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Original Articles: Kristina Orth-Gomér, Neil Schneiderman, Hui-Xin Wang, Christina Walldin, May Blom, and Tomas Jernberg Stress Reduction Prolongs Life in Women With Coronary Disease: The Stockholm Women’s Intervention Trial for Coronary Heart Disease (SWITCHD) Circ Cardiovasc Qual Outcomes 2009; 2: 25-32 [Abstract] [Full text] [PDF]

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Letter regarding Orth-Gomér et al.

Edward P. Havranek   (2 February 2009)

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Letter regarding Orth-Gomér et al. 2 February 2009
Edward P. Havranek, Staff Cardiologist Denver Health Medical Center Send letter to journal: Re: Letter regarding Orth-Gomér et al. ehavrane{at}dhha.org Edward P. Havranek	To the Editor: Orth-Gomér et al 1 report the results of a carefully performed randomized study of a thoughtfully formulated group-based psychosocial intervention designed to reduce stress in patients with coronary disease. They report that the intervention was associated with a striking decrease in all-cause mortality when compared with usual care. Given the well-documented association between psychosocial factors and outcome in coronary heart disease, studies such as this are a welcome addition to the literature. I have concerns, however, that the proposed mechanism for mortality reduction implied in the title of the paper is not supported by the results. First, stress questionnaire results obtained during follow-up are not reported. Given the primary importance of stress in the objective of the study, it would be helpful to readers to know the results of follow-up testing. The intervention as described may have had many psychological effects other than stress reduction that are known to affect health, including improvement in self-efficacy and reduction in depression. In the absence of follow-up testing the psychological effects of the intervention remain speculative. Second, it seems equally plausible that a simple reduction in social isolation rather than reduced stress was responsible for the demonstrated benefit. Studies ranging from animal experiments 2 to human observational studies 3 have documented a role for isolation in the progression of atherosclerotic disease. If the intervention group had superior outcomes compared to those of a control group whose subjects participated in a sham exercise such as a book club that met for 40-50 hours over 20 sessions, it might be more possible to ascribe improvements to changes in stress. Finally, studies that exclude potential subjects by gender when there is no biological imperative to do so create ethical challenges for investigators. No such biological imperative exists for the current study. Coronary heart disease affects men and women in equal numbers. When gender stereotypes are put aside, there is no a priori reason to believe psychosocial stress and efforts to reduce it affect women exclusively. Might the authors be willing to more fully explain their decision to exclude men from this study? 1. Orth-Gomér K, Schneiderman N, Wang HX, Walldin C, Blom M, Jernberg T. Stress reduction prolongs life in women with coronary disease. Circ Cardiovasc Qual Outcomes, published online Jan 6, 2009. 2. Shively CA, Clarkson TB, Kaplan JR. Socail deprivation and coronary artery atherosclerosis in female cynomolgus monkeys. Atherosclerosis 1989; 77: 69-76. 3. Welin L, Tibblin G, Svärdsudd K, Tibblin B, Ander-Peciva S, Larsson B, Wilhelmsen L. Prospective study of social influences on mortality. The study of men born in 1913 and 1923. Lancet. 1985 Apr 20;1(8434):915-8. Sincerely, Edward P. Havranek, MD Staff Cardiologist, Denver Health Medical Center Professor, University of Colorado Denver School of Medicine