Science of The Heart:
Exploring the Role of the Heart in Human Performance

An Overview of Research Conducted by the Institute of HeartMath

1. Introduction
2. Heart Rate Variability
3. Entrainment, Coherence & Autonomic Balance
4. Head-Heart Interactions
5. Emotional Balance & Health
6. Music Research
7. HeartMath Technology in Business
8. HeartMath in Education
9. Clinical Research
10. Assessment Services
11. Scientific Advisory Board & Physics of Humanity Council
12. Bibliography

Clinical Research

As far back as the middle of the last century, it was recognized that the heart "overtaxed by constant emotional influences or excessive physical effort and thus deprived of its appropriate rest" suffers disorders of function and becomes vulnerable to disease (Hilton, 1863). An early editorial on the relationships between mind and heart accepted the proposition that in about half of patients, heart failure was precipitated by gross emotional upsets. Current research suggests that the progression of a number of diseases is influenced by the consequences of carrying effort beyond physiological tolerance into a condition of depletion and exhaustion that leads to dysregulation of the autonomic nervous system. Unspecified negative emotional arousal, often described as stress, distress or upset, has been associated with a variety of pathological conditions, including hypertension, silent myocardial ischemia, sudden cardiac death, coronary disease, cardiac arrhythmia, sleep disorders, diabetes, digestive disorders, fatigue and many other disorders. Stress and negative emotions have been shown to increase disease severity and worsen prognosis in individuals suffering from a number of different pathologies. On the other hand, positive emotions and effective emotional self-regulation skills have been shown to prolong health and significantly reduce premature mortality.

The fact that the HeartMath techniques target the source of people’s emotional arousal, greatly enhance psychological well-being and lead to significant improvements in autonomic and hormonal function and balance makes them potent interventions to facilitate the healing process and improve clinical outcomes. Many health care professionals worldwide, representing both mental health and biomedical fields, have incorporated HeartMath interventions in treating patients, with notable success. A growing number of case histories document substantial reductions in symptomatology and improvements in clinical status achieved by patients with a wide variety of conditions after learning and practicing the interventions for a relatively brief time period, with no other changes in their lifestyle or treatment regimens. (See shaded box for a partial list of patient populations that have benefited from the HeartMath techniques). Many of these cases describe chronic conditions that are typically difficult to address using standard approaches. In several cases, autonomic nervous system analyses revealed the restoration of normal, healthy autonomic function and balance concurrent with symptom improvements in patients who practiced the techniques.

HeartMath interventions have facilitated health improvements in patients with:

• Hypertension
• Arrhythmias
• Autoimmune disorders
• Environmental sensitivity
• Chronic pain
• Fibromyalgia
• Chronic fatigue
• Anxiety disorders
• Clinical depression
• Post-traumatic stress disorder

Treatment outcome studies have examined the benefits of HeartMath interventions used with a number of clinical populations. Results of studies conducted on patients with hypertension, diabetes, congestive heart failure and HIV/AIDS are summarized here. This research showed that practice of the techniques was associated with improvements in a variety of health-related measures, including key indicators of physical health status, psychological well-being and quality of life. These pilot studies serve as useful models demonstrating how the HeartMath interventions can be successfully integrated in the treatment of patients with different types of medical conditions. In addition to ongoing intervention studies, the HeartMath Research Center is actively involved in studying heart rate variability as a noninvasive clinical assessment and research tool. HRV is useful for monitoring autonomic function and assessing ANS involvement in a number of clinical conditions. Importantly, low HRV has been found to be predictive of increased risk of heart disease, sudden cardiac death as well as all-cause mortality. IHM has established and maintains an extensive HRV normals database which provides data on variations in measures of HRV among normal, healthy individuals. An understanding of how HRV varies naturally with age and gender (as described in one of the studies summarized below) greatly increases its value as a diagnostic and prognostic tool in clinical settings.

HRV also provides an important research tool to expand our knowledge of the alterations in autonomic nervous system function that contribute to different pathologies. Low heart rate variability has been observed in an extremely wide range of disorders, including disease states as diverse as structural heart disease, congestive heart failure, hypertension, diabetes, chronic renal failure, AIDS, cancer, Alzheimer’s disease, multiple sclerosis, alcoholism and obesity, to offer only an abbreviated list. Our research, together with others’, also indicates that HRV is altered in individuals suffering from a number of psychological disorders, such as depression, anxiety and panic, suggesting that these emotional disturbances are associated with autonomic nervous system imbalances. Studies assessing HRV as an indicator of autonomic function in chronic fatigue and panic disorder are described in this section. Finally, the last study in this section uses HRV analysis as a probe to explore changes that occur in the heart’s neural connections and rhythmic patterns following a heart transplant.

Treatment Outcome Studies

Impact of a Workplace Stress Reduction Program on Blood Pressure and Emotional Health in Hypertensive Employees

Rollin McCraty, PhD, Mike Atkinson and Dana Tomasino, BA.
Journal of Alternative and Complementary Medicine. 2003; 9 (3): 355-369.

Key findings: Hypertensive individuals enrolled in a workplace-based risk reduction program exhibited significant reductions in blood pressure after using HeartMath tools for three months. Participants also experienced significant reductions in distress and depression, concurrent with improvements in work performance-related parameters following the intervention.

Summary: Hypertension, defined as a blood pressure (BP) of 140/90 mm Hg or higher, is considered one of the most prominent public health issues faced by the United States today, affecting approximately 60 million Americans, or one in four adults. This disease has been called the "Silent Killer" because it usually causes no symptoms. However, hypertension is a major risk factor for death and disability related to coronary heart disease, heart attacks, strokes, kidney disease and vascular complications. In addition, high systolic BP has been linked with decreased cognitive performance, memory loss and the loss of healthy brain tissue. Conversely, numerous controlled clinical trials have demonstrated that lowering blood pressure significantly reduces morbidity and premature mortality.

There is considerable evidence to suggest that high BP is linked to persistent stress and the way in which people cope. Chronically elevated sympathetic nervous system activity has been implicated in the development and maintenance of hypertension. Thus, behavioral interventions that reduce negative emotional arousal and stress-induced sympathetic activation have been shown to be effective non-pharmacological treatments for hypertension, resulting in clinically significant and sustainable BP reductions.

Results of previous pilot studies and case histories have shown the HeartMath techniques to be effective in improving BP in hypertensive individuals, many of whom had not responded to other treatment approaches. In the present study, the impact of a workplace-based HeartMath Inner Quality Management (IQM) Program was investigated in larger sample of hypertensive individuals, using a randomized controlled trial design. Specifically, the program sought to reduce employee stress, depression and high blood pressure, three major and well-recognized risks to the workforce. This study also sought to determine the general feasibility of the implementation of such an intervention in an organizational setting as a means to improve health, well-being and performance in a hypertensive employee population.

Thirty-two individuals, all employed by the same organization, participated in the study. All participants had been diagnosed with hypertension by their primary care physician and were either currently taking antihypertensive medication or had abnormal BP readings during the 4-week run-in period. Participants were assigned through incomplete randomization to the treatment group (18 participants) or waiting control group (14 participants). The Inner Quality Management Training was delivered to the treatment group in three sessions conducted over the course of two weeks. In the training, participants learned tools and techniques to reduce stress, improve health and enhance performance. During the three months following the training, participants were encouraged to practice the HeartMath tools daily. To facilitate learning and effective implementation of the interventions, six emWave^® PC/Mac Emotional Management Enhancer units were made available to treatment group participants for use in the workplace and personal use during weekends. Participants used this computer-based performance enhancement system to visualize the positive shifts in autonomic function and balance they could achieve using the techniques, and to become familiar with the experience of the internal emotional shift necessary to increase physiological coherence. One optional 2-hour follow-up session was held eight weeks after the training to review the techniques and answer participants’ questions and concerns regarding their practice. Treatment group participants were also encouraged to arrange informal meetings among themselves to support one another in their continued practice of the tools.

Blood pressure measurements were obtained using a standardized protocol, before and three months after the completion of the training program. Psychological and performance-related parameters were assessed concurrently with blood pressure changes to determine the overall impact of the program on employees health, well-being and effectiveness.

Three months following the intervention program, the treatment group exhibited significant reductions in symptoms of depression and overall psychological distress, relative to the control group, as measured by the Brief Symptom Inventory (BSI). The Personal and Organizational Quality Assessment (POQA) survey also revealed reductions in stress symptoms along with improvements in items assessing emotional health and psychosocial functioning. These changes were concurrent with improvements measured in a number of work performance-related parameters, including perceived work quality, communication and attitude toward the organization.

Additionally, trained employees exhibited substantial reductions in blood pressure (BP) after the intervention program. As shown in Figure 44, the reduction in systolic BP in the treatment group was significantly larger than that in the control group. Specifically, the trained group demonstrated a mean adjusted reduction of 10.6 mm Hg in systolic BP and of 6.3 mm Hg in diastolic BP, as compared to reductions of 3.7 mm Hg (systolic) and 3.9 mm Hg (diastolic) in the control group. In addition, three individuals in the trained group were able to reduce their BP medication usage, with their physicians’ approval, during the study period. Of these, one participant was permitted to discontinue antihypertensive medication usage entirely following completion of the study.

These BP improvements achieved by the treatment group are notable when viewed in comparison to blood pressure reductions typically achieved with other types of interventions. For example, the reduction in BP obtained with the HeartMath training in this study is similar in magnitude to the average reduction in BP reported in a meta-analysis of controlled trials of antihypertensive drug therapy of several years’ duration. This reduction is the equivalent of a 40 lbs-weight loss, and is twice the size of the average reduction seen with a low-salt diet or exercise training.

Blood Pressure Reductions in Hypertensive Individuals

Clinical evidence indicates that blood pressure reductions of the magnitude measured in this study, if sustained over 2 to 3 years, should be expected to significantly reduce long-term health risks, including morbidity and mortality from stroke, cardiovascular and coronary diseases, as well as impairment of cognitive function. For example, a meta-analysis of randomized trials of antihypertensive treatment, with BP reductions similar to the present trial, found that cardiovascular mortality decreased 22%, stroke mortality 33% and coronary mortality 26%. Moreover, research indicates that the reduction in systolic BP achieved in this study should be expected to lower the risk of later impairment of cognitive function by 7 to 9%.

In conclusion, results indicate that over a 3-month period, the HeartMath Inner Quality Management program was effective in reducing blood pressure in a group of hypertensive individuals, with no other changes to their lifestyle or health care regimens. Concurrent reductions in measures of emotional distress and improvements in psychological well-being suggest that by learning to manage stress more effectively and decrease negative emotional arousal, participants were able to self-generate measurable and significant changes in their physiology and health status. Physiological and psychological improvements were also accompanied by performance-relevant gains, suggesting the interrelation among all these measures. The implications are that workplace-based programs that promote effective blood pressure management and improve well-being in hypertensive employees may result in a healthier and more productive workforce, reducing cognitive decline, performance impairment, morbidity and premature mortality. Results encourage the implementation of such programs either alone or in association with other treatment approaches to maximize blood pressure reduction and health maintenance.

Emotional Self-Regulation Program Enhances Psychological Health and Quality of Life in Patients with Diabetes

Rollin McCraty, PhD, Mike Atkinson and Lee Lipsenthal, MD.
HeartMath Research Center, Institute of HeartMath, Publication No. 00-006. Boulder Creek, CA, 2000.

Key findings: Diabetic patients demonstrated significant reductions in psychological distress and enhancement of quality of life after using the HeartMath interventions for six months. Increased practice of the Heart Lock-In technique was associated with HbA1c reductions in patients with Type II diabetes, indicating improved glucose regulation.

Summary: Diabetes is one of the most common chronic diseases, affecting more than 16 million people in the U.S. alone. Individuals with diabetes commonly must undergo extensive lifestyle changes in order to effectively manage their disease, and often suffer substantial stress and negative affect. Studies confirm that people with diabetes frequently suffer from emotional disorders: diabetic patients are reported to have almost three times the rate of anxiety and at least three to four times the rate of depression found in the general population.

A recent report of the World Health Organization and International Diabetes Federation has drawn attention to the importance of encouraging psychological well-being in diabetic patients. The establishment and maintenance of psychological well-being is recognized as an important goal of diabetes management, which is expected to reduce the occurrence of metabolic problems and complications. Education in emotional self-regulation may have particular clinical relevance in diabetes, as emotional disturbances and ineffective coping styles have been associated with significantly poorer glycemic control, the increased report of clinical symptoms, decreased compliance and increased risk for complications. Emotional stress can contribute to the exacerbation of diabetes by direct physiological effects on glucose regulation, as well as by reducing adherence to self-care behaviors. Conversely, studies have shown that significant relationships exist between self-efficacy, self-care and measures of glycemic control. Thus, multiple lines of evidence clearly support the integration of an effective stress reduction and emotional management intervention program as a fundamental component of any diabetes management regimen.

A collaborative 6-month pilot study was undertaken by IHM and LifeScan to determine the efficacy of the HeartMath interventions in improving hematologic measures, health and psychological well-being in a sample of individuals with Type I and Type II diabetes. Twenty-two subjects (mean age 49, age range 31-67) participated in the study. Fourteen of the participants had Type II diabetes and eight had Type I. Participants attended a 2-day workshop in which they learned the HeartMath interventions. The program included instruction and practice in Freeze-Frame, Heart Lock-In and communication techniques, as well as various practical applications of the techniques specifically geared toward addressing stressors and challenges inherent in the lives of individuals with diabetes. Participants also used the emWave^® PC/Mac Stress Relief System to facilitate their practice of the techniques and visualize the shifts to increased physiological coherence they could achieve through using the interventions. For the duration of the study, participants were asked to perform at least five 15- minute Heart Lock-Ins per week with the music Heart Zones, and to keep a written record of their Lock-In practice. Three 2-hour follow-up sessions were conducted once per month for the first three months after the initial training to help reinforce the use of the interventions, and during the last three months of the study participants received regular support from an IHM health coach.

Psychological self-report surveys assessing participants’ stress, emotions, psychological symptoms and quality of life were administered three weeks before and six months following the initial training. Physiological measurements, including hemoglobin A1c (HbA1c), cholesterol and triglyceride levels, and blood pressure, were also collected at these time points. Results of pre- versus 6-month post-treatment assessments revealed significant decreases in psychological distress as indicated by the Global Severity Index, the Positive Symptom Total, and the Positive Symptom Distress Index of the Brief Symptom Inventory (BSI). Significant improvements in the following individual symptom scales were also measured: Somatization, Interpersonal Sensitivity, Depression, Anxiety, Phobic Anxiety, Psychoticism and Paranoid Ideation (Figure 45). Consistent with these results, participants experienced significant reductions in global negative emotion, anger, distress, depression, sadness, fatigue, sleeplessness and anxiety, and significant increases in peacefulness, vitality and social support, as measured by the Personal and Organizational Quality Assessment (POQA). Overall quality of life improved as indicated by significant increases on the Quality of Life Inventory (QOLI). Before the training the participants’ mean score for overall quality of life was near the bottom of the average range, whereas after the intervention it had moved into the high range (Figure 46). In addition, there were significant improvements in the individual scales of Health, Self-Esteem, Love and Home. The Daily Stress Inventory (DSI) results showed no significant change in the number of daily stressful events participants commonly experienced; however, both the Impact score (perceived stressfulness of the events) and the Impact/ Events ratio (sensitivity to the events) dropped significantly following the intervention.

Linear regression analysis revealed a significant relationship between self-reported practice of the Heart Lock-In intervention and the pre-post change in hemoglobin A1c levels, a key indicator of glycemic control, in participants with Type II diabetes. Increased intervention practice was associated with reductions in HbA1c, indicating improved glucose metabolism, while HbA1c increased in patients who did not practice or practiced only minimally (5 Heart Lock-Ins) throughout the study period (Figure 47). A similar trend was observed in the Type I diabetic patients, although the relation did not achieve statistical significance in this small sample.

Psychological Improvements in Diabetic Patients

Quality of Life Improvements in Diabetic Patients

HbA1c Pre-Post Change in Type II Diabetic Patients
Versus Amount of HeartMath Practice

Anecdotal evidence from interviews and informal interactions with the participants indicated their receptivity, appreciation and enthusiasm regarding learning and practicing the techniques. Substantial positive shifts in participants’ attitudes, behavior and overall psychological demeanor impressed both the trainers and researchers who interacted directly with them, as well as participants’ spouses and family members. Notably, during the post-intervention follow-up period, a number of the participants experienced major and unforeseen stressful life events. Participants who faced these stressors reported being able to maintain far greater peace and emotional balance in addressing them than they anticipated, thus lessening the intensity and duration of their distress considerably; all attributed this to their consistent practice of the techniques during the challenging periods.

In conclusion, the results of this pilot study suggest that practice of the HeartMath interventions can lead to a substantial reduction in psychological stress, enhancement of quality of life, and improved glycemic control in individuals with diabetes. It is likely that these effects were mediated, at least in part, by reduced cortisol production, decreased inappropriate autonomic activation and improved autonomic balance as a result of using the techniques to transmute stress and negative emotions, and enhance positive emotions and physiological coherence. The indication that diabetic patients can lower their HbA1c levels by utilizing practical, straightforward stress management techniques is of particular clinical relevance, as patients who are able to maintain lower levels reduce their risk for major complications, such as blindness, kidney disease and nerve damage, and incur significantly lower health care costs. In addition, improvements in patients’ emotional well-being and attitudes toward their health are likely to lead to increased compliance with self-care behaviors critical to the effective management of their disease. Collectively, the positive outcomes achieved in this study can be expected to reduce health care usage and both short- and long-term costs to the health care provider. This study provides a practical model for a stress and emotional management intervention that can be easily integrated into existing diabetes management programs and expanded to meet the needs of larger diabetic populations.

A Controlled Pilot Study of Stress Management Training of Elderly Patients with Congestive Heart Failure

Frederic Luskin, PhD, Megan Reitz, BA, Kathryn Newell, MA, Thomas Gregory Quinn, MD, and William Haskell, PhD. Preventive Cardiology. 2002; 5 (4): 168-172, 176.

Key findings: Patients with congestive heart failure demonstrated significantly increased functional capacity as well as reduced stress and depression after learning HeartMath techniques.

Summary: A pilot study conducted by the Stanford Center for Research in Disease Prevention at Stanford University examined the effectiveness of HeartMath interventions used with elderly congestive heart failure (CHF) patients. Despite recent advances, heart failure remains a difficult condition to manage in clinical practice and is the single most frequent cause of hospitalization in adults over the age of 65. The hallmark of CHF is exercise intolerance and activity restriction most commonly due to symptoms of impaired breathing and fatigue. These symptoms result in low functional capacity and progressive physical disability, often requiring intensive medical management. In addition to physical decline, patients with CHF often report depressed mood, anxiety and increased incidence of hostility.

Chronic heart failure has been associated with abnormalities in autonomic control of the cardiovascular system that include chronic sympathetic activation, decreased parasympathetic activity and impaired arterial baroreflex activity. Because of the relationship between autonomic imbalances, progression of the disease and increased mortality, recent studies have examined various types of pharmacological interventions that may reduce sympathetic activity and improve autonomic balance in patients with heart failure. However, nonpharmacological interventions for this patient population have generally been limited to exercise training. Comparatively little attention has been paid to psychosocial interventions and their impact on physiological processes, functional capacity and psychosocial functioning in CHF patients. A strongly needed next step is to evaluate the feasibility and efficacy of various nonpharmacologic therapies and to establish an optimal intervention that has a positive impact on the progression of heart failure as well as on the psychosocial environment of the individual. To our knowledge, this pilot study, funded by the National Institute of Health and the Office of Alternative Medicine, is one of the few to examine the effects of stress and emotional management training on psychosocial functioning and functional capacity in patients with CHF.

Thirty-three patients (mean age 66) participated in the study. All participants had had a NYHA Class I-III diagnosis of CHF for at least three months and had been on a stable medication regimen for at least one month. Participants were assigned to an 8-week psychosocial intervention or a wait-listed control group through incomplete randomization. Treatment group participants received a total of ten hours of training offered during eight weekly 75-minute sessions spread over ten weeks. The program was conducted in small groups of six to eight participants in a psychoeducational format. All training was performed by a licensed psychotherapist who was also a certified HeartMath trainer. Participants were taught Freeze-Frame and the Heart Lock-In as the core techniques in the intervention program, with an emphasis on guided practice of the techniques. For the study’s duration, each participant was asked to do two 15-minute Heart Lock-Ins per day and to use Freeze-Frame at least three times per day, as well as to look for additional opportunities during the day to practice Freeze-Frame. Measurements of psychosocial functioning and functional capacity were obtained one to two weeks prior to the intervention, and again one to two weeks following the program.

Post-intervention, the treatment group exhibited significant reductions in perceived stress (Perceived Stress Scale) and depression (Geriatric Depression Scale) relative to the control group. Further, as compared to control subjects, treatment group participants demonstrated significant improvements in mental health and vitality as measured by the SF-36 Health Status Profile. Positive trends were noted for measures of anxiety, optimism, perceived physical fitness and health-related quality of life. Finally, on the Six-Minute Walk, a measure of functional capacity, patients in the treatment group significantly improved performance by over 14 percent (1088 feet pre-intervention – 1241 feet post-intervention), while control group subjects showed a slight decline (1191 feet pre-test – 1171 feet post-test).

Stress

Depression

Functional Capacity

Collectively, the data suggest that the significant reduction in stress and negative emotional arousal experienced by patients who practiced the techniques may have promoted physiological changes permitting the observed improvements in functional capacity. Given the significant sympathetic involvement in CHF, it is likely that a reduction in excessive or inappropriate emotionally-induced sympathetic activation and an increase in parasympathetic activity associated with use of the interventions may have precipitated improvements in patients’ physical status.

The psychotherapist who administered the intervention program was particularly impressed with the patients’ overall response to HeartMath. Attendance and compliance were excellent, and in post-test debriefings the participants expressed singular appreciation for the program, reporting that the experience was both enjoyable and valuable. Patients were extremely receptive to the idea that unmanaged stress could impede recovery from their disease, and many felt considerably more hopeful as a result of learning the techniques. Most mentioned the lack of psychosocial support they experienced for their condition and their frustration at the number of drugs required for medical management.

In conclusion, this pilot study suggests that HeartMath techniques are a feasible and effective intervention for CHF patients, demonstrating that stress and depression levels can be reduced and functional capacity increased in this population through training in emotional self-management. This study’s promising indications clearly warrant larger-scale controlled trials to confirm the observed psychosocial and functional improvements and further explore the implications of such outcomes for physiological rehabilitation.

A Pilot Intervention Program Which Reduces Psychological Symptomatology in Individuals with Human Immunodeficiency Virus

Deborah Rozman, PhD, Rupert Whitaker, PhD, Tom Beckman, BS and Dan Jones.
Complementary Therapies in Medicine. 1996; 4 (4): 226-232.

Key findings: Individuals with HIV infection and AIDS demonstrated significantly reduced anxiety and stress, improved psychological well-being, increased physical vitality and reductions in pathological symptoms after practicing HeartMath interventions for six months.

Summary: Individuals with human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) face not only the extreme personal stress of living with a chronic, life-threatening condition with no effective cure, but also the social stress and frequent isolation generated by society’s perceptions of HIV-positive individuals. A clear association between psychosocial factors and the prognosis of AIDS has been demonstrated. Negative emotions and attitudes, including anxiety and depression, and the lack of effective coping skills have been related to a more severe clinical progression. In contrast, psychological factors associated with improvements of AIDS symptoms and increased survival include the presence of a positive attitude, emotions or moods, as well as good coping ability. Research further suggests that the ability to manage stress effectively may deter the loss of natural killer cell function in HIV-positive individuals.

This pilot study was conducted to determine the efficacy of the HeartMath interventions in managing psychological status and improving quality of life in individuals with human immunodeficiency virus. The study was named "AIDS for Hope," denoting its intent to provide participants with tools (as in "aids") for less stressful and more hopeful lives. In this investigation, 24 HIV-seropositive men and women, most with AIDS, completed a HeartMath training program. The program provides tools for stress reduction and mental and emotional self-management that enable participants to recognize and minimize inefficient thoughts and feelings such as anger, resentment, fear, guilt and anxiety, as well as enhance positive emotional states, such as love, care and appreciation.

Participants attended three 2-day weekend training sessions, which were conducted at 3-month intervals over a period of six months. In addition, they were given home study assignments of approximately one hour in length per day for the 6-month study period. Two of the core HeartMath tools taught to participants were Freeze-Frame and the Heart Lock-In technique. Each participant committed to regularly using Freeze-Frame and practicing the Heart Lock-In five times a week with the music Heart Zones for the duration of the study. Further, each participant was assigned a counselor from the Institute of HeartMath who contacted the participant by telephone every two weeks throughout the study to answer questions and provide support regarding practice of the techniques. Participants were assessed prior to and at the completion of the 6-month period using (1) an Irritability Scale, (2) a Symptom Questionnaire developed to assess the number and severity of symptoms specifically associated with AIDS, (3) the State-Trait Anxiety Inventory, (4) the General Well-Being Scale, and (5) the Essi Systems StressMap^® Research Tool.

At the end of the six months, there was a significant reduction in both state and trait anxiety, as well as significant improvements in irritability, positive affect, physical vitality, hardy outlook, behavioral and emotional symptoms of stress, and general well-being. Significant improvements were also measured in the following stress-related variables: major changes, work pressures, home environment, perspective and personal beliefs. Participants’ self-reports indicated reductions in a wide variety of pathological symptoms, including infections, anemia, herpes and fatigue. Nine of the 18 participants who reported physical symptoms at the start of the study reported no symptoms after completion of the training program. The remaining nine individuals reported either fewer symptoms, less intense symptoms or no change. Two of the participants were able to discontinue their medications with their physicians’ approval by the end of the study.

Results of this study are notable, given that other research has demonstrated the relative stability of psychological measures over time in HIV-positive individuals. Some of the participants stated that in using the HeartMath interventions, they experienced changes in perception, attitudes and behavior more profound than they had previously been able to achieve through years in various treatment programs, self-help groups and individual psychological counseling. It appears that through using the self-management tools to recognize and minimize unhealthy attitudes and feelings such as anger, resentment, fear, guilt and anxiety, and enhance positive emotions such as love, care and appreciation, participants were able to transform their outlook on life, reduce psychological symptomatology and in many cases improve their clinical status. Other studies demonstrating the impact of the HeartMath interventions on the immune, nervous and hormonal systems provide a potential basis for the observed health improvements. In conclusion, the results of this pilot study indicate that the HeartMath techniques hold promise as a nonpharmaceutical intervention that can significantly improve the well-being and quality of life in individuals with HIV infection and AIDS.

Comments from AIDS for Hope Study Participants

Twenty-Four Hour Time Domain Heart Rate Variability and Heart Rate: Relations to Age and Gender Over Nine Decades

Ken Umetani, MD, Donald H. Singer, MD, FACC, Rollin McCraty, PhD and Mike Atkinson.
Journal of the American College of Cardiology. 1998; 31 (3): 593-601.

Key findings: Twenty-four-hour time domain HRV decreases with normal aging and is affected by gender. This study establishes age-adjusted normal ranges for five standard 24-hour time-domain HRV measures over a 9-decade time span, thereby enhancing the diagnostic and predictive utility of HRV in clinical settings.

Summary: Heart rate variability is an established index of autonomic activity. Low HRV is considered an independent marker of a number of pathophysiological conditions, including ischemic heart disease and risk of mortality/sudden cardiac death. However, the natural age-related decline in HRV may limit its clinical utility, due to difficulty in discriminating between low HRV associated with disease and risk of mortality and that associated with the normal aging process. Gender also influences HRV. However, there is little published information concerning the effects of aging and gender on 24-hour HRV over a broad age span. This study sought to define age and gender effects for healthy individuals on 24-hour time domain HRV and heart rate (HR) over nine decades and to establish age-adjusted normal ranges for each HRV measure.

HRV was determined for 260 healthy subjects, ages 10-99, on a decade basis. Five standard time domain measures of HRV were used: SDNN, SDANN, SDNN index, rMSSD and pNN50. All HRV measures decreased with aging, but at varying rates and to different degrees. The SDNN and SDANN decreased gradually over the nine decades. The pNN50 and rMMSSD declined at different rates, but both stabilized after age 59. The SDNN index decreased linearly with aging across the entire lifespan, thus providing a useful physiologic marker of aging. In some healthy subjects over 65, the SDNN index, rMSSD and pNN50 fell below published cut-off points for increased risk of mortality, suggesting the need for revision of these values. HRV in females below age 30 was lower than in age-matched males. Gender-related differences disappeared after age 50.

The results of this study expand our understanding of how HRV measures vary with age and gender in healthy individuals. The data acquired were applied to the establishment of new, age-adjusted normal ranges for each HRV measure. This information greatly enhances the clinical utility of 24-hour time domain HRV as a marker for risk of mortality and pathophysiologic states, particularly in older populations.

Assessment of Autonomic Function and Balance in Chronic Fatigue Patients Using 24-Hour Heart Rate Variability Analysis

Rollin McCraty, PhD, Stuart Lanson, MD and Mike Atkinson. Clinical Autonomic Research. 1997; 7: 237.

Key findings: Assessment of 24-hour heart rate variability revealed impaired autonomic nervous system function in individuals with chronic fatigue syndrome. Measures of both sympathetic and parasympathetic activity were significantly lower in chronic fatigue patients as compared to healthy age- and gender-matched controls, suggesting that this syndrome is associated with autonomic exhaustion.

Summary: Chronic fatigue syndrome (CFS) is a medically unexplained disorder characterized by chronic, disabling fatigue, muscle pain, impaired concentration and a variety of neurobiological symptoms that make everyday activities extremely difficult. While it has been suggested that patients with CFS may have impaired autonomic nervous system function, few studies have examined this question directly. Thus, this study compared autonomic function, as assessed by 24-hour heart rate variability (HRV) analysis, in 22 CFS patients (age range 31-69, mean age 45.5) versus healthy age- and gender-matched controls. Holter monitoring was performed on all subjects, and HRV data were evaluated by time domain, frequency domain and circadian rhythm analysis.

HRV in Chronic Fatigue Patients vs. Healthy Controls

In CFS patients, the SDNN index (mostly sympathetic) and RMS-SD (parasympathetic) measures were significantly lower than in controls. In the frequency domain, 5-minute total power, very low frequency (VLF; mostly sympathetic), low frequency (LF) and high frequency (HF; parasympathetic) power were all significantly lower in CFS patients (Figure 52). Circadian rhythm analysis indicated that differences in time and frequency domain measures between patients and controls were significant primarily during the daytime hours; 5-minute total power, LF power and HF power were also significantly lower in CFS patients during the latter part of the sleep cycle. There were no significant differences in mean heart rate or in the LF/HF ratio. Results indicate that autonomic function is indeed impaired in CFS patients, as both sympathetic and parasympathetic activity are significantly depressed with respect to healthy age and gender-matched controls. This suggests that autonomic exhaustion may play an important role in the pathophysiology of chronic fatigue.

Analysis of Twenty-Four Hour Heart Rate Variability in Patients with Panic Disorder

Rollin McCraty, PhD, Mike Atkinson, Dana Tomasino, BA and William P. Stuppy, MD. Biological Psychology. 2001; 56 (2-3): 131-150.

Key findings: Analysis of 24-hour heart rate variability in patients with panic disorder revealed that sympathetic nervous system activity is depressed with respect to healthy individuals, whereas parasympathetic activity is normal under usual life conditions.

Summary: Since most psychological disorders are really emotional disorders and emotions affect the autonomic nervous system, it is not surprising that autonomic dysfunction has been documented in a wide range of such disturbances. Recently, measurements of HRV have been used to investigate autonomic function in various affective disorders, and aberrant patterns of autonomic regulation have been observed in individuals with conditions including depression, generalized anxiety and worry. Growing evidence suggests that alterations in autonomic function may also contribute to the pathophysiology of panic disorder (PD).

This retrospective study employed 24-hour HRV analysis of Holter records to compare autonomic function in 38 PD patients with healthy, age- and gender-matched controls. Both time and frequency domain HRV measures were calculated and a circadian rhythm analysis was performed to compare HRV patterns during waking and sleeping hours.

Data showed that the SDNN index, 5-minute total power, very low frequency (VLF) and low frequency (LF) power were significantly lower in panic patients relative to healthy controls over the 24-hour period; hourly means were significantly lower during some of the waking hours as well as the latter part of the sleep cycle. In contrast, mean heart rate, RMSSD and high frequency (HF) power were comparable in patients and controls. These results suggest that sympathetic activity is depressed and parasympathetic tone normal in individuals with PD under usual life conditions.

Previous short-term HRV studies have suggested that patients with panic disorder may be characterized by exaggerated sympathetic reactivity and/or parasympathetic withdrawal in response to certain laboratory-administered autonomic nervous system challenges. This study’s 24-hour data extend previous findings, providing evidence that low baseline sympathetic tone and a relative predominance of parasympathetic activity characterize PD patients under nonchallenging conditions in their usual environments. If bouts of sympathetic hyperarousal are indeed implicated in the dramatic elevations in heart rate, blood pressure and other alarming somatic symptoms generally observed in panic attacks, it is possible that these surges of overactivity over time could lead to sympathetic exhaustion, causing the sympathetic system to adopt a lower set-point of baseline functioning.

HRV in Panic Disorder Patients vs. Healthy Controls

Findings of low HRV in PD patients are consistent with the high rate of cardiovascular morbidity and mortality in this population, since reduced HRV has been identified as a powerful predictor of heart disease and increased risk of sudden cardiac death. Furthermore, given that high variability in heart rate is considered a marker of flexible responsivity and stress resiliency, findings of low HRV in this patient population are also consistent with the emerging view of panic as a disorder involving reduced flexibility and adaptability across biological, affective and behavioral dimensions. In sum, this study expands understandings of autonomic function in panic disorder and adds to the growing body of data confirming the value of HRV analysis as a sensitive tool to explore the relationships between autonomic dysfunction and psychopathology.

The Heart Reinnervates After Transplantation

David A. Murphy, MD, Gregory W. Thompson, BS, Jeffrey L. Ardell, PhD, Rollin McCraty, PhD, Robert S. Stevenson, BS, Virgilio E. Sangalang, MD, Renÿ Cardinal, PhD, Michael Wilkinson, PhD, Sylvia Craig, DVM, Frank M. Smith, PhD, John G. Kingma, PhD and J. Andrew Armour, MD, PhD. Annals of Thoracic Surgery. 2000; 69: 1769-1781.

Key findings: One year after cardiac autotransplantation, sympathetic efferent nerves reinnervated canine hearts to some degree. Reinnervation by paraysmpathetic nerves occurred to a lesser extent, and was absent in some cases. Heart rate variability patterns in the transplanted heart may be due in part to rhythms generated by the heart’s intrinsic nervous system, which undergoes a functional remodeling process after cardiac transplantation.

Summary: Whether autonomic nerves reconnect to the heart after a heart transplant has remained controversial, despite extensive anatomical, physiological and pharmacological testing. Generally, heart transplant recipients tend to display little beat-to-beat heart rate variability, suggesting that cardiac autonomic neurons do not reinnervate the heart after transplantation. On the other hand, several studies have indicated that some variability does return post-transplant, which has been interpreted as evidence of autonomic reinnervation of the heart. Furthermore, those studies reporting reinnervation after transplantation have not elucidated the extent to which the sympathetic versus parasympathetic limb of the autonomic efferent nervous system influences the transplanted heart. Finally, recent evidence indicates that the heart’s intrinsic nervous system influences cardiodynamics and heart rate variability, thus providing a potential intrinsic source of HRV in the transplanted heart; however, the role played by this intrinisic nervous system in maintaining cardiac function after long-term heart transplantation remains unknown.

To help resolve these issues, IHM participated in a collaborative study with Dr. J. Andrew Armour of Dalhousie University in Halifax, Canada, an acknowledged leader in the field of neurocardiology. This investigation was undertaken (1) to determine whether sympathetic and parasympathetic efferent neurons reinnervate the mammalian heart by one year after transplantation; (2) if reinnervation does occur, to determine the functional capacity of sympathetic versus parasympathetic neurons to influence cardiodynamics one year post-operatively; (3) to determine whether HRV, as assessed by power spectral analysis throughout the year following transplantation, correlates to the patterns of functional reinnervation by sympathetic and parasympathetic efferent neurons, (4) to assess whether the intrinsic cardiac nervous system remodels itself after cardiac transplantation.

In this study, HRV was assessed for one year after cardiac autotransplantation in nine dogs. At 3, 6, 9 and 12 months following autotransplantation, IHM’s Research Center performed both time domain and power spectral analyses of 24-hour HRV from Holter recordings of these dogs. Holter monitoring and 24- hour HRV analysis was also performed on three control dogs (without operation) to obtain comparison data. At the conclusion of the year, a number of electrophysiological, histological, pharmacological and biochemical methods were used to determine if autonomic nerves reinnervated the transplanted hearts, and the extent to which sympathetic versus parasympathetic nerves influenced cardiac function in these animals.

It was found that cardiac autonomic nerves did reinnervate the heart to some degree, but in a sporadic and inconsistent manner. The degree of cardiac rein-nervation varied considerably from animal to animal. Overall, data showed that sympathetic neurons do reinnervate the canine heart within one year after transplantation, while parasympathetic neurons reinnervate the transplanted heart to a lesser extent, being absent in some cases. Interestingly, heart rate variability analysis was not able to predict either the extent of reinnervation or what type of reinnervation occurred in this study. Power spectral analysis revealed that the same spectral peaks present in normal dogs were also present in the autotransplanted animals, with little difference at 3, 6, 9 and 12 months post-transplantation. In fact, overall variability was greater in the transplanted group than in normal dogs.

This study also found that the intrinsic cardiac nervous system continues to function after transplantation and undergoes a remodeling process in order to sustain adequate cardiac function. These findings, coupled with the lack of correlation between HRV data and actual reinnervation patterns, suggests that heart rate variability after heart transplantation may be related not only to reinnervation of the heart by extrinsic efferent autonomic nerves, but also to the influence of intrinsic cardiac neurons. This would indicate that the heart is capable of generating complex rhythms and patterns independent of input from the brain and central nervous system. Among the clinical implications of this study is that remodeling of the intrinsic cardiac nervous system should be taken into consideration when studying the functional status of the heart after transplantation.

Heart Rhythms Generated by a Transplanted Heart

Auto-Transplant