Mindfulness in Cardiovascular Disease Patients: Improvements and Future Perspectives

Over the last decades, a growing body of scientific evidence has confirmed the efficacy of some contemplative practices used in ancient Eastern in the clinical setting, also clarifying their underpinning neurobiological correlates.[1] The use of mind–body interventions, such as mindfulness, yoga, or meditation, can undoubtedly help to reduce stress, to improve memory and cognitive function as well as to change lifestyle, consequently enhancing well-being among users.[1] Mindfulness is the ability to intentionally be in the present moment without judgment.[2] Two principal mindfulness-based approaches have been explored in the clinical setting: mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). MBSR is a structured intervention initially designed for the treatment of chronic pain and is now used to minimize psychological morbidity and treat emotional and behavioral disorders related to chronic illnesses such as fibromyalgia, cancer, arthritis, and coronary artery disease.[3] MBCT, derived from MBSR, was developed for people with a history of recurrent depression to reduce the risk of illness recurrence.[4] It has been recently adapted to apply in different clinical chronic conditions.[4] Recent neuroimaging studies have explored the changes in functional activity, neural connectivity, and structural brain changes associated with the positive effects of mindfulness meditation.[5] Tang et al., in their meta-analysis,[6] concluded that six brain areas were continually influenced by mindfulness meditation: prefrontal cortex, anterior and posterior cingulate, insula, striatum, and amygdala. Based on the known function of these areas, the authors reported that mindfulness could improve the users’ well-being through these neural circuits controlling emotions, self-awareness, and present-moment awareness. This is in line with the conclusions of an earlier review by Hölzel et al.,[7] which proved that mindfulness meditation improved attention, emotion regulation, body awareness, and self-awareness. However, the underlying neural mechanisms are unclear, and further studies are needed to understand the neuronal and molecular bases of the changes in the brain linked to mindfulness meditation. Stress is a threat to the physical, mental, and social integrity of individuals which are exposed to it by external stimuli or internal body milieu.[8,9] Furthermore, anxiety and depression are often highly associated with stress as direct effects or co-stressors, possibly contributing to the onset of other stress-related diseases. During the acute stress reaction, the anterior cingulate cortex and the amygdala interplay to identify the threat to subjective well-being.[10-12] Two pathways are consequently activated: the locus coeruleus, norepinephrine-based system, and the hypothalamic–pituitary–adrenal (HPA) axis, with the release of several hormones such as growth hormone, adreno-corticotropic hormone, cortisol, prolactin, epinephrine, and norepinephrine, as well as a parasympathetic withdrawal.[13] Thus, these molecules may cause somatic effects, such as insulin resistance, activation of renin–angiotensin–aldosterone system, metabolic syndrome, diabetes, impaired immune response, endothelial dysfunction, and hence, the development of cardiovascular diseases (CVDs).[13] It is estimated that 46% of people reporting mental health problems are affected from chronic diseases, such as heart conditions, stroke, diabetes, and cancer.[14] The research aims to tailor treatments integrating mind–body theoretical models that may identify the shared mechanisms of physical conditions that show mental health comorbidity. CVDs are the leading cause of high levels of morbidity and mortality globally.[15] CVD prevention is mainly based on minimizing the cardiovascular risk factors (CVRFs). Poor mental health such as depression, anxiety, and stress have been considered among risk factors for CVDs, thereby raising the related mortality.[16] In these circumstances, mindfulness-based interventions (MBIs) may be effective to control some CVRFs such as systolic blood pressure (SBP) and diastolic blood pressure, anxiety, depression, and perceived stress.[17,18] Most of the studies included in a systematic review conducted by Marino et al. reported that mindfulness programs positively influence patients’ psychological outcomes, enhancing their physiological fitness. Random-effects meta-analysis models showed a moderate-to-large effect size of mindfulness in decreasing anxiety, depression, stress, SBP, heart palpitations, and rate in patients with CVDs.[19] Abbott et al. conducted a systematic review and meta-analysis on the effectiveness of mindfulness-based therapy intervention for people with, or at risk of, vascular disease. Nine articles assessing the effects on psychosocial and physical outcomes were examined. The review confirmed that mindfulness therapy was successful in reducing the levels of depression, anxiety, and psychosocial stress. Slight-to-moderate beneficial effects were reported for stress, depression, and anxiety. In conclusion, people with CVDs reported considerable psychological advantages from MBSR/MBCT interventions, but the effects on the physical parameters of the disease were not yet determined.[20] Lately, an umbrella review of systematic reviews and meta-analyses has demonstrated that MBIs were effective in reducing CVRFs, but the results were contradictory. This study aimed to summarize the literature findings available on CVRFs associated with MBIs. The results revealed that MBIs may successfully improve six specific CVRFs, including blood pressure, smoking habits, glycate-hemoglobin, binge eating patterns, depression, and stress levels. In general, based on an assessment of the quality and credibility of the evidence, MBIs may enhance cardiovascular health by improving risk factors for CVDs.[21,22] Furthermore, a recent meta-analysis revealed that anxiety, depression, perceived stress, and SBP levels in patients with CVDs are tightly interconnected and could be all improved by mindfulness-based training.[23,24] SBP and diastolic blood pressure decreased in 2 months after the mindfulness program.[25] Younge et al.[26] conducted a research, in which patients with CVD were subjected to a 12-week online mindfulness training in addition to the usual care (UC) compared to UC alone. The main objective of the project was to evaluate the exercise capacity with the 6-min walk test (6MWT). The secondary aim was to assess other physiological parameters (i.e., heart rate and blood pressure), subjective health status, perceived stress, psychological well-being, social support as well as a composite endpoint (all-cause mortality, heart failure, symptomatic arrhythmia, cardiac surgery, and percutaneous cardiac intervention). MBI led to a considerable improvement in the parameters of 6MWT. It was also registered an improvement in heart rate, a specific risk factor for CVDs, such as hypertension, heart failure, and acute coronary syndromes, in favor of the group treated with mindfulness. A systematic review conducted by Kang and Luo recently confirmed these findings.[27] Zou et al. evaluated nine randomized clinical trials which considered the controlled effects of MBIs on CVD patients’ psychological outcomes, their CVRFs, and quality of life.[18] Patients showed significant improvements in depression and stress, but not anxiety and blood pressure compared with controls. Furthermore, MBIs enhanced psychological and social domains: depression, anxiety, perceived stress, and quality of life. Only one study assessed the effects on other CVRFs and the results were inconclusive. These studies supported the use of MBIs in patients with coronary heart disease, with a reduction of depression and stress. Nonetheless, the effects on CVRFs and quality of life were inconclusive. Finally, some evidence also showed the role of MBRS in decreasing anxiety and depressive symptoms in women with heart diseases. A pilot study conducted by Tacón et al. showed that the MBSR program improved the scoring of anxiety, emotional control, and reactive coping in women with heart disease in the postintervention assessment.[28] Furthermore, Ahmadpanah et al. have demonstrated that mindfulness treatment in a sample of female patients with hypertension decreased their blood pressure levels and symptoms of depression and anxiety.[29] Modern neurosciences are promoting an integration of the evidence regarding the heart and mind binomial. The use of meditation techniques such as mindfulness in the treatment of CVD further supports the theory that there is a close correlation between mental illness and chronic inflammatory state. Mechanisms on the base of mindfulness-related improvements in cardiovascular patients may include the reduced sympathetic nervous system activity and the HPA activation associated with lower stress and levels of saliva alpha-amylase and saliva cortisol, improved vagus nerve control, and psychological distress linked with CVD.[18,19,30] Thus, it is essential to identify depression in patients with CVD. Patients with CVD are at high risk of depression and should be screened periodically. Furthermore, several trials have shown that MBIs were associated with a significant reduction of traditional CVD risk factors such as fatigue, heart rate, anxiety, depression, perceived stress, blood pressure, and body mass index.[26,31-33] These results may suggest that mindfulness is efficacious in improving the outcome in CVDs, beyond their psychological correlates, as well as in their primary and secondary prevention. Table 1a and 1b summarize the evidence from the review articles and randomized clinical trials included in this report.Table 1a: Systematic review and meta-analyses included in the reviewTable 1b: Randomized clinical trials included in the reviewNonetheless, there are limitations in these studies, including the heterogeneity of clinical trials, the small sample size, the risk of bias, and the scarce information about the efficacy of meditation on clinical outcomes. It would be desirable for mindfulness programs to become an integral part of standard care protocols for CVD. Healthcare providers could routinely recommend mindfulness practices alongside traditional treatments, promoting a holistic approach to heart health. Apps and online platforms could offer accessible mindfulness training tailored for CVD patients, helping them incorporate mindfulness into their daily routines. Integrating mindfulness programs could enhance participants’ overall experience and outcomes, addressing both the physical and psychological aspects of recovery. In addition, training programs for healthcare providers could be developed with the aim of teaching mindfulness practices to patients, thereby strengthening patient-provider relationships. Future research could pave the way for more personalized mindfulness interventions based on patient characteristics, circumstances, and preferences. Factors such as age, disease severity, and psychosocial background could help tailor mindfulness practices, optimizing their effectiveness for each individual. Further strictly-designed and well-reported trials should be conducted to increase the evidence regarding the systematic employment of mindfulness in clinical cardiology and to verify the full effectiveness of such interventions. Author contributions Fabiana Ricci and Antonio Ventriglio designed, concepted and drafted the manuscript. All authors participated in acquisition of data, data analysis and critical revision. All authors have given final approval for the current version to be published. Conflicts of interest Dr. Domenico De Berardis is an Editorial Board Member of Heart and Mind. The article was subject to the journal’s standard procedures, with peer review handled independently of Dr. Domenico De Berardis and the research groups. There are no conflicts of interest.