide some biological plausibility for beneficial consequences on the physiological basal state and on cardiovascular risk.
Studies of the effects of meditation on cardiovascular risk have included those investigating physiological response to stress, smoking cessation, blood pressure reduction, insulin resistance and metabolic syndrome, endothelial function, inducible myocardial ischemia, and primary and secondary prevention of cardiovascular disease.
Overall, studies of meditation suggest a possible benefit on cardiovascular risk, although the overall quality and, in some cases, quantity of study data are modest. Given the low costs and low risks of this intervention, meditation may be considered as an adjunct to guideline‐directed cardiovascular risk reduction by those interested in this lifestyle modification, with the understanding that the benefits of such intervention remain to be better established. Further research on meditation and cardiovascular risk is warranted.
Levine GN et al. Meditation and Cardiovascular Risk Reduction. A Scientific Statement From the American Heart Association; 2017 Journal of the American Heart Association; Vol6: Issue 10.
PART 2 – MINDFULNESS AND MEDITATION IN THE MANAGEMENT AND TREATMENT OF HEART DISEASE
1. Meditation cuts death risk in half
From 2012 this 5 year, randomised controlled study of 201 people with coronary disease found those who practiced meditation were 48% less likely to have a heart attack, stroke or die from all causes, compared to a group of study participants who merely attended a health education class over more than five years.
The authors hypothesised reducing stress by managing the mind-body connection would help improve rates of this epidemic disease. They also found the meditators were able to lower their blood pressure and decrease their overall stress and anger.
Schneider RH et al. Stress reduction in the secondary prevention of cardiovascular disease: randomized, controlled trial of transcendental meditation and health education in Blacks. Circ Cardiovasc Qual Outcomes. 2012 Nov;5(6):750-8.
2. 2019 Major review recommends meditation
In this highly objective paper, the authors screened 3,540 research papers, reducing that number to 45 final papers that met their strict criteria for inclusion in their actual analysis. They point out the quality and quantity of published research in this field is limited and complicated by the different methods taught and studied.
Even so they concluded available data suggest a potential influence of meditation interventions on various factors of cardiovascular disease. The authors state that in clinical practice, meditation as an intervention may be suggested to patients at cardiovascular risk in addition to conservative treatment protocols because of its non-invasive and cost-effective nature. In particular, as recommended by the European Society of Cardiology, treating psychosocial factors can counteract stress, depression and anxiety, and therefore facilitate behaviour change and improve general quality of life.
The authors reported the quintessence of this expert opinion
Heterogenous data suggest a link between meditation interventions and cardiovascular disease.
Meditation can be suggested to patients in addition to conservative treatment or prophylactic protocols.
In particular, meditation can help to reduce stress, depression and anxiety.
Schnaubelt S et al. Meditation and Cardiovascular Health: What is the Link? European Cardiology Review 2019;14(3):161–4
3. Mindfulness reduces depression and anxiety, improves Quality of life
This review from 2020 searched 7 English and 2 Chinese electronic databases for experimental studies that examined mindfulness-based interventions in adults with heart failure. Five studies involving 467 patients with heart failure met the inclusion criteria. They had weak to moderate quality.
There were consistent findings that mindfulness-based interventions could significantly reduce depression (three studies) and anxiety (two studies) and improve health-related quality of life (two studies) after intervention. However, the effects on physical symptoms were inconsistent in three studies.
Zou H, Cao X, Geng J, Chair SY. Effects of mindfulness-based interventions on health-related outcomes for patients with heart failure: a systematic review. European Journal of Cardiovascular Nursing. 2020;19(1):44-54.
PART 3 – ONLINE MINDFULNESS AND MEDITATION PROGRAMS FOR PEOPLE WITH HEART DISEASE
1. Early follow up of online program shows benefits
This study, based upon 12 week follow-up was a pragmatic, randomized, controlled single-blind trial involving 324 patients with heart disease assigned to a 12-week online mindfulness training in addition to usual care (UC) compared to UC alone.
The authors reported mindfulness training showed positive effects on the physiological parameters, exercise capacity and heart rate and concluded it might therefore be a useful adjunct to current clinical therapy in patients with heart disease. Physiological parameters included heart rate, blood pressure, respiratory rate, and NT-proBNP.
Younge JO et al. Web-Based Mindfulness Intervention in Heart Disease: A Randomized Controlled Trial. PLoS One December 7, 2015 :
2. Online Mindfulness Based Stress Reduction improves outcomes over 12 months
This 2017 paper, evaluated the effect at 12-month follow-up of 324 patients randomized in a 2:1 ratio to additional 3-month online mindfulness training or to usual care alone. Online delivery of the training was chosen for pragmatic reasons: the training was designed to be self-directed, easily accessible and engaging to a wide audience by keeping practice sessions and lessons short, usually ten to fifteen minutes per exercise.
Online mindfulness training shows favorable albeit small long-term effects on exercise capacity, systolic blood pressure, mental functioning, and depressive symptomatology in patients with heart disease and might therefore be a beneficial addition to current clinical care.
Gotink RA, Younge JO, Wery MF, et al. Online mindfulness as a promising method to improve exercise capacity in heart disease: 12-month follow-up of a randomized controlled trial. PLoS One. 2017;12(5):e0175923. Published 2017 May 9. doi:10.1371/journal.pone.0175923
3. Online programs and their benefits – a meta-analysis
The aim of this meta-analysis of 15 randomised controlled studies was to estimate the overall effects of online MBIs on mental health. Results showed that online MBIs have a small but significant beneficial impact on depression, anxiety, well-being and mindfulness. The largest effect was found for stress, with a moderate effect size.
For stress and mindfulness, analysis demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, effect sizes for stress were significantly moderated by the number of intervention sessions.
The researchers concluded their findings indicate online MBIs have potential to contribute to improving mental health outcomes.
Spijkerman MPJ et al. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clinical Psychology Review Vol 45, 2016, 102-114
PART 4 – CONCLUSION
There is a solid evidence base for mindfulness and meditation being used to help people affected by heart disease. These interventions can play a part in prevention and they can reduce the associated symptoms of heart disease such as stress, anxiety and depression, as well as assist in recovery.
Also, there is good evidence online mindfulness – based programs have positive benefits and that these benefits are increased with the support of an on-line guide or mentor. Further, the evidence concludes that increasing the number of guided sessions increases the measured benefits.