Stress Reduction in the Prevention of Left Ventricular Hypertrophy: A Randomized Controlled Trial of Transcendental Meditation and Health Education in Hypertensive African Americans

The promising role of Transcendental Meditation in the prevention and treatment of cardiometabolic diseases: A systematic review

Psychological distress has a demonstrable impact on cardiovascular diseases (CVD) and risk factors. Transcendental Meditation (TM) has been shown to reduce stress and improve health and well-being. The current review aimed to synthesize the evidence on the effects of TM on cardiometabolic outcomes and identify gaps for future research. We searched PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science databases for relevant literature. Forty-five papers that reported studies of TM on cardiometabolic risk factors and diseases were included. Evidence shows that TM is effective in reducing blood pressure (BP). We found some evidence that TM can improve insulin resistance and may play a role in improving dyslipidemia, exercise tolerance, and myocardial blood flow, and in reducing carotid intima-media thickness and left ventricular mass. Studies show that long-term TM practice can reduce the risk of myocardial infarction, stroke, and CVD mortality. This review identified that certain studies have high participant drop-out rates, and fewer studies targeted comprehensive cardiometabolic outcomes beyond BP with longer follow-up periods. We found that most studies were conducted in specific populations, which may limit generalizability. In conclusion, TM has the potential to improve cardiometabolic health; however, research gaps highlight the need for larger phase III multicenter clinical trials with long-term follow-ups.

Comprehensive Review of Chronic Stress Pathways and the Efficacy of Behavioral Stress Reduction Programs (BSRPs) in Managing Diseases

The connection between chronic psychological stress and the onset of various diseases, including diabetes, HIV, cancer, and cardiovascular conditions, is well documented. This review synthesizes current research on the neurological, immune, hormonal, and genetic pathways through which stress influences disease progression, affecting multiple body systems: nervous, immune, cardiovascular, respiratory, reproductive, musculoskeletal, and integumentary. Central to this review is an evaluation of 16 Behavioral Stress Reduction Programs (BSRPs) across over 200 studies, assessing their effectiveness in mitigating stress-related health outcomes. While our findings suggest that BSRPs have the potential to enhance the effectiveness of medical therapies and reverse disease progression, the variability in study designs, sample sizes, and methodologies raises questions about the generalizability and robustness of these results. Future research should focus on long-term, large-scale studies with rigorous methodologies to validate the effectiveness of BSRPs.

Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation

BACKGROUND

Depression and anxiety occur frequently (with reported prevalence rates of around 40%) in individuals with coronary heart disease (CHD), heart failure (HF) or atrial fibrillation (AF) and are associated with a poor prognosis, such as decreased health-related quality of life (HRQoL), and increased morbidity and mortality. Psychological interventions are developed and delivered by psychologists or specifically trained healthcare workers and commonly include cognitive behavioural therapies and mindfulness-based stress reduction. They have been shown to reduce depression and anxiety in the general population, though the exact mechanism of action is not well understood. Further, their effects on psychological and clinical outcomes in patients with CHD, HF or AF are unclear.

OBJECTIVES

To assess the effects of psychological interventions (alone, or with cardiac rehabilitation or pharmacotherapy, or both) in adults who have a diagnosis of CHD, HF or AF, compared to no psychological intervention, on psychological and clinical outcomes.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2009 to July 2022. We also searched three clinical trials registers in September 2020, and checked the reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing psychological interventions with no psychological intervention for a minimum of six months follow-up in adults aged over 18 years with a clinical diagnosis of CHD, HF or AF, with or without depression or anxiety. Studies had to report on either depression or anxiety or both.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were depression and anxiety, and our secondary outcomes of interest were HRQoL mental and physical components, all-cause mortality and major adverse cardiovascular events (MACE). We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

Twenty-one studies (2591 participants) met our inclusion criteria. Sixteen studies included people with CHD, five with HF and none with AF. Study sample sizes ranged from 29 to 430. Twenty and 17 studies reported the primary outcomes of depression and anxiety, respectively. Despite the high heterogeneity and variation, we decided to pool the studies using a random-effects model, recognising that the model does not eliminate heterogeneity and findings should be interpreted cautiously. We found that psychological interventions probably have a moderate effect on reducing depression (standardised mean difference (SMD) -0.36, 95% confidence interval (CI) -0.65 to -0.06; 20 studies, 2531 participants; moderate-certainty evidence) and anxiety (SMD -0.57, 95% CI -0.96 to -0.18; 17 studies, 2235 participants; moderate-certainty evidence), compared to no psychological intervention. Psychological interventions may have little to no effect on HRQoL physical component summary scores (PCS) (SMD 0.48, 95% CI -0.02 to 0.98; 12 studies, 1454 participants; low-certainty evidence), but may have a moderate effect on improving HRQoL mental component summary scores (MCS) (SMD 0.63, 95% CI 0.01 to 1.26; 12 studies, 1454 participants; low-certainty evidence), compared to no psychological intervention. Psychological interventions probably have little to no effect on all-cause mortality (risk ratio (RR) 0.81, 95% CI 0.39 to 1.69; 3 studies, 615 participants; moderate-certainty evidence) and may have little to no effect on MACE (RR 1.22, 95% CI 0.77 to 1.92; 4 studies, 450 participants; low-certainty evidence), compared to no psychological intervention.

AUTHORS' CONCLUSIONS

Current evidence suggests that psychological interventions for depression and anxiety probably result in a moderate reduction in depression and anxiety and may result in a moderate improvement in HRQoL MCS, compared to no intervention. However, they may have little to no effect on HRQoL PCS and MACE, and probably do not reduce mortality (all-cause) in adults who have a diagnosis of CHD or HF, compared with no psychological intervention. There was moderate to substantial heterogeneity identified across studies. Thus, evidence of treatment effects on these outcomes warrants careful interpretation. As there were no studies of psychological interventions for patients with AF included in our review, this is a gap that needs to be addressed in future studies, particularly in view of the rapid growth of research on management of AF. Studies investigating cost-effectiveness, return to work and cardiovascular morbidity (revascularisation) are also needed to better understand the benefits of psychological interventions in populations with heart disease.

Effect of Meditation, Mindfulness-Based Stress Reduction, and Relaxation Techniques as Mind-Body Medicine Practices to Reduce Blood Pressure in Cardiac Patients: A Systematic Review and Meta-Analysis

Elevated blood pressure is one of the major risk factors for cardiovascular diseases. Available evidence on mind-body medicine (MBM) techniques on blood pressure is inconclusive and provides conflicting results. The objective of the current systematic review and meta-analysis is to evaluate the effect of MBM techniques on blood pressure in patients with cardiovascular disease. Randomized control trials (RCTs) done between the years 2000 and 2020 on cardiovascular disease, using MBM techniques such as meditation, mindfulness-based stress reduction and relaxation techniques were searched through electronic databases such as PubMed, Cumulative Index to Nursing & Allied Health (CINAHL), EMBASE and Cochrane Library. Three authors independently performed article selection, data extraction and validation. Meta-analysis was performed using a random effect model and standardized mean difference (SMD) with 95% confidence interval (CI) estimated for the effect size. Fifteen RCTs with 927 patients were included in the meta-analysis. Heterogeneity among the studies was very high for all analyses (I2>94%). For studies comparing systolic blood pressure, MBM interventions show a significant (p=0.01) effect when compared to conventional treatment, an overall estimated effect size of SMD - 0.78 (95% CI: -1.36, -0.20). For studies comparing the diastolic blood pressure, MBM intervention did not show any significant effect when compared to the conventional treatment, an overall effect size of SMD -0.26 (95% CI: -0.91, 0.39). The findings of the meta-analysis suggest that MBM interventions may improve systolic blood pressure alone in patients with cardiac diseases. With high heterogeneity and low quality of the included studies, more robust evidence is required before suggesting MBM as an effective treatment modality for reducing blood pressure in cardiovascular diseases.

Meditation for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Interventions incorporating meditation to address stress, anxiety, and depression, and improve self-management, are becoming popular for many health conditions. Stress is a risk factor for cardiovascular disease (CVD) and clusters with other modifiable behavioural risk factors, such as smoking. Meditation may therefore be a useful CVD prevention strategy.

OBJECTIVES

To determine the effectiveness of meditation, primarily mindfulness-based interventions (MBIs) and transcendental meditation (TM), for the primary and secondary prevention of CVD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 14 November 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of 12 weeks or more in adults at high risk of CVD and those with established CVD. We explored four comparisons: MBIs versus active comparators (alternative interventions); MBIs versus non-active comparators (no intervention, wait list, usual care); TM versus active comparators; TM versus non-active comparators.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were CVD clinical events (e.g. cardiovascular mortality), blood pressure, measures of psychological distress and well-being, and adverse events. Secondary outcomes included other CVD risk factors (e.g. blood lipid levels), quality of life, and coping abilities. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included 81 RCTs (6971 participants), with most studies at unclear risk of bias. MBIs versus active comparators (29 RCTs, 2883 participants) Systolic (SBP) and diastolic (DBP) blood pressure were reported in six trials (388 participants) where heterogeneity was considerable (SBP: MD -6.08 mmHg, 95% CI -12.79 to 0.63, I2 = 88%; DBP: MD -5.18 mmHg, 95% CI -10.65 to 0.29, I2 = 91%; both outcomes based on low-certainty evidence). There was little or no effect of MBIs on anxiety (SMD -0.06 units, 95% CI -0.25 to 0.13; I2 = 0%; 9 trials, 438 participants; moderate-certainty evidence), or depression (SMD 0.08 units, 95% CI -0.08 to 0.24; I2 = 0%; 11 trials, 595 participants; moderate-certainty evidence). Perceived stress was reduced with MBIs (SMD -0.24 units, 95% CI -0.45 to -0.03; I2 = 0%; P = 0.03; 6 trials, 357 participants; moderate-certainty evidence). There was little to no effect on well-being (SMD -0.18 units, 95% CI -0.67 to 0.32; 1 trial, 63 participants; low-certainty evidence). There was little to no effect on smoking cessation (RR 1.45, 95% CI 0.78 to 2.68; I2 = 79%; 6 trials, 1087 participants; low-certainty evidence). None of the trials reported CVD clinical events or adverse events. MBIs versus non-active comparators (38 RCTs, 2905 participants) Clinical events were reported in one trial (110 participants), providing very low-certainty evidence (RR 0.94, 95% CI 0.37 to 2.42). SBP and DBP were reduced in nine trials (379 participants) but heterogeneity was substantial (SBP: MD -6.62 mmHg, 95% CI -13.15 to -0.1, I2 = 87%; DBP: MD -3.35 mmHg, 95% CI -5.86 to -0.85, I2 = 61%; both outcomes based on low-certainty evidence). There was low-certainty evidence of reductions in anxiety (SMD -0.78 units, 95% CI -1.09 to -0.41; I2 = 61%; 9 trials, 533 participants; low-certainty evidence), depression (SMD -0.66 units, 95% CI -0.91 to -0.41; I2 = 67%; 15 trials, 912 participants; low-certainty evidence) and perceived stress (SMD -0.59 units, 95% CI -0.89 to -0.29; I2 = 70%; 11 trials, 708 participants; low-certainty evidence) but heterogeneity was substantial. Well-being increased (SMD 0.5 units, 95% CI 0.09 to 0.91; I2 = 47%; 2 trials, 198 participants; moderate-certainty evidence). There was little to no effect on smoking cessation (RR 1.36, 95% CI 0.86 to 2.13; I2 = 0%; 2 trials, 453 participants; low-certainty evidence). One small study (18 participants) reported two adverse events in the MBI group, which were not regarded as serious by the study investigators (RR 5.0, 95% CI 0.27 to 91.52; low-certainty evidence). No subgroup effects were seen for SBP, DBP, anxiety, depression, or perceived stress by primary and secondary prevention. TM versus active comparators (8 RCTs, 830 participants) Clinical events were reported in one trial (201 participants) based on low-certainty evidence (RR 0.91, 95% CI 0.56 to 1.49). SBP was reduced (MD -2.33 mmHg, 95% CI -3.99 to -0.68; I2 = 2%; 8 trials, 774 participants; moderate-certainty evidence), with an uncertain effect on DBP (MD -1.15 mmHg, 95% CI -2.85 to 0.55; I2 = 53%; low-certainty evidence). There was little or no effect on anxiety (SMD 0.06 units, 95% CI -0.22 to 0.33; I2 = 0%; 3 trials, 200 participants; low-certainty evidence), depression (SMD -0.12 units, 95% CI -0.31 to 0.07; I2 = 0%; 5 trials, 421 participants; moderate-certainty evidence), or perceived stress (SMD 0.04 units, 95% CI -0.49 to 0.57; I2 = 70%; 3 trials, 194 participants; very low-certainty evidence). None of the trials reported adverse events or smoking rates. No subgroup effects were seen for SBP or DBP by primary and secondary prevention. TM versus non-active comparators (2 RCTs, 186 participants) Two trials (139 participants) reported blood pressure, where reductions were seen in SBP (MD -6.34 mmHg, 95% CI -9.86 to -2.81; I2 = 0%; low-certainty evidence) and DBP (MD -5.13 mmHg, 95% CI -9.07 to -1.19; I2 = 18%; very low-certainty evidence). One trial (112 participants) reported anxiety and depression and found reductions in both (anxiety SMD -0.71 units, 95% CI -1.09 to -0.32; depression SMD -0.48 units, 95% CI -0.86 to -0.11; low-certainty evidence). None of the trials reported CVD clinical events, adverse events, or smoking rates.

AUTHORS' CONCLUSIONS

Despite the large number of studies included in the review, heterogeneity was substantial for many of the outcomes, which reduced the certainty of our findings. We attempted to address this by presenting four main comparisons of MBIs or TM versus active or inactive comparators, and by subgroup analyses according to primary or secondary prevention, where there were sufficient studies. The majority of studies were small and there was unclear risk of bias for most domains. Overall, we found very little information on the effects of meditation on CVD clinical endpoints, and limited information on blood pressure and psychological outcomes, for people at risk of or with established CVD. This is a very active area of research as shown by the large number of ongoing studies, with some having been completed at the time of writing this review. The status of all ongoing studies will be formally assessed and incorporated in further updates.

Transcendental Meditation practitioners show reduced expression of the Conserved Transcriptional Response to Adversity

BACKGROUND AND OBJECTIVES

A recent exploratory study of transcriptional effects of long-term practice of Transcendental Meditation (TM) technologies found evidence for altered expression of genes associated with health and disease. In the present secondary analysis of those data, we test the more specific hypothesis that this sample of long-term practitioners shows a significant reduction in markers of the "Conserved Transcriptional Response to Adversity" (CTRA), an RNA profile characterized by up-regulated inflammation and down-regulated Type I interferon (IFN) activity.

MATERIALS AND METHODS

Data come from a previously published study providing genome-wide transcriptional profiles of peripheral blood mononuclear cells (PBMC) from healthy, 38-year practitioners of TM technologies and matched controls (n = 12, mean age 65). The current analysis specifically tests for differential expression of a previously established CTRA indicator gene score, with cross-validation by promoter-based bioinformatic analysis of CTRA-typical differences in transcription factor activity and monocyte subset cellular origins.

RESULTS

Compared to controls, the TM group showed lower expression of a pre-specified set of CTRA indicator genes. These effects were accompanied by genome-wide indications of down-regulated pro-inflammatory transcription factor activity (NF-κB, AP-1), up-regulated activity of Interferon Response Factors (IRF) and reduced transcriptional activity of classical monocytes. Conclusions: A sample of long-term practitioners of TM showed reduced CTRA gene expression in PBMC compared to matched controls, supporting the likely value of further research to evaluate causality and specificity of this potential mechanism of health benefits in meditators.

Associations of Cumulative Perceived Stress with Cardiovascular Risk Factors and Outcomes: Findings from The Dallas Heart Study

Background

Data remain sparse regarding the impact of chronic stress on cardiovascular disease (CVD) risk factors and outcomes. Prior work has been limited by incomplete assessments of perceived stress and focus on single stress domains. We evaluated the association between a composite measure of perceived stress and CVD risk factors and outcomes.

Methods

Participants from the Dallas Heart Study phase 2 (2007-2009) without prevalent CVD who completed questionnaire assessments of perceived stress were included (n=2685). Individual perceived stress subcomponents (generalized stress, psychosocial, financial, and neighborhood stress) were standardized and integrated into a single cumulative stress score (CSS) with equal weighting for each component. Associations between CSS and demographics, psychosocial variables and cardiac risk factors were assessed in univariable and multivariable analyses. Cox proportional hazards models were used to determine associations of the CSS with atherosclerotic CVD (ASCVD) and Global CVD (ASCVD, heart failure, and atrial fibrillation) after adjustment for demographics and traditional risk factors.

Results

Median age of the study population was 48 years, 55% were female, 49% Black and 15% Hispanic/Latinx. CSS was higher among participants who were younger, female, Black or Hispanic, and those with lower income and educational attainment (p<.0001 for each). Higher CSS was associated with self-report of racial/ethnic discrimination, lack of health insurance and last medical contact > one year previously (p<.0001 for each). In multivariable regression models adjusting for age, gender, race/ethnicity, income and education, higher CSS associated with hypertension, smoking, and higher body mass index, waist circumference Hemoglobin A1C, hs-CRP and sedentary time (p< 0.01 for each). Over a median follow-up of 12.4 years, higher CSS associated with ASCVD (adjusted HR 1.22 per SD, 95% CI 1.01-1.47) and Global CVD (HR 1.20, 95% CI 1.03-1.40). No interactions were seen between CSS, demographic factors, and outcomes.

Conclusion

Composite multidimensional assessments of perceived stress may help to identify individuals at risk for CVD who may be targeted for stress mitigation or enhanced prevention strategies. These approaches may be best focused on vulnerable populations, given the higher burden of stress in women, Black and Hispanic individuals, and those with lower income and education.

WHAT IS NEW?

A novel measure of cumulative stress was created that integrates generalized, psychosocial, financial, and neighborhood perceived stress.Cumulative stress was higher among women, Black and Hispanic participants, younger individuals and persons with lower income and educational attainment and was associated with adverse health behaviors and increased burden of cardiovascular disease (CVD) risk factors.In a diverse cohort, higher cumulative stress associated with incident CVD after adjustment for demographics and traditional risk factors. No interactions were seen based on demographic factors.

CLINICAL IMPLICATIONS

Although associations of chronic stress with CVD were similar across demographic subgroups, the higher burden of stress among younger individuals, women, Black and Hispanic participants, and those with lower SES suggests that CVD risk associated with higher stress affects marginalized groups disproportionately.Cumulative Stress is associated with modifiable risk factors and health behaviors. Future studies should explore targeting behavioral modification and risk factor reduction programs, as well as stress reduction strategies, to individuals with high cumulative stress.Additional research is needed to uncover mechanisms that underly the association between chronic stress and cardiovascular disease.

Stress interventions and hypertension in Black women

Hypertension is a risk factor for cardiovascular disease. Black women have high rates of hypertension compared to women of other racial or ethnic groups and are disproportionately affected by psychosocial stressors such as racial discrimination, gender discrimination, and caregiving stress. Evidence suggests that stress is associated with incident hypertension and hypertension risk. Stress management is associated with improvements improved blood pressure outcomes. The purpose of this review is to synthesize evidence on effects of stress management interventions on blood pressure in Black women. A comprehensive search of scientific databases was conducted. Inclusion criteria included studies that were: (1) primary research that tested an intervention; (2) in the English language; (3) included African-American women; (4) incorporated stress in the intervention; (5) included blood pressure as an outcome; and (6) were US based. Eighteen studies met inclusion criteria. Ten (56%) studies tested meditation-based interventions, two (11%) tested coping and affirmation interventions, and six (33%) tested lifestyle modification interventions that included stress management content. Thirteen of the studies were randomized controlled trials. Reductions in blood pressure were observed in all of the meditation-based interventions, although the magnitude and statistical significance varied. Comprehensive lifestyle interventions were also efficacious for reducing blood pressure, although the relative contribution of stress management versus behavior modification could not be evaluated. Coping and affirmation interventions did not affect blood pressure. Most of the reviewed studies included small numbers of Black women and did not stratify results by race and gender, so effects remain unclear. This review highlights the urgent need for studies specifically focusing on Black women. Given the extensive disparities in cardiovascular disease morbidity and mortality, whether stress management can lower blood pressure and improve primary and secondary cardiovascular disease prevention among Black women is an important question for future research.

Social Determinants of Cardiovascular Health in African American Children With CKD: An Analysis of the Chronic Kidney Disease in Children (CKiD) Study

RATIONALE & OBJECTIVE

To identify differences in socioeconomic factors (SES) and subclinical cardiovascular disease (CVD) markers by race among Chronic Kidney Disease in Children (CKiD) participants and determine whether differences in CVD markers persist after adjusting for SES.

STUDY DESIGN

Analysis of 3,103 visits with repeated measures from 628 children (497 White participants; 131 African American participants) enrolled in the CKiD study.

SETTING & PARTICIPANTS

Children with mild-moderate CKD with at least 1 cardiovascular (CV) parameter (ambulatory blood pressure, left ventricular mass index [LVMI], or lipid profile) measured.

EXPOSURE

African American race.

OUTCOMES

Ambulatory hypertension, LVMI, triglycerides, high-density lipoprotein cholesterol.

ANALYTICAL APPROACH

Due to increased CV risks of glomerular disease, the analysis was stratified by CKD cause. Inverse probability weighting was used to adjust for SES (health insurance, household income, maternal education, food insecurity, abnormal birth history). Linear and logistic regression were used to evaluate association of race with CV markers.

RESULTS

African American children were disproportionately affected by adverse SES. African Americans with nonglomerular CKD had more instances of ambulatory hypertension and higher LVMI but more favorable lipid profiles. After adjustment for SES, age, and sex, the magnitude of differences in these CV markers was attenuated but remained statistically significant. Only LVMI differed by race in the glomerular CKD group, despite adjustment for SES.

LIMITATIONS

Study design limits causal inference.

CONCLUSION

African American children with CKD are disproportionately affected by socioeconomic disadvantages compared with White children. The degree to which CV markers differ by race is influenced by disease etiology. African Americans with nonglomerular CKD have increased LVMI, more ambulatory hypertension, and favorable lipid profile, but attenuation in magnitude after adjustment for SES was observed. African Americans with glomerular CKD had increased LVMI, which persisted after SES adjustment. As many social determinants of health were not captured, future research should examine effects of systemic racism on CV health in this population.