Behavioral Cardiology - Where the Heart and Head Meet

Behavioral Cardiology - Where the Heart and Head Meet

Thomas Randal J
European Cardiology 2006
Published: November 2005
download article
dots

The need for a patient to consult a cardiologist can be exemplified by the case a 65-year-old man who recently suffered an anterior wall myocardial infarction (MI) and who has been participating in cardiac rehabilitation, who presents with feelings of overwhelming depression and hopelessness. On three occasions since his hospitalization he has been evaluated in the local emergency department (ED) for recurrent chest symptoms. Each time his evaluations have been suggestive of non-cardiac causes for his symptoms and he has been advised to continue with his recommended medications with follow-up through his primary care provider (PCP). After these processes, it is time for the cardiologist to identify and treat the cause of his current distress.

While this case is somewhat extreme and unusual, it is not uncommon. It typifies an unusual dilemma in current cardiovascular (CV) healthcare-coronary artery disease risk is associated with certain psychosocial factors, such as depression, yet treatments that effectively treat both psychosocial and coronary artery disease outcomes have been somewhat elusive. Results of recent clinical research have strengthened the understanding and management of the links between psychosocial and CV health, and have moved the field of behavioral cardiology steadily closer into the mainstream of current clinical cardiology.1,2

Behavioral cardiology is the study and application of psychosocial factors in the assessment and reduction of coronary artery disease risk. It is an important field for a number of reasons, including:

  • adverse psychosocial factors are common in persons with coronary artery disease,3 with up to 50% of survivors of MI having evidence of significant anxiety and/or depressive disorders;4
  • the presence of adverse psychosocial factors can significantly worsen coronary artery disease risk and prognosis;5-12 and
  • psychosocial health status is generally responsive to behavioral and pharmacologic therapies.13,16

Behavioral cardiology is a complex field, as with many areas within behavioral medicine, and is one that hinges largely on the ability of non-behavioralists (generally cardiologists) to identify affected patients and to initiate the early steps in their psychosocial care. CV clinicians are in an important position to identify and help individuals with co-existing coronary artery disease and psychosocial distress because they are often among the first to see patients during and after coronary artery disease events (MI and coronary artery bypass surgery, etc.)—a time when adverse psychosocial factors may become more visible and when patients are often more open to therapeutic recommendations.

Behavioral and Psychosocial Factors and coronary artery disease Risk

Certain behavioral lifestyle factors, such as cigarette smoking, dietary intake, and physical activity, have been strongly linked to risk of coronary artery disease events and are common targets for therapeutic lifestyle change recommendations. These and other traditional coronary artery disease risk factors, such as family history of coronary artery disease and diabetes, are thought to explain up to 70% to 80% of coronary artery disease risk.17,18 Other factors, including various psychosocial and novel biologic factors, may help explain the remaining 20% to 30% of coronary artery disease risk variability.

Psychosocial factors are generally not included in multivariate predictive models of coronary artery disease risk prediction, such as those from the Framingham Heart Study, despite the fact that the strength of their association with coronary artery disease is similar to the risk factors included in coronary artery disease risk prediction equations—hypertension, smoking, diabetes, and hyperlipidemia.19,20 Psychosocial factors associated with coronary artery disease risk include some with negative and others with positive relationships to coronary artery disease (see Table 1). Psychosocial factors that have a negative influence on coronary artery disease risk include depression, anxiety, anger, hostility, and chronic stressors such as social isolation, low socioeconomic status, and chronic strain from difficult interpersonal relationships and/or responsibilities (occupational and caregiver roles, for example).1,5-12 Depression has been identified for many years as perhaps the strongest negative psychosocial risk factor for coronary artery disease risk,8 increasing the risk of morbidity and mortality by more than two-fold in people with existing coronary artery disease.21

1234next ›last »
References:
  1. Rozanski A, Blumenthal J A, Davidson K W, Saab P G, Kubzansky L, “The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology”, J. Am. Coll. Cardiol. (2005);45(5): pp. 637–651.
  2. Pickering T, Clemow L, Davidson K, Gerin W, “Behavioral cardiology—has its time finally arrived?”, Mt Sinai J. Med. (2003);70: pp. 101–112.
  3. Bankier B, Januzzi J L, Littman A B, “The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease”, Psychosom. Med. (2004);66: pp. 645–650.
  4. Lane D, Carroll D, Ring C, Beevers D G, Lip G Y, “The prevalence and persistence of depression and anxiety following myocardial infarction”, Br. J. Health Psychol. (2002);7(pt 1): pp. 11–21.
  5. Strike P C, Steptoe A, “Psychosocial factors in the development of coronary artery disease”, Progress. Cardiovasc. Dis. (2004);46: pp. 337–347.
  6. Frasure-Smith N, Lesperance F, “Reflections on depression as a cardiac risk factor”, Psychosom. Med. (2005);67 suppl. 1: pp. S19–S25.
  7. Ramachandruni S, Handberg E, Sheps D S,“Acute and chronic psychological stress in coronary disease”, Curr. Opin Cardiol. (2004);19: pp. 494–499.
  8. Haynes S G, Feinleib M, Kannel W B, “The relationship of psychosocial factors to coronary heart disease in the Framingham Study. III. Eight-year incidence of coronary heart disease”, Am. J. Epidemiol. (1980);111: pp. 37–58.
  9. Rutledge T, Reis S E, Olson M et al., National Heart, Lung, and Blood Institute, “Social networks are associated with lower mortality rates among women with suspected coronary disease: the National Heart, Lung, and Blood Institute-Sponsored Women’s Ischemia Syndrome Evaluation study”, Psychosom Med. (2004);66: pp. 882–888.
  10. Rowan P J, Haas D, Campbell J A, Maclean D R, Davidson K W,“Depressive symptoms have an independent, gradient risk for coronary heart disease incidence in a random, population-based sample”, Ann. Epidemiol. (2005);15: pp. 316–320.
  11. Todaro J F, Shen B J, Niaura R, Spiro A 3rd,Ward K D,“Effect of negative emotions on frequency of coronary heart disease (The Normative Aging Study)”, Am. J. Cardiol. (2003);92: pp. 901–906.
  12. Everson-Rose S A, Lewis T T, “Psychosocial factors and cardiovascular diseases”, Annu. Rev. Public Health. (2005);26: pp. 469–500.
  13. Sebregts E H, Falger P R, Appels A, Kester A D, Bar F W, “Psychological effects of a short behavior modification program in patients with acute myocardial infarction or coronary artery bypass grafting. A randomized controlled trial”, J. Psychosom. Res. (2005);58: pp. 417–424.
  14. Lett H S, Davidson J, Blumenthal J A, “Nonpharmacologic treatments for depression in patients with coronary heart disease”, Psychosom. Med. (2005);67 suppl. 1:S58–S62.
  15. Roose S P, Miyazaki M,“Pharmacologic treatment of depression in patients with heart disease”, Psychosom. Med. (2005);67 suppl. 1:S54–S57.
  16. Lavie C J, Milani R V, “Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training”,Mayo Clin. Proc. (March 2005);80: pp. 335–342.
  17. Emberson J R,Whincup P H, Morris R W,Walker M, “Re-assessing the contribution of serum total cholesterol, blood pressure and cigarette smoking to the aetiology of coronary heart disease: impact of regression dilution bias”, Eur. Heart J. (2003);24: pp. 1,719–1,726.
  18. Daviglus M L, Stamler J, Pirzada A et al., “Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality”, JAMA (October 6 2004);292(13): pp. 1,588–1,592.
  19. Lloyd-Jones D M, Wilson P W, Larson M G et al., “Framingham risk score and prediction of lifetime risk for coronary heart disease”, Am. J. Cardiol. (July 1 2004);94(1): pp. 20–24.
  20. Rugulies R, “Depression as a predictor for coronary heart disease.A review and meta-analysis”, Am. J. Prev. Med. (2002);23: pp. 51–61.
  21. van Melle J P, de Jonge P, Spijkerman T A et al.,“Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis”, Psychosom. Med. (2004);66: pp. 814–822.
  22. Bruce E C, Musselman D L, “Depression, alterations in platelet function, and ischemic heart disease”, Psychosom. Med. (2005);67 suppl. 1:S34–36.
  23. Carney R M, Freedland K E,Veith R C,“Depression, the autonomic nervous system, and coronary heart disease”, Psychosom. Med. (2005);67 suppl. 1:S29–S33.
  24. Carney R M, Blumenthal J A, Freedland K E et al.,“Low heart rate variability and the effect of depression on post-myocardial infarction mortality”, Arch. Intern. Med. (2005);165: pp. 1,486–1,491.
  25. Lawler K A,Younger J W, Piferi R L et al.,“A change of heart: cardiovascular correlates of forgiveness in response to interpersonal conflict”, J. Behav. Med. (2003);26: pp. 373–393.
  26. Gerin W, Pieper C, Levy R, Pickering T G, “Social support in social interaction: a moderator of cardiovascular reactivity”, Psychosom. Med. (1992);54: pp. 324–336.
  27. Kubzansky L D, Sparrow D,Vokonas P, Kawachi I, “Is the glass half empty or half full? A prospective study of optimism and coronary heart disease in the normative aging study”, Psychosom. Med. (2001);63: pp. 910–916.
  28. Rozanski A, Kubzansky L D, “Psychologic functioning and physical health: a paradigm of flexibility”, Psychosom. Med. (2005);67 suppl. 1:S47–S53.
  29. O’Keefe J H Jr, Poston W S, Haddock C K, Moe R M, Harris W,“Psychosocial stress and cardiovascular disease: how to heal a broken heart”, Comp.Ther. (2004);30: pp. 37–43.
  30. Clark A, Seidler A, Miller M, “Inverse association between sense of humor and coronary heart disease”, Int. J. Cardiol. (2001);80: pp. 87–88.
  31. Fredrickson B L, Levenson R W,“Positive emotions speed recovery from the cardiovascular sequelae of negative emotions”, Cogn. Emotion (1998);12: pp. 191–220.
  32. Cohen S, Doyle W J,Turner R B,Alper C M, Skoner D P,“Emotional style and susceptibility to the common cold”, Psychosom. Med. (2003);65: pp. 652–657.
  33. Peyrot M, McMurry J F Jr, Kruger D F, “A biopsychosocial model of glycemic control in diabetes: stress, coping and regimen adherence”, J. Health Soc. Behav. (1999);40(2): pp. 141–158.
  34. Ziegelstein R C, Kim S Y, Kao D et al., “Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening?”, Psychosom. Med. (2005);67: pp. 393–397.
  35. Blumenthal J A, Babyak M A, Carney R M et al., “Exercise, depression, and mortality after myocardial infarction in the ENRICHD trial”, Med. Sci. Sports Exerc. (2004);36: pp. 746–755.
  36. Berkman L F, Blumenthal J, Burg M et al., “Enhancing Recovery in Coronary Heart Disease Patients Investigators (ENRICHD). Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial”, JAMA (2003);289: pp. 3,106–3,116.
  37. Glassman A H, O’Connor C M, Califf R M et al., “Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) Group. Sertraline treatment of major depression in patients with acute MI or unstable angina”, JAMA (2002);288: pp. 701–719.
  38. Taylor C B,Youngblood M E, Catellier D et al.,“ENRICHD Investigators. Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction”, Arch. Gen. Psychiatry (2005);62: pp. 792–798.
  39. Blumenthal J A,Wei J, Babyak M et al., “Stress management and exercise training in cardiac patients with myocardial ischemia: effects on prognosis and on makers of myocardial ischemia”, Arch. Intern. Med. (1997);157: pp. 2,213–2,223.
  40. Blumenthal J A, Babyak M,Wei J et al., “Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men”, Am. J. Cardiol. (2002);89: pp. 164–168.
  41. Janz N K, Dodge J A, Janevic M R et al., “Understanding and reducing stress and psychological distress in older women with heart disease”, J.Women Aging (2004);16: pp. 19–38.
  42. Bennett M P, Zeller J M, Rosenberg L, McCann J, “The effect of mirthful laughter on stress and natural killer cell activity”, Altern.Ther. Health Med. (2003);9: pp. 38–45.
  43. Netz Y,Wu M J, Becker B J,Tenenbaum G, “Physical activity and psychological well-being in advanced age: a meta-analysis of intervention studies”, Psychol.Aging (2005);20: pp. 272–284.
  44. Haskell W L, “Cardiovascular disease prevention and lifestyle interventions. Effectiveness and efficacy”, J. Cardiovasc. Nurs. (2003);18: pp. 245–255.
  45. Glasgow R E, Goldstein M G, Ockene J K, Pronk N P, “Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care”, Am. J. Prev. Med. (2004);27(suppl. 2): pp. 88–101.
  46. DeBusk R F, Miller N H, Superko H R et al., “A case-management system for coronary risk factor modification after acute myocardial infarction”, Ann. Intern. Med. (1994);120: pp. 721–729.

add new comment Comments


Have something to say? Post a comment on this article!