The presence of transient myocardial ischemia is an important functional expression of coronary heart disease (CHD). Recent research has shown that mental stress can trigger ischemia in the laboratory and during daily life, and that mental stress-induced ischemia is associated with increased risk for coronary events over and above exercise-induced ischemia. The present study is designed to examine the extent to which a program of exercise or stress management training reduces ischemic activity measured in the laboratory using radionuclide ventriculography and during daily life using ambulatory monitoring. In addition, we propose to examine the bio-behavioral mechanisms by which mental stress triggers ischemia, and the mechanisms by which the inter-ventions reduce ischemic activity. Two hundred and ten patients with documented CHD and evidence of exercise-induced myocardial ischemia will serve as subjects for this study. Patients will be withdrawn from anti-ischemic medications and undergo comprehensive evaluations both in-hospital and out-of-hospital. In-hospital assessments will include provocative mental stress testing to elicit myocardial ischemia, ultrasound testing to assess endothelial function, and psychometric testing to assess underlying personality traits and behavioral dispositions. The out-of-hospital assessment will consist of 48-hour ischemia monitoring with concurrent blood pressure monitoring and behavioral diary recording. Following completion of the assessments, patients will resume their usual medications and will be randomly assigned to either Aerobic Exercise, Stress Management or Education/Routine Care. Patients will be re-evaluated after the four-month treatment program and thereafter followed for at least six months. It is hypothesized that exercise and stress management training will be associated with a reduction in ischemic activity, associated with reductions in blood pressure and systemic vascular resistance, and improved endothelial function. Data from this study will provide new scientific insights into the mechanisms of stress-induced myocardial ischemia, as well as important knowledge regarding the clinical benefits of exercise and stress management training in the treatment of CHD patients with myocardial ischemia.
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