Discussion
depression, stress reduction, Sleep disorders, anxiety
ADVERSE EVENTS, CARDIAC EVENTS, SECONDARY, CORONARY HEART DISEASE
In this study, a program was developed for the first time to reduce perceived stress in HF patients, combining coping, mindfulness, and purpose in life tools. No serious adverse events were observed during the intervention.Regarding the primary outcome, there was a significant improvement in perceived stress in the intervention group (p-value<0.001), observed in previous studies using stress management training for patients with coronary heart disease.In the latter, a significant improvement was also observed in the variable mindfulness, a secondary outcome achieved in patients under intervention in the present study (p-value <0.041) not yet identified in RCTs assessing patients with HF.Regarding the other secondary outcomes, there was a significant improvement in the patients’ quality of life (p -value<0.013), which was associated with prognosis, mortality, and hospitalization.Sleep disorders are prevalent in patients with HF.The intervention also significantly improved the exercise capacity (6MWT), in agreement with previous studies that used stress management tools.The control group presented a worsening in the scores of the variables above, showing that the intervention not only brought improvements but also prevented the progression of perceived stress and deterioration of life quality, Mindfulness, sleep quality, and functional capacity with the progression of HF.A trend towards non-significant improvement was observed in anxiety and depression outcomes. Future studies that evaluate behavioral interventions to improve these variables may need to last longer to demonstrate significant effects, as proposed in a previous study.Regarding the biomarkers CRP, ESR, NT-proBNP, and cortisol, a significant result was found only concerning cortisol, demonstrating a tendency for this variable to increase over time in both groups, with a wider average variation in the control group in relation to the intervention (2.2 vs. 1.8, p-value<0.04).Cortisol secretion increases in response to stress, and this biomarker is an independent factor (p-value=0.02) in predicting cardiac events in patients with HF.A Brazilian study evaluating the impact of a 12-week meditation program on the levels of another stress-related hormone (norepinephrine) demonstrated a significant improvement in the reduction of levels of this marker in the intervention group (p-value=0.008) compared to the control, with a p-value=0.009.The difference between these results comparing the populations studied (68.4% in NYHA functional class II in the present study Future studies aimed at patients with symptomatic HF, using longer intervention protocols, will be necessary to assess the impact of stress reduction programs on the clinical outcomes and biomarkers analyzed. The study’s limitation was the loss of part of the sample of patients. This factor may have represented the absence of statistical significance in some of the outcomes analyzed. The main reason given by the patients for leaving the study was the distance from their homes to the intervention center. This result highlights the need to establish a distance limit between the patients’ homes and the intervention center.