Patients in cardiac rehabilitation programs may have fewer complications when the training includes stress management, a recent study suggests.

Compared to patients who didn't receive stress reduction training, those who did had a 50 percent lower risk of complications like heart attacks and strokes, the study found.

"We know that exercise alone has important psychological benefits - and improves overall health, said lead study author James Blumenthal, a psychiatry researcher at Duke University in Durham, North Carolina. In this study, he noted, adding stress management to comprehensive, exercise-based cardiac rehab provided even further benefit.

All 151 heart disease patients in the study received 12 weeks of exercise-based rehab. Half of them also got weekly group sessions for stress management that focused on things like relaxation techniques and coping skills.

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Researchers also tracked an additional 75 patients who were similar to the rehab participants in age and health status but opted not to join the exercise program.

Half the patients were followed for at least three years.

All rehab participants completed questionnaires measuring depression, anxiety, anger and stress. They also had tests to assess biomarkers of heart health such as cholesterol and heart rate.

As reported in the American Heart Association journal Circulation, the people who received rehab and stress management fared better than everyone else. In this group, 18 percent died or experienced cardiac events such as heart attacks, strokes or recurrent chest pains requiring hospitalization.

For the group that only received rehab, 33 percent experienced these cardiac events, as did 47 percent of the group that opted against rehab.

Due to its small size, the study didn't include many deaths or serious cardiac events, the authors note. The study was also too small to measure the effects of specific interventions designed to reduce stress.

Researchers also didn't assess why certain people opted against rehab, and it's possible these patients differed in their medical, financial or social circumstances in some way that influenced the study results.

Still, the findings suggest that this approach may help improve cardiac rehab programs, which are standard for patients with heart disease, said Dr. Eric Aldrich, a researcher in neurology and rehabilitation at Johns Hopkins University School of Medicine in Baltimore and vice president for medical affairs at Howard County General Hospital.

"Given that heart disease is the leading cause of death in the U.S., this could represent a new treatment that will help us reduce the impact of this disease," Aldrich, who wasn't involved in the study, said by email.

Even though stress management may help, it isn't a panacea, cautioned Dr. Rod Taylor of the Institute of Health Research at the University of Exeter Medical School in the U.K.

"Stress management is not curative therapy, does not necessarily reverse the underlying disease, and will not work for all patients - so hence some patients will continue to have adverse outcomes," Taylor, who wasn't involved in the study, said by email.