Special Issue: The Promise of Cardio-Plasticity: Psychophysiological Approaches to Cardiovascular Rehabilitation

The cover photo shows Dana Schneeberger, a member of the Cleveland Clinic heart transplant research team, going to the operating room to recover an explanted failing heart to be used in laboratory research. The cover article by Christine S. Moravec and Michael G. McKee of the Cleveland Clinic describes how their research on patients awaiting heart transplant has raised hope that biofeedback may benefit patients with chronic heart failure. (My thanks to the Cleveland Clinic for the photo.)This Special Issue explores “The Promise of Cardio-Plasticity.” The meaning of cardio-plasticity is best understood by the analogy of neuroplasticity. Both heart disease and brain damage were once considered to be irreversible processes, one-way pathways toward loss of function and often death. The concept of neuroplasticity was developed to suggest that there is hope for patients with brain damage from head injuries and stroke. The brain can reorganize neural pathways and, to a limited extent, regenerate neural tissue to support the recovery of lost intellectual functions. It remains “plastic” and subject to change even after critical damage.The research reported in the lead article in this Special Issue, by Drs. Moravec and McKee raises similar hope for cardio-plasticity, that is, the suggestion of previously unexpected recovery of cardiovascular function. Their past research showed that patients whose cardiac pumping function was taken over by a Left Ventricular Assistive Device (LVAD—an artificial pump), allowing heart muscle to rest while awaiting transplant, showed a significant restoration or “remodeling” of the patients' depleted hearts. When the natural hearts were removed at the time patients later received transplants, the remodeling was evident in heart cells and heart muscle.In a later phase of their research, the Cleveland Clinic team provided biofeedback to a subgroup of the patients awaiting heart transplant. Amazingly, they found that biofeedback may cause some of the same remodeling that was caused by the LVAD device in their earlier research.This Special Issue of Biofeedback includes articles by leading figures in psychophysiology, examining cardiovascular physiology and its role in cardiac disease and in cardiac rehabilitation. Until now, medical practice has given a relatively small place to behavioral intervention in cardiovascular rehabilitation. Stress management has been shown in research to be as effective as, and sometimes more effective than, exercise in cardiac rehabilitation (Blumenthal et al., 1997). Similarly, negative emotion, and especially depression and hostility, have been identified as destructive for heart health (Carney et al., 2001; Dembrowski, MacDougall, Williams, Haney, & Blumenthal, 1985; Kawachi et al., 1996). Ornish showed in carefully replicated research that a combination of vegetarian diet, meditation, yoga, and stress management were effective in reversing many parameters of coronary artery disease, including atherosclerosis (Ornish, 1996; Ornish et al., 1998; Silberman et al., 2010). Recent small studies have shown a positive role for biofeedback, specifically heart rate variability (HRV) biofeedback, in cardiovascular rehabilitation in patients with moderate disease (Del Pozo, Gevirtz, Scher, & Guarneri, 2004). However, most cardiac rehabilitation has continued to emphasize physical exercise over behavioral and emotional interventions. Jan Newman, in this issue, provides a more detailed picture of the research evidence that behavioral and emotional factors are critical in heart disease. This Special Issue claims a larger place for behavioral intervention and specifically for biofeedback in the treatment of cardiovascular disease.An article by Fredric Shaffer, Judy Crawford, and Donald Moss announces a new Biofeedback Certification International Alliance (BCIA) “Certificate of Completion” program in heart rate variability biofeedback, which attests that a professional has completed an approved and standardized course of education and training in HRV biofeedback. The Certificate of Completion is a new concept and new path for BCIA, and the advantages of such a certificate are discussed in the Shaffer article. The BCIA has announced a specific “blueprint of knowledge,” which describes a 19-hour didactic training sequence covering knowledge in nine distinct areas. This is a useful new program, assuring a clearer standard for excellence in this emerging practice area of HRV biofeedback.The lead article by Christine Moravec and Michael McKee shows the potential therapeutic benefit of biofeedback with end-stage heart failure patients: one of the most challenging groups for intervention. Eight of the 12 patients that they treated with biofeedback showed some degree of recovery in functional alterations in heart cells and heart muscle after biofeedback—that is, a reversal in markers for heart failure!Fredric Shaffer and John Venner provide a detailed review of the anatomy and physiology of heart rate variability. They also examine the medical implications of HRV biofeedback for both cardiovascular rehabilitation and inflammatory disorders.Paul Lehrer, the pioneer who brought the concept of HRV biofeedback training to the United States, provides an article examining current conceptual models for the effects of HRV biofeedback, including effects on the cardiovascular system, the respiratory system, and emotional reactivity. He examines the concept of resonance in the cardiovascular system, and the role of the “baroreceptor system” (the regulatory receptors in the blood pressure system) in HRV biofeedback training.Richard Gevirtz emphasizes the growing recognition today, that the parasympathetic nervous system plays a critical role in the progression of heart disease. In the past, research on the impact of stress on the heart emphasized an overactivation of the sympathetic nervous system. Today, the problem of diminished parasympathetic activity (or vagal activity) receives greater emphasis, leading to such therapeutic breakthroughs as the use of vagal nerve stimulation in heart disease. Gevirtz emphasizes that heart rate variability biofeedback training offers a benign pathway to enhance vagal tone (improving parasympathetic activation) and improve cardiovascular function, with minimal adverse effects.Finally, Jan Newman summarizes the research on the role of the emotions and stress in cardiovascular disease. She highlights the negative role that anxiety, anger, depression, and stress play on cardiovascular function. She highlights the twin processes of sympathetic activation and parasympathetic withdrawal as heart disease progresses. She emphasizes today's emerging biomedical therapies for heart disease, including medication, sympathetic nervous system ablation, and vagal nerve stimulation. Finally, she argues that biofeedback, especially heart rate variability biofeedback, can provide an effective intervention for managing the autonomic dysregulation that seems to play such a central role in the various forms of heart disease.