Leveraging Mindfulness for Cardiovascular Health
Thank you to Emily J. Jones, PhD, RNC-OB, and Nicole Crossley, MS, RN, RD for this article on mindfulness for cardiovascular health.
Stress is ubiquitous in society and certainly in the midst of a global pandemic. Stress can range from acute and time-limited to chronic and enduring. Increasingly, over the past several decades, research has shown that stress, through biochemical and psychoneuroimmunological pathways, gets “under the skin,” and can alter epigenetic mechanisms, producing poor health.1
Psychological stress, depression, and anxiety are independent risk factors for cardiovascular morbidity and mortality2, and individuals who have experienced distressing life events such as myocardial infarction (MI) or stroke face unique stressors after these events. For these reasons, stress management strategies have long been incorporated into cardiac rehabilitation guidelines.3 Clinical interventions to empower individuals to build skills and coping strategies to reduce and manage stress represents an important secondary prevention strategy for individuals living with CVD, and, potentially, also primary prevention for individuals with CVD risk factors.4
Mindfulness is a bit of a buzz word these days, and, simultaneously, evidence is mounting that mindfulness-based interventions (MBIs) may promote cardiovascular health.4, 5 As a result, it is important for cardiovascular nurses to have a general understanding of mindfulness so that they might make appropriate referrals and recommendations to enhance patients’ coping strategies and overall quality of life.
Mindfulness is commonly defined as the capacity to intentionally be in the present moment without judgement.6 Mindfulness training commonly focuses on developing skills to foster awareness of thoughts, feelings, and emotions. The evidence base of MBIs such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) reports clinically significant reductions in stress and enhanced self-efficacy for and engagement in health behaviors associated with health and well-being.7-10 Mindfulness enhances self-regulation through effects on attention, emotion regulation, and self-awareness.11, 12 Specifically, enhanced attention improves focus on goal-related behaviors and health needs and reduces impulsive behaviors that undermine goals; improved emotional regulation reduces stress response and enhances self-efficacy to manage cravings for unhealthy foods, cigarettes, etc. Enhanced self-awareness improves self-monitoring ability and identification of sources of stress and may reduce stress-related emotional eating.13
Mindfulness Improves Psychological Outcomes and Shows Promise in Improving Physiological Outcomes
Two recent systematic reviews/meta-analyses capture current knowledge and recommend next steps for advancing knowledge pertaining to the impact of MBIs in persons living with CVD or CVD risk. Together, these two meta-analyses represent 20 randomized controlled trials (N = 1,800) from North America, Europe, and Asia with individual study sample sizes ranging from 19 to 324.4, 5 Articles describing these studies were published between 1995 and 2017. Collectively, these studies included participants with diagnosed CVD including hypertension, type 1 and type 2 diabetes, stroke, heart disease (percutaneous coronary intervention), angina/CHF, valve disorders, coronary heart disease, and heart failure.
Overall, these two meta-analyses concluded that MBIs consistently demonstrated favorable effects on psychological outcomes (e.g., depression, anxiety, distress, perceived stress) and inconsistent yet favorable effects on physiological outcomes (e.g., systolic hypertension, albuminuria, and stress hormones).4, 5 Major limitations of the current evidence relate to the relatively short follow-up period in the randomized controlled studies as well as a general bias introduced through participants knowing that they were part of the intervention group by nature of the MBIs. Future research should incorporate longer periods of follow-up to assess improvements in cardiovascular-related physiological outcomes as well as focus on meaningful ways to adapt MBIs to promote acceptability and effectiveness in diverse populations.
Takeaways for Nurses on Mindfulness for Cardiovascular Health
The provision of holistic care is a traditional hallmark of nursing care and is based on an understanding of physical, psychological, emotional, and spiritual dimensions impacting one’s health.14 Cardiovascular nurses, particularly those in cardiac rehabilitation and primary care settings, are well-positioned to share their knowledge about the benefits of mindfulness-based care strategies and refer individuals to mindfulness-based programs to promote self-care and improve health. Nurse scientists and clinicians are also positioned to lead and/or participate in team science to conduct research studies that will advance the science of mindfulness and, ultimately, promote CVD prevention in cardiovascular care settings and in communities.
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- Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, Blackett KN, Sitthi-amorn C, Sato H, Yusuf S and investigators I. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:953-62.
- Leon AS, Franklin BA, Costa F, Balady GJ, Berra KA, Stewart KJ, Thompson PD, Williams MA, Lauer MS, American Heart A, Council on Clinical C, Council on Nutrition PA, Metabolism, American association of C and Pulmonary R. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111:369-76.
- Abbott RA, Whear R, Rodgers LR, Bethel A, Thompson Coon J, Kuyken W, Stein K and Dickens C. Effectiveness of mindfulness-based stress reduction and mindfulness based cognitive therapy in vascular disease: A systematic review and meta-analysis of randomised controlled trials. J Psychosom Res. 2014;76:341-51.
- Scott-Sheldon LAJ, Gathright EC, Donahue ML, Balletto B, Feulner MM, DeCosta J, Cruess DG, Wing RR, Carey MP and Salmoirago-Blotcher E. Mindfulness-Based Interventions for Adults with Cardiovascular Disease: A Systematic Review and Meta-Analysis. Ann Behav Med. 2020;54:67-73.
- Kabat-Zinn J. Full catastrophe living : using the wisdom of your body and mind to face stress, pain, and illness. Revised and updated edition. ed. New York: Bantam Books trade paperback; 2013.
- Grossman P, Niemann L, Schmidt S and Walach H. Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research. 2004;57:35-43.
- Khoury B, Sharma M, Rush SE and Fournier C. Mindfulness-based stress reduction for healthy individuals: A meta-analysis. J Psychosom Res. 2015;78:519-28.
- Loucks EB, Schuman-Olivier Z, Britton WB, Fresco DM, Desbordes G, Brewer JA and Fulwiler C. Mindfulness and Cardiovascular Disease Risk: State of the Evidence, Plausible Mechanisms, and Theoretical Framework. Curr Cardiol Rep. 2015;17:112.
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- H√∂lzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR and Ott U. How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspectives on Psychological Science. 2011;6:537-559.
- Tang YY, Holzel BK and Posner MI. The neuroscience of mindfulness meditation. Nat Rev Neurosci. 2015;16:213-25.
- Levoy E, Lazaridou A, Brewer J and Fulwiler C. An exploratory study of Mindfulness Based Stress Reduction for emotional eating. Appetite. 2017;109:124-130.
- Jasemi M, Valizadeh L, Zamanzadeh V and Keogh B. A Concept Analysis of Holistic Care by Hybrid Model. Indian J Palliat Care. 2017;23:71-80.