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Behavioral Cardiovascular Risk Factors: Changing Perspective to Approach the Problem

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  • Casa di Cura Talamoni Lecco Italy

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Several studies indicate that psychological factors strongly influence the neuro hormonal and behavioral cardiovascular risk factors and the course of coronary artery disease and event onset. New epidemiologic evidence for the association between psychosocial risk factors and coronary artery disease identifies pathologic mechanisms that may be responsible for this association. Not much attention is paid to finding and managing the stressing factors that provoke psychological distress and then multiple adverse peripheral effects. This short review highlights a new way to look at the behavioral risk factors; putting attention to what there is behind the onset of stress and psychological distress that are related with cardiovascular risk factors, atherosclerosis and events. The role of cardiologist in finding out, assessing and managing stressors and behavioral risk factors is emphasized and an emerging cardiological field based on the understanding that psycho behavioral risk factors require a new approach and a new more effective health care system is suggested.
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Review Article
Volume 2 Issue 1 - November 2016
DOI: 10.19080/JOCCT.2016.02.555577
J Cardiol & Cardiovasc Ther
Copyright © All rights are reserved by Giuseppe Gullace
Behavioral Cardiovascular Risk Factors: Changing
Perspective to Approach the Problem
Giuseppe Gullace *
Consultant Cardiologist, Multimedica Hospital Group, Italy
Submission: October 25, 2016; Published: November 09, 2016
*Corresponding author: Giuseppe Gullace, Consultant Cardiologist, Multimedica Hospital Group, Via San Leonardo 11 23864 Malgrate (Lecco),
Italy, Tel: ; Email:
Abstract

      
         

      
   
  

Keywords:
Introduction
Atherosclerosis is a multi factorial disease of polygenic
inheritance and the interrelation with environmental and
social factors adds to complexity of the disease; in addition

       
cardiovascular and cerebrovascular diseases has been widely
      
      
as obesity, hypertension, physical inactivity, dyslipidemia,
diabetes) and psychosocial (such as stress, depression, anxiety,
type A personality, hostility and anger) [1-7]. The use of
 
         
term follow-up of the Framingham Offspring cohort [8] allowed
        
and overall cardiovascular event. However, depending on this
        

The European action on secondary prevention through
      
out in eight European countries [9] reports that despite
    
        
obesity and diabetes were seen in patients with established
        
factors for the development of atherosclerotic disease, which


present in 50 % of those who develop atherosclerotic problems
[10]. These individuals appear to have other genetic disorders or


Moreover, epidemiological research suggests that
psychological factors, stress and undesirable social
circumstances play an important role in the occurrence of
various cardiovascular diseases [11,12] and are considered
        
prone behavior pattern, called type A, that was originally
described by Friedman & Rosenman [13] in the late 1950’s,
has been considered a clinically derived behavioral syndrome
  
strong job involvement. Characteristics as anger or aggression
of a group of patients have been demonstrated to be important
J Cardiol & Cardiovasc Ther 2(1): JOCCT.MS.ID.555577 (2016) 001
Journal of
Cardiology & Cardiovascular Therapy
ISSN: 2474-7580
How to cite this article: Giuseppe G. Behavioral Cardiovascular Risk Factors: Changing Perspective to Approach the Problem. J Cardiol & Cardiovasc
Ther. 2016; 2(1): 555577. DOI: 10.19080/JOCCT.2016.02.555577
002
Journal of Cardiology & Cardiovascular erapy
factors for cardiovascular and cerebrovascular disease [14] and
to be related to carotid atherosclerosis, while depression was
associated with endothelial dysfunction in diabetic patients
[15], predicts incident coronary artery disease and worsens its
prognosis [16-19], and anxiety is considered an independent
        
mortality following acute myocardial infarction and cardiac
events [20,21]. In addition, there are different lifestyle behaviors
        
promote atherosclerosis and cardiac events, including unhealthy

are related to emotional status and experience of chronic stress
[22].
Purpose
As reported above, the relationship among cardiovascular

occurrence appears a complex and intriguing issue not yet
completely and fully disentangled. The relationship between
psychological (stress, anxiety, depression, etc.) and behavioral
       
        
hypertension, diabetes and dyslipidemia) factors is one of the
interesting issues that we try to deal with in the present paper

at them from a different point of view.
The Current Way
We are convinced, from a wide literature and daily practice,
that the four pillars of good health, related to the individual’s
lifestyle and depending on his behavior, are:
 
ii. Eating little
 
iv. Sex a lot

   
obesity is highly present in general population, only less than
50% of adult people practice regular physical activity and sexual
        
psychological, social, economic, political, cultural, ethical, legal,
historical, religious, and spiritual factors; but also by violence
   

For the latter, the report concludes: “Sexual and reproductive
health is fundamental to the social and economic development of
 
 
[23]. All of them are related to person’s psychological factors,
behavior and life style.
Within this context, we note that although cardiologists are
accustomed to managing lifestyle behaviors such as overeating,
        
       
their limited time, interest or familiarity with effective strategies
and recommendations [24] or because a systematic review,

counseling, is associated with favorable but modest changes
         

For instance, regarding physical activity, only 47% of primary
care physicians include an exercise history as part of their initial
examination, whereas13% of patients report physicians giving
advice about exercise and physically active physicians are more
         
main issue of this situation is that the four pillars of good healthy

 
the relationship with either the inside self emotions and feelings
or the outside, people and events included. More attention
should be paid to study all these aspects.
The structure of the individual
        
       
mechanisms are strictly related to social behaviors whose main
 
       
means that neuro hormonal structure of individual is related to

[29]. There exisists a wide literature reported in an interesting
review [30] that lists the numerous examples of reciprocal
 
         
psychological components that may be central to developing


of energy and enthusiasm and a sense of aliveness [31]; it is
         
fueled by both a sense of purpose and a sense of self-worth and
connotes a sense of positive excitement [24] and attitude.
Vitality promotes two adaptive responses (which may in turn
   
positive response mechanisms (such as patience, discipline,
       
optimism) and emotional competence, that represents the ability
to regulate emotions across a range of situations [32], important
  
   
terms of a greater sense of vitality; this provides energy needed
to develop and mantain greater emotional competence and
How to cite this article: Giuseppe G. Behavioral Cardiovascular Risk Factors: Changing Perspective to Approach the Problem. J Cardiol & Cardiovasc
Ther. 2016; 2(1): 555577. DOI: 10.19080/JOCCT.2016.02.555577
003
Journal of Cardiology & Cardiovascular erapy

force for maintaining a sense of vitality [24].
All this process well represents the individual’s relationship
(balance) between inner and outer and between neuro
hormonal and psycho behavioral structures. When several
factors negatively affect the structures the relationship is
unbalanced and anxiety, depression, stress, affective disorders

responses that cause multiple peripheral adverse effects such as
endothelial dysfunction, insulin resistance, obesity, hypertension,
      
is evident that stress as a complex of several psychological
situations, is the effect of multiple long acting factors that
progressively determine unbalancing of neuro hormonal and
psycho behavioral structures reducing the sense of purpose
and the sense of self-worth negatively modifying vitality,
emotional competence and positive response mechanisms and

Changing perspective to approach the problem

   
psychologist and philosopher [34]. This is very useful to do
  
and complex and the solutions to problems are confused and

           
solutions or the best one or when a new way to cope situations
and problems is needed to give suitable answers and acceptable
       
      
  
reported above it is important to experiment a new point of view
orienting the attention towards person’s perception of them
       


persons have, either with themselves (inner) or with the others


process: (Figure 1) where several factors disturb along the time
      
stress; this induces multiple adverse peripheral effects related to

Figure 1: Process as a ow chart.

more attention to the persons (subjects or preclinical patients),
striving to understand what there is behind them that pushes to
unsuitable and deleterious lifestyle. Hippocrates wrote that “it



        
Investigators and clinical practitioners pay great attention to the

factors and their potential effect on disease onset [35]. However,
at the same time, literature is stingy in considering, for example,
        
the cause of something but rather the effect of an incorrect and
inappropriate interpretation and management of relationships
that persons establish with those.
        
experimented orienting the attention towards what there
is behind their onset. A statement from the World Health
        
social values and health behavior without creating the
       
      
and coronary artery disease suggests that cardiologists and
physicians in general need to be proactive in addressing this
important aspect of patient care [25]. Querying patients about

How to cite this article: Giuseppe G. Behavioral Cardiovascular Risk Factors: Changing Perspective to Approach the Problem. J Cardiol & Cardiovasc
Ther. 2016; 2(1): 555577. DOI: 10.19080/JOCCT.2016.02.555577
004
Journal of Cardiology & Cardiovascular erapy
are important and relevant to providing optimal care. Screening
has been suggested using structured interviews or validated
        
history and assessment of the patient additional information
      
emotional factors, such as depression, anxiety, and anger;
         
somatic complaints that maybe stress-related, such as fatigue
and disrupted sleep [25].

          
        
distress; more attention should be paid to the patient’s neuro
       
the level of factor stressors, what is disturbing the patient
         
infarction or post heart surgery patients usually come daily to


they can change their deleterious lifestyle; we cannot dismiss
          
psyco behavioral problems trying to identify and understand
the distress stressor factors and helping him to remove them.
The role of the cardiologist is important by exploring various
ways for effective clinical involvement and also by managing
       
involvement of other specialists is recommended [37-39].
In our daily experience with patients’ problems we use,
with positive results in the majority of them, an approach in
         
 

 

is disturbing or not and help him in his decision to remove them;
 
          
        
cardiovascular diseases, relationship among neuro hormonal
structure and function, behavior and cardiovascular apparatus
are given.

          
of view, to give him the necessary information to better manage
his disturbing factors and to help him to recover the emotional
energy and the positive sense of purpose and self worth: in few

at the future in a better way.
The Way Forward

perception of themselves regarding their internal world and
wishing to be themselves balanced against the external world
are the main topics to be stressed in the incoming future, and
cardiologists and all the specialists involved, should play a
preminent role in promoting more attention, more time to
spend and more research for a better comprehension of stress

time to dedicate to treatment. Behavioral Cardiology could be
         
manage and treat stressing factors that produce adverse
lifestyle behaviors, emotional distress, and chronic life stress
contributing to promote atherosclerosis and adverse cardiac

  
       
distress and , recovering the old way of medical profession’s
 
the disease.
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
11.  

12.  

How to cite this article: Giuseppe G. Behavioral Cardiovascular Risk Factors: Changing Perspective to Approach the Problem. J Cardiol & Cardiovasc
Ther. 2016; 2(1): 555577. DOI: 10.19080/JOCCT.2016.02.555577
005
Journal of Cardiology & Cardiovascular erapy
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  
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 
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           
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

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        
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  
         
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
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26.           


27.      
  
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
16(4): 307-313.
29. 
relationship to social psychology. Soc Cogn 28(6): 675-685.
30. Marta C Soares, Redouan Bshary, Leonida Fusani, Wolfgang Goymann,
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
31.          
  
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 

33.      
         
      
15(7): 482-487.
34. 
35. 
          
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behavior: patient provider interaction and health care outcomes.
    
 
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... Chronic stress, through its modality of presentation, may be considered one of the main promoters affecting cardiovascular risk factors such as physical inactivity, smoke, hypertension, sexual inactivity, and unhealthy eating and consequently obesity, diabetes, dyslipidemia [2,[52][53][54][55]. It is present in 77% of adult population (experienced physical symptoms due to stress 77%, experienced psychological symptoms due to stress 73%, living with extreme stress 33%) [56] and represents the common risk factor of 75% -90% of the diseases [53]; the most common stress-related diseases are hypertension, diabetes, atherosclerosis, Alzheimer, tumors [52] and, in addition, cardiovascular risk factors in world areas included lifestyle factors in > 55% of cases and psychosocial factors in > 35% of cases [57]. ...
... In an Italian observational study, more than 55% of female students, workers and unemployed ones declared to have a daily stress feeling compared with about 30% of male [79]. Lifestyle and psychosocial factors for cardiovascular diseases are largely higher in women compared to men [57] and may be considered common key factor acting behind in affecting lifestyle and cardiovascular risk factors such as physical inactivity, smoke, unhealthy eating (dyslipidemia, diabetes and obesity), hypertension, sexual inactivity, whose prevalence is higher in some cases, or lower but continuously increasing in some others, in women compared to men [54][55][56]76]. This is associated with higher prevalence in women compared with men of Alzheimer, hypertension, diabetes, atherosclerotic diseases, tumors and chronic obstructive pulmonary diseases [80,81]. ...
... Emotional and behavioral stress, to which women are more exposed, is mainly related to all these pathologies [52,53,80,88,89] and represents the main link acting behind the risk factors [55] through the influence of the lifestyle changes; emotional stress is the cause more frequently reported by women prior an acute coronary syndrome onset [67]. Moreover, stress seems to alter the composition of the gut microbiota and can also trigger mood disorders like anxiety and depression promoting obesity and suggesting that the impact of stress on mood disorders and obesity might be at least partially attributable to the changes it causes in the gut microbiota [92]; there is emerging evidence for increased microbiome mediated contribution in women to cardiovascular risk factors and comorbidities including inflammatory processes, autoimmune disease, cardiometabolic disorders, and major depression [93]. ...
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the physician must study the customs, the regimen, the lifestyle, the age of each patient…. because, the biggest mistake that is committed today is to separate the psyche from the soma…."-Hippocrates Stress is defined as a real or interpreted threat to physiological or integrity of an individual that results in physiological and behav-ioral responses; as a reaction to internal/external stimuli, it is considered a normal physiological response of the body to protect or to adapt itself to changed conditions occurring at biochemical or biological or behavioral level. Depending on different cultures, stress is viewed as an absence of inner peace (eastern countries) or as a loss of control (western countries). Stress responses are quite different in man and woman in many situations as well as their susceptibility to lifestyle changes, risk factors and diseases. Woman is more exposed to stress due to her different biological, neuro hormonal and psycho behavioral structures influencing day life, the occurrence of specific diseases, social condition and the continuous attempt to overcome inequality. The present paper tries to review the knowledges about the physiopathology of stress, the sex/gender different structures, the prevalence of stress related risk factors and diseases with special reference to woman and the different stress responses, with the addition of a short personal experience.
... How much richness in the relationship between Medicine and Psychology, between psyche and body, which is expressed through the harmonious function of being and doing of the subject/patient. A close and dynamic correlation between the neuro-hormonal and psycho-behavioral systems that influence each other and remain harmonious in physiological conditions but become disharmonious in conditions of disequilibrium due to disturbing factors [7][8][9] both on an individual level and in the Doctor -Patient relationship, where attention to the latter, which is also expressed through listening, is an extremely important and facilitating factor in the relationship itself. ...
... It is therefore evident that communicating with the patient effectively means putting them in the best possible conditions of attention and receptive availability, possible only if the doctor has adequate knowledge of the person and his psycho-behavioral profile [7][8][9]11,17]; but it also means using adequate ways and means of communication, transmitting safety and responsibility, showing the willingness to take charge of the patient's diagnostic and therapeutic path, using an understandable and suitable language for an effective explanation, transmitting what one is able to respond to expectations and satisfying needs, avoiding disturbing factors as much as possible and encour- aging the patient's participation in choosing the pathways to follow and the decisions to be taken [17]. ...
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This third part of the paper we cope the different psychological aspects of communication with the patient that influences his relationship with the doctor. The words used in talking with the patient and the story that he tells, the capability of listening by the doctor, the attitudes and the ability to create empathy shall be considered with attention in the doctor-patient relationship due to the influence that they have on it. Above all, to cure (medically) and to care (psychologically) patient, taking the responsibility of his pathway are emphasized seen the implications that this behavior has in the management of the patient with his disease. One must be a doctor to do the doctor well without forgetting that patient with his disease is the final goal of the medical profession.
... The disease is a biological, psychic, social and spiritual manifestation that further destabilizes the psycho-behavioral balance, in the vast majority of cases already destabilized by the chronic stress linked to the individual experience that modifies lifestyle and behavior, and makes the person fragile and leads her to reflect on values, affects and existence [31][32][33][34]. The sick person is a person worried for his life, for his business, for his family; once the diagnosis is made he wants to know what his future is, so he is more interested in the prognosis, the chances of survival and above all, the chances of not having pain. ...
... With current knowledge, chronic diseases can be prevented and controlled; to do that, integrated and broadspectrum interventions are needed [62]. Multidisciplinarity of interventions, therapeutic diagnostic pathways, taking care of the patient's path, continuity of care, understood as an integrated system of accompanying the patient in his different phases of necessities [43] and a follow-up plan are fundamental activities within a modern healthcare organization that seeks to meet the health needs of patients in accordance with the Hippocratic principles (more time to know the patient, feasibility of the diagnostic process, appropriateness of examinations and hospital admissions, adequate communication, training and respect of roles and competencies, more attention to their problems and their psychological profile) [63]. Even the physician recovers credibility and has the opportunity to re-appropriate his profession by giving it back the prestige and, above all, the fundamental role in the alliance with the patient and in the management and assumption of responsibility for the patient, his family and society. ...
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Hippocratic revolution in Medicine has been an extraordinary event considering the years when it occurred and the medical situation of that time. The struggle against philosophers and priests was tough and winning their beliefs was even more difficult and complicated. Anyway, the greatness was that of having laid the underpinnings of Medicine whose principles are still alive today and constitute the foundations of the Modern Medicine. Nevertheless, many of these principles are disregarded in clinical practice today and sometimes constitute real critical issues within the health system. This review reports some information about the ancient long period of practicing medicine until Hippocrates’ period, taking into account the main structure of Hippocratic revolution and comparing, with the eyes of one who is daily an observer operating on the battlefield, those principles that today occur in the Modern Medicine practice. Critical issues are discussed, and some proposals are suggested, just as personal opinions, coming from experience and daily activity in continuous contact with patient.
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To determine whether the Joint European Societies guidelines on cardiovascular prevention are being followed in everyday clinical practice of secondary prevention and to describe the lifestyle, risk factor and therapeutic management of coronary patients across Europe. EUROASPIRE IV was a cross-sectional study undertaken at 78 centres from 24 European countries. Patients <80 years with coronary disease who had coronary artery bypass graft, percutaneous coronary intervention or an acute coronary syndrome were identified from hospital records and interviewed and examined ≥ 6 months later. A total of 16,426 medical records were reviewed and 7998 patients (24.4% females) interviewed. At interview, 16.0% of patients smoked cigarettes, and 48.6% of those smoking at the time of the event were persistent smokers. Little or no physical activity was reported by 59.9%; 37.6% were obese (BMI ≥ 30 kg/m(2)) and 58.2% centrally obese (waist circumference ≥ 102 cm in men or ≥88 cm in women); 42.7% had blood pressure ≥ 140/90 mmHg (≥140/80 in people with diabetes); 80.5% had low-density lipoprotein cholesterol ≥ 1.8 mmol/l and 26.8% reported having diabetes. Cardioprotective medication was: anti-platelets 93.8%; beta-blockers 82.6%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75.1%; and statins 85.7%. Of the patients 50.7% were advised to participate in a cardiac rehabilitation programme and 81.3% of those advised attended at least one-half of the sessions. A large majority of coronary patients do not achieve the guideline standards for secondary prevention with high prevalences of persistent smoking, unhealthy diets, physical inactivity and consequently most patients are overweight or obese with a high prevalence of diabetes. Risk factor control is inadequate despite high reported use of medications and there are large variations in secondary prevention practice between centres. Less than one-half of the coronary patients access cardiac prevention and rehabilitation programmes. All coronary and vascular patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control and adherence with cardioprotective medications. © The European Society of Cardiology 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
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Studies have shown the association of mood disorders and endothelial dysfunction, and increased risk of cardiovascular disease; however, mediatory mechanisms are not entirely clarified in this regard. We investigated the relationship between depression/anxiety symptoms with systemic inflammation and endothelial function. This cross-sectional study was performed in 2011 on employees of an oil company located in the Isfahan city (central Iran). Participants were selected with clustered random sampling. Anxiety and depression were evaluated by Hospital Anxiety Depression Scale (HADS). Systemic inflammatory status was evaluated by measuring sensitive C-reactive protein (high sensitive-CRP). To evaluate the endothelial function flow-mediated dilation (FMD) was measured. During the study period, 254 participants (mean age = 51.4 ± 6.1 years) were evaluated. No significant relationship was found between high sensitive-CRP or FMD and any of the variables of anxiety or depression. In multivariate analysis, by controlling the possible confounding factors, no association was found between anxiety score, depression, or the overall score of HADS with high sensitive-CRP or FMD. After the separate analysis of patients with and without diabetes, depression score was correlated inversely with FMD among patients with diabetes (r = 0.525, P = 0.021). According to the results, in the studied population, there was no relationship between anxiety/depression with systemic inflammation or endothelial dysfunction, while in individuals with diabetes, depression was associated with endothelial dysfunction. In this regard more cohort studies are recommended.
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Social species create emergent organizations beyond the individual. These emergent structures evolved hand in hand with neural, hormonal, cellular, and genetic mechanisms to support them because the consequent social behaviors helped these organisms survive, reproduce, and care for offspring sufficiently long that they too reproduced. Social neuroscience seeks to specify the neural, hormonal, cellular, and genetic mechanisms underlying social behavior, and in so doing to understand the associations and influences between social and biological levels of organization. Success in the field, therefore, is not measured in terms of the contributions to social psychology per se, but rather in terms of the specification of the biological mechanisms underlying social interactions and behavior-one of the major problems for the neurosciences to address in the 21(st) century.
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Atherosclerosis is a multifactorial disease of polygenic inheritance and the interrelation with environmental and social factors adds to complexity of the disease. Atherosclerosis starts during childhood but manifests later during life. Early diagnosis is possible but the value of knowing is that you can take action. Different modalities of preclinical diagnosis of atherosclerosis include genotyping, non-invasive imaging techniques and traditional risk factors. This article highlights the value and limitation of each modality and elaborates on how to progress without being confronted by a patient having an unexpected heart attack when this can be anticipated and prevented.
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The Framingham Heart Study (FHS) was started in 1948 as a prospective investigation of cardiovascular disease in a cohort of adult men and women. Continuous surveillance of this sample of 5209 subjects has been maintained through biennial physical examinations. In 1971 examinations were begun on the children of the FHS cohort. This study, called the Framingham Offspring Study (FOS), was undertaken to expand upon knowledge of cardiovascular disease, particularly in the area of familial clustering of the disease and its risk factors. This report reviews the sampling design of the FHS and describes the nature of the FOS sample. The FOS families appear to be of typical size and age structure for families with parents born in the late 19th or early 20th century. In addition, there is little evidence that coronary heart disease (CHD) experience and CHO risk factors differ in parents of those who volunteered for this study and the parents ot those who did not volunteer.
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The Framingham Heart Study (FHS) was started in 1948 as a prospective investigation of cardiovascular disease in a cohort of adult men and women. Continuous surveillance of this sample of 5209 subjects has been maintained through biennial physical examinations. In 1971 examinations were begun on the children of the FHS cohort. This study, called the Framingham Offspring Study (FOS), was undertaken to expand upon knowledge of cardiovascular disease, particularly in the area of familial clustering of the disease and its risk factors. This report reviews the sampling design of the FHS and describes the nature of the FOS sample. The FOS families appear to be of typical size and age structure for families with parents born in the late 19th or early 20th century. In addition, there is little evidence that coronary heart disease (CHD) experience and CHD risk factors differ in parents of those who volunteered for this study and the parents of those who did not volunteer.
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Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome. Writing group members were approved by the American Heart Association's Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes. Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.
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provide a brief historical overview of models of patient-provider relationships, describe current social-psychological perspectives on patient-provider interaction, review the observational and experimental research on patient-provider communication and health care outcomes, and discuss this research in light of these frameworks current perspectives on patient-provider interaction [cognition and information processing, interpersonal interaction, conflict between patient and provider perspectives, social influence] my research on patient and provider interaction consists of observational studies of the association between patient-provider communication behaviors and a variety of health care outcomes / the few experimental studies have examined the effects of interventions to enhance patient-provider interaction and health care outcomes (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Acute myocardial infarction is triggered by various factors, such as physical exertion, stressful events, heavy meals, or increases in air pollution. However, the importance and relevance of each trigger are uncertain. We compared triggers of myocardial infarction at an individual and population level. We searched PubMed and the Web of Science citation databases to identify studies of triggers of non-fatal myocardial infarction to calculate population attributable fractions (PAF). When feasible, we did a meta-regression analysis for studies of the same trigger. Of the epidemiologic studies reviewed, 36 provided sufficient details to be considered. In the studied populations, the exposure prevalence for triggers in the relevant control time window ranged from 0.04% for cocaine use to 100% for air pollution. The reported odds ratios (OR) ranged from 1.05 to 23.7. Ranking triggers from the highest to the lowest OR resulted in the following order: use of cocaine, heavy meal, smoking of marijuana, negative emotions, physical exertion, positive emotions, anger, sexual activity, traffic exposure, respiratory infections, coffee consumption, air pollution (based on a difference of 30 μg/m3 in particulate matter with a diameter <10 μm [PM10]). Taking into account the OR and the prevalences of exposure, the highest PAF was estimated for traffic exposure (7.4%), followed by physical exertion (6.2%), alcohol (5.0%), coffee (5.0%), a difference of 30 μg/m3 in PM10 (4.8%), negative emotions (3.9%), anger (3.1%), heavy meal (2.7%), positive emotions (2.4%), sexual activity (2.2%), cocaine use (0.9%), marijuana smoking (0.8%) and respiratory infections (0.6%). Interpretation In view of both the magnitude of the risk and the prevalence in the population, air pollution is an important trigger of myocardial infarction, it is of similar magnitude (PAF 5-7%) as other well accepted triggers such as physical exertion, alcohol, and coffee. Our work shows that ever-present small risks might have considerable public health relevance. The research on air pollution and health at Hasselt University is supported by a grant from the Flemish Scientific Fund (FWO, Krediet aan navorsers/G.0873.11), tUL-impulse financing, and bijzonder onderzoeksfonds (BOF) and at the Katholieke Universiteit Leuven by the sustainable development programme of BELSPO (Belgian Science Policy).