Novel Virtual Reality Intervention for Stress Reduction Among Patients With or at Risk for Cardiovascular Disease: Mixed Methods Pilot Study

Abstract

Background: Virtual reality (VR) has emerged as a promising, low-risk strategy to manage many forms of psychological stress and may be a modality to improve cardiovascular health. Recent scientific statements on the mind-heart-body connection call for better adherence to psychological screening and adoption of more holistic "behavioral cardiology" interventions that improve the overall health of patients with or at risk for cardiovascular disease (CVD).

Objective: The aim of this study is to assess safety and preliminarily explore how a VR experience can aid in stress reduction among patients with or at risk for CVD.

Methods: A convergent mixed methods approach was used for this single-arm prospective pilot study. In total, 20 patients were recruited from the University of California Los Angeles adult cardiology clinics and cardiac rehabilitation. Surveys and physiologic parameters were collected before, during, and after a 30-minute VR experience aimed at relaxation. The primary outcome was the State-Trait Anxiety Inventory-State (STAI-S) scale. They participated in a 90-minute visit, during which they completed surveys, including the STAI-S scale, before and after a 30-minute VR experience. Physiological parameters were also collected before, during, and after the experience. Visits concluded with semistructured interviews analyzed with inductive thematic analysis to add depth and nuance to our analysis.

Results: STAI-S scale scores after the VR experience were significantly decreased from baseline (median 31, IQR 28-38 vs median 24, IQR-29.25; P<.001). Verbal feedback revealed that participants experienced a relaxing sense of "distance from stress" moderated by unexpected, intense audiovisual components. Heart rate significantly decreased (mean 73, SD 8 vs mean 67, SD 6 beats per minute; P<.001), while blood pressure (mean systolic 128, SD 14 vs mean systolic 129, SD 18 mm Hg; P=.75 and mean diastolic 79, SD 9 vs mean diastolic 80, SD 10 mm Hg; P=.60) and galvanic skin response (mean 0.74, SD 0.89 vs mean 0.70, SD 0.57 microsiemens; P=.45) remained the same. Changes in heart rate variability parameters were consistent with increased vagal tone over time but were only statistically significant at certain time points. Survey results and interviews generally indicated safety, tolerability, and openness to using VR again.

Conclusions: This sample of patients with CVD or risk of CVD had above-average stress, consistent with epidemiological data; the statistically and clinically significant decrease in subjective perception of stress partially converged with physiologic data. Overall, the VR intervention was a safe and feasible stress reduction method. Future research is needed to evaluate the effectiveness of this immersive therapy in reducing cardiovascular risk profiles.

Keywords: CVD; behavioral cardiology; blood pressure; cardiac rehabilitation; cardiology; cardiovascular disease; digital health; heart disease risk factors; heart rate; mixed methods; pilot; risk; stress; stress reduction; survey; virtual reality.

Figure 1.. Study procedure flowchart. GSR: galvanic skin response; HR: heart rate; HRV: heart rate variability.

Figure 2.. Representative images of virtual reality experience (courtesy of Harmony Media).

Figure 3.. Change in average heart rate (beats per minute). Error bars represent SE. Post: recorded 5 minutes after experience; Pre: recorded 5-10 minutes before experience. *P<.001.

Figure 4.. Change in median RMSSD (milliseconds). Error bars represent SE. Post: recorded 5 minutes after experience; Pre: recorded 5-10 minutes before experience; RMSSD: root-mean-square of successive differences.

Figure 5.. Change in relative frequency band power. HF: high frequency; LF: low frequency; Post: recorded 5 minutes after experience; Pre: recorded 5-10 minutes before experience; VLF: very low frequency. *P<.05 (see Multimedia Appendix 1 for specific values).

Figure 6.. Change in median LF:HF ratio. HF: high frequency; LF: low frequency; Post: recorded 5 minutes after experience; Pre: recorded 5-10 minutes before experience.

Figure 7.. Qualitative interview results using inductive thematic analysis: 4 themes and 2 subthemes. VR: virtual reality.