Mental stress: A novel cardiovascular risk factor

Table 5 Some recent studies on various interventions against stress

Ref.	Setting	Main results
Hewett et al[369], 2017	Eligible adults were randomized to an experimental group or a CTRL group. Experimental group participants were instructed to attend three to five supervised Bikram yoga classes per week for 16 weeks at local studios	No significant change in the high-frequency component of HRV (P = 0.912) or in any secondary outcome between groups. Regression analyses revealed that higher attendance in the experimental group was associated with significant reductions in DBP (P = 0.039), body fat percentage (P = 0.001), fat mass (P = 0.003), and BMI (P = 0.05)
Cheung et al[359], 2018	Twenty TC practitioners and 20 non-practitioners volunteered joined the study. After baseline measurements were taken, the TC group performed TC for 10 minutes while their cognitive states and cardiovascular responses were concurrently monitored. Stress levels were measured using PSS	Perceived stress level decreased from baseline to post-test in exclusively the TC group (P = 0.005). HR increased during TC (P = 0.001) and decreased thereafter (P = 0.001)
von Känel et al[340], 2018	Within 48 hours of hospital admission, patients with high distress during ACS were randomized to a single-session intervention of either trauma-focused counselling or an active control intervention targeting the general role of stress in patients with heart disease. Blind interviewer-rated PTSD (primary outcome) and additional health outcomes were assessed at 3 months of follow-up	No difference in interviewer-rated PTSD between trauma-focused counselling (mean = 11.33; 95%CI: 923-13.43) and stress counselling (9.88; 7.36-12.40; P = 0.40), global psychological distress (5.15, 4.07-6.23, vs 3.80, 2.60-5.00; P = 0.11), and the risk for CV-related hospitalization/all-cause mortality (OR = 0.67; 95%CI: 0.37-1.23). Self-rated PTSD indicated less beneficial effects with trauma-focused (6.54; 4.95-8.14) vs stress counselling (3.74; 2.39-5.08; P = 0.017)
Jalali et al[346], 2019	Overall, 60 patients were selected, clinically interviewed by a cardiologist and randomized to two groups; experimental and control, to investigate the effectiveness of a mindfulness-based stress reduction; then they completed General Self-Efficacy Scale and 36-item Short Form Survey	The mean pre-test scores of self-efficacy and QoL of patients were not significantly different between the experimental and control groups (P = 0.05). However, the mean scores of the two variables were found to be significantly different between the experimental group and the control group on the post-test and follow-up (P = 0.01)
Bourassa et al[338], 2021	Secondary analysis of a large intervention study of active-duty soldiers with PTSD randomized to an exposure therapy-either or a waitlist control condition	Changes in resting HR and HR reactivity were not significantly correlated with either self-reported or clinician-rated PTSD symptom change
Chandler et al[343], 2020	Twelve-month RCT of a breathing meditation smart phone app (TT) involving pre-hypertensive adults. The TT app captures continuous real-time HR from a user’s fingertip placed over a video camera lens during sessions. Users receive both immediate feedback graphs, showing their HR changes, and motivational and social reinforcement SMS text messages. Each group received a twice-daily dosage schedule of TT or walking	Mixed modelling results revealed a significant group x time effect for SBP (P < 0.01). The TT group showed greater SBP reductions at months 3 (-8.0 vs -1.9), 6 (-10.0 vs -0.7), and 12 (-11.6 mmHg vs-0.4 mmHg); all P values < 0.04
Chelidoni et al[345], 2020	The study aimed to assess the effectiveness of a brief app-based breathing intervention (BioBase) in enhancing physiological recovery among employees who were induced to cognitive and emotional stress. Interbeat (RR) intervals were recorded continuously for 5 minutes at baseline and during cognitive and emotional stress induction. The session ended with a 5-minute recovery period during which participants were randomly allocated into 3 conditions: Commercially available app-based breathing BioBase, mindfulness body scan, or CTRL	Subjective tension significantly increased following stress induction. HRV significantly decreased following the stress period. In the recovery phase, the root mean square of successive RR interval differences (P = 0.002), the percentage of successive RR intervals that differed by > 50 milliseconds (P = 0.008), and HF (P = 0.01) were significantly higher in the BioBase breathing condition than in the mindfulness body scan and the CTRL groups
Fonkoue et al[344], 2020	Veterans with PTSD were studied and randomized to either 8 weeks of daily DGB or of sham device (Sham). BP, HR, and MSNA were measured at rest and during mental math. Arterial BRS was assessed using the modified Oxford technique	Resting MSNA, BP, and HR remained comparable before and after 8 weeks in both groups. Likewise, the change in sympathetic and cardiovagal BRS was not different. DGB significantly decreased MSNA reactivity to mental math when expressed as burst frequency (P = 0.012) or burst incidence (P = 0.008) compared with Sham. Pulse pressure reactivity was also comparable
Hruska et al[380], 2020	Fifty-four workers eligible for paid vacation time were recruited; stress ratings obtained via weekly surveys and ambulatory HR readings obtained via a wrist-worn consumer device were collected before and after the vacation	A statistically significant interaction was observed between weekly stress and the period leading up to the vacation on ambulatory HR (P = 0.01). The relationship between weekly stress and HR was stronger when the vacation was further away in the future and imparted less of an effect as the vacation approached
Kirk et al[347], 2020	Fully randomized 10-day longitudinal trial of mindfulness practice, explicitly controlling for practice effects with an active-control group (music listening) and CTRL group. To assess chronic CV effects, authors asked participants to complete 2-day HRV pre- and post-intervention measurement sessions	Increased HRV during the daily practice sessions in both the mindfulness and active-control group indicating that both interventions were effective in decreasing acute physiological stress. For the chronic phase increased HRV in both the day- and nighttime indicating increased sleep quality, specifically in the mindfulness group
Lachowska et al[354], 2020	BP and HR were measured in 21 patients with HFrEF (23.9% ± 5.9%) at rest, during laboratory stressors handgrip, mental and CPT, before and after acute SLOWB, and 12 weeks after SLOWB home training (30 minutes daily). HRQoL (MacNew questionaries) was assessed before and 12 weeks after SLOWB home training	Both acute and long-term SLOWB significantly reduced BP and HR responses to mental stress (P < 0.05), but not to isometric and cold pressor tests. SLOWB improved scores of all domains of QoL (P < 0.05) at 12 weeks follow-up
Nourisaeed et al[398], 2021	Overall, patients after AMI were randomly divided into 3 groups of 15 individuals (2 interventions including cognitive-behavioural therapy and dialectical behavioural therapy, and 1 CTRL group). In the IG, participants underwent 8 weekly 90-minute sessions. Data were collected including the Ways of Coping Questionnaire, and the PSS-14	Significant main effects of group (P = 0.005) and time (P < 0.001), and a significant group-by-time interaction (P < 0.001) on PSS. For problem-focused coping scores, findings indicated significant main effects of group (P = 0.002) and time (P < 0.001), and a significant group-by-time interaction (P < 0.001). For emotion-focused coping scores, significant main effects of group (P < 0.001) and time (P < 0.001), and a significant group-by-time interaction (P < 0.001) were observed
Kunikullaya Ubrangala et al[374], 2022	Single session of auditory stimulation with three different ‘Modes’ of Indian music (Mode/Raga Miyan ki Todi, Malkauns, and Puriya) musical stimuli on anxiety, biomarkers of stress, and CV parameters were measured among 140 healthy young adults. The outcome measurements of the State-Trait Anxiety Inventory, BP, and HRV were collected	State anxiety was reduced significantly with raga Puriya (P = 0.018), followed by raga Malkauns and raga Miyan Ki Todi. All the groups showed a significant reduction in sAA. Raga Miyan ki Todi and Puriya caused an arousal effect (as evidenced by HRV) during the intervention and significant relaxation after the intervention (both P < 0.005). Raga Malkauns and the CTRL group had a sustained rise in parasympathetic activity over 30 minutes
Balakrishnan et al[371], 2023	Cross-sectional study, conducted at a regional university and community wellness centre, included convenience sampling of Hatha yoga practitioners and healthy controls	Compared with CTRL group, the yoga group had significantly greater mean HF power (P = 0.04) and mean HF normalized units (P = 0.02) and a significantly lower LF/HF ratio (1.1 ± 0.5 vs 2.2 ± 1.1; P = 0.01). No significant intergroup differences were observed for LF power, or any time-domain measures of HRV
Banerjee et al[373], 2023	Participants were subjected to a 10-item yoga questionnaire. Based on Likert scale scoring, 32 subjects (group I) were selected as long-term yogic breathing practitioners, and autonomic function tests using HRV and a provocative stress test and CV reactivity to HUT	A highly significant decrease in values of both high HF and LF variables was observed in group ІІ as compared to group I. A highly significant rise in LF/HF has been observed in group ІІ compared to group I (P = 0.004), indicating a greater withdrawal of vagal tone during the HUT test and during recovery (P = 0.001)
Bhagat et al[366], 2023	Pre-training measurements of SBP, DBP, HRV, and BRS were done, and the Medical Student Stressor Questionnaire was administered to participants. They were then trained in RYM	RYM training decreased DBP (P = 0.01) but not SBP. BRS showed a trend towards an increase after RYM practice, but it was not statistically significant (P = 0.44). The SDNN (P = 0.03), LF (P = 0.003), and HF (P = 0.04) showed a statistically significant change
Raj et al[367], 2023	Cross-sectional study included 202 yoga and 181 non-yoga participants	Following adjustments, cfPWV was significantly lower in yoga participants with a mean difference: -0.28 (95%CI: -0.55 to 0.08)
Ng et al[387], 2024	Participants from the Stress and Well-being in Everyday Life Study which included adults residing in the United States provided background and social network information in a baseline interview, followed by a 4-day ecological assessment in which they reported social encounters every 3 hours	At times when individuals encountered friends (particularly positive encounters), they exhibited a momentary reduction in HRV (within-person association). But those with more friend encounters during the study period had higher HRV than those with fewer friend encounters during the study period
Zou et al[349], 2024	This study was a 2-arm, parallel-group RCT. Patients with ACS recruited at 2 tertiary hospitals in Jinan, China were randomly assigned to a Mindfulness Psycho-Behavioural Intervention group or control group. The 6-week intervention consisted of 1 face-to-face session (phase I) and 5 weekly WeChat (Tencent Holdings Ltd) - delivered sessions (phase II) on mindfulness training and health education and lifestyle modification	Significantly greater improvements were observed in psychological stress (β = -1.186, 95%CI: 1.678-0.694, P < 0.001), physical HRQoL (β = 0.088, 95%CI: 0.008-0.167, P = 0.03), emotional HRQoL (β = 0.294, 95%CI: 0.169-0.419, P < 0.001), and general HRQoL (β = 0.147, 95%CI: 0.070-0.224) at T1, as well as dietary behaviour (β = 0.069, 95%CI: 0.003-0.136, P = 0.04), physical activity level (β = 177.542, 95%CI: -39.073 to 316.011, P = 0.01), and SBP (β = -3.326, 95%CI: -5.928 to 0.725, P = 0.01) at T2
Weiss et al[356], 2024	Controlled non-randomized longitudinal pilot intervention study enrolling individuals with CVD. After the first interview, a 12-week Metta meditation course starts for the IG, while the CTRL group will receive no intervention	The health-promoting personal competencies of sense of coherence, resilience, and self-compassion were not strengthened by the practice of Metta meditation in individuals with cardiovascular disease. However, there was a significant reduction in perceived stress and improved stress coping skills in the IG. Furthermore, the frequency of rehospitalization differed significantly in the pre-post comparison
Zureigat et al[389], 2024	A subset of participants from the Mass General Brigham Biobank adults who completed a PA period underwent 18F-fluorodeoxyglucose positron emission tomography/computed tomographic imaging. Stress-related neural activity was measured as the ratio of resting AmygAC	Greater PA was associated with both lower AmygAC (standardized β = -0.245; 95%CI: -0.444 to -0.046; P = 0.016) and CVD events (HR = 0.802; 95%CI: 0.719-0.896; P < 0.001). AmygAC reductions partially mediated PA’s CVD benefit (OR = 0.96; 95%CI: 0.92-0.99; P < 0.05)
Cui et al[360], 2025	Patients with CCS were randomly assigned to 12 weeks of either a TCCRP or a CECRP	Within the TCCRP group, the Chinese version of the PSS score significantly decreased (P < 0.05) from baseline to the end of the intervention. Notably, in the CECRP group, the Chinese PSS score increased (P < 0.05) at the end of the intervention. The antioxidant enzymes catalase and glutathione peroxidase levels increased markedly in the TCCRP group after the intervention (P < 0.001). Chinese version of the PSS was positively correlated with oxidised low-density lipoprotein (P < 0.05)
Johnson and Ezouah[368], 2025	In this 4-week pilot study, grounded in Pender’s Health Promotion Model, participants engaged in daily online health education and yoga activities through YouTube videos. Using Fitbit trackers, electronic blood pressure monitors, and web-based logs, the study measured metabolic syndrome risk factors and sedentary behaviour. Participant experiences were further explored through postintervention focus groups aiming to contextualize the intervention’s impact	Specifically, viewing over one-half of the instructional videos (P = 0.04) and daily BP monitoring (P = 0.02) were key to participant adherence. The qualitative focus group data unveiled 4 major themes: (1) Accountability, emphasizing the shift toward self-prioritization and collective health responsibility; (2) Increased awareness, highlighting enhanced understanding of health behaviours and metabolic syndrome risks; (3) Health benefits, noting observed improvements in blood pressure and stress levels; and (4) Unanticipated stressors, identifying external factors that challenged engagement
Canella et al[348], 2025	This one-group pretest-posttest quasi-experimental design recruited adult volunteers to partake in a standard 8-week MBSR program. The main outcomes were psychological well-being (perceived stress, anxiety and awareness) and stress-related biomarkers (SBP, DBP, salivary cortisol, IL-6 and IL-8 levels, plasma carotenoids concentration)	MBSR decreased stress (P = 0.002) and anxiety (P = 0.05) and increased awareness (P = 0.01). MBSR also significantly lowered SBP and DBP (P = 0.02 and 0.001), cortisol (P = 0.01), and IL-6 and IL-8 pro-inflammatory cytokines (P = 0.02 and 0.03), and enhanced carotenoids (P = 0.03). A strong positive correlation between ΔPSS and ΔSTAI-Y1 (P = 0.008), ΔSTAI-Y1 and ΔIL8 (P = 0.0007), and ΔPSS and ΔIL8 (P = 0.04), and significant negative correlations were observed between ΔPSS and ΔMAAS (P = 0.0003), ΔSTAI-Y1 and ΔMAAS (P = 0.04), and ΔMAAS and ΔIL8 (P = 0.003)

CTRL: Control; HRV: Heart rate variability; DBP: Diastolic blood pressure; BMI: Body mass index; TC: Tai Chi; PSS: Perceived Stress Scale; HR: Heart rate; ACS: Acute coronary syndrome; PTSD: Post-traumatic stress disorder; CI: Confidence interval; CV: Cardiovascular; OR: Odds ratio; QoL: Quality of life; RCT: Randomized controlled trial; TT: Tension Tamer; SBP: Systolic blood pressure; HF: High frequency; DGB: Device-guided slow breathing; BP: Blood pressure; MSNA: Muscle sympathetic activity; BRS: Baroreflex sensitivity; HFrEF: Heart failure with reduced ejection fraction; CPT: Cold pressure test; SLOWB: Slow breathing; AMI: Acute myocardial infarction; sAA: Salivary alpha-amylase; LF: Low frequency; HUT: Head up tilt; RYM: Raj Yoga meditation; SDNN: Standard deviation of N-N intervals; cfPWV: Carotid femoral pulse wave velocity; CI: Confidence interval; HRQoL: Health-related quality of life; CVD: Cardiovascular disease; IG: Intervention group; PA: Physical Activity; AmygAC: Amygdalar-to-cortical activity; HR: Hazard ratio; CCS: Chronic coronary syndrome; TCCRP: Tai Chi cardiac rehabilitation programme; CECRP: Conventional exercise cardiac rehabilitation programme; MBSR: Mindfulness Based Stress Reduction; IL: Interleukin; STAI: State-Trait Anxiety Inventory.