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James et al. in their study demonstrated an increase in QT dispersion as a result of psychological stress in patients with coronary artery disease. The authors suggest that ischaemia is a critical component of the response to psychological stress and mention beta-blocker therapy as one of the underlying issues. Yet in the studied patients the increase in QT dispersion was observed both in patients taking beta-adrenergic blockers and in those not using these drugs. In our opinion this clearly underlines the need for further evaluation of non-pharmacological therapeutic approaches to psychological stress in coronary artery disease. The working group of Hoffman et al. demonstrated reduced sympathetic nervous system responsivity after regular elicitation of the relaxation response. Blumenthal et al. conducted a randomized trial with 107 patients with coronary artery disease and ischaemia during mental stress testing. Patients assigned to a 4-month programme of stress management had significantly fewer cardiac events and ambulatory ischaemia in the follow-up of 4 years. Relaxation techniques were also successfully implemented in situations which are associated with an increased risk of cardiac arrhythmias, such as cardiac surgery. James’s study further points to the therapeutic potential that lies in the reduction of mental stress in patients with coronary artery disease. In our clinic, all inpatients with cardiac arrhythmias and coronary artery disease are treated with relaxation techniques; patients appreciate it as an instrument for self-help and show excellent compliance. There is, however, a need to compare the already evaluated methods of mental stress testing in order to better select patients for stress therapy. Furthermore, intervention trials should not only focus on beta-adrenergic blockers but evaluate the efficacy of relaxation techniques and stress reduction programmes in cardiac patients at risk. This will hopefully be useful in closing the gap between theory and clinical practice in stress-reduction treatments in patients with coronary artery disease.

european heart journal

Use of low-molecular-weight heparin as bridge anticoagulation therapy in patients with atrial fibrillation undergoing transoesophageal echocardiography guided cardioversion