The epidemiology pathophysiology, and management of psychosocial risk factors in cardiac practice: The emerging field of behavioral cardiology

Division of Cardiology, St Luke's-Roosevelt Hospital Center, and the Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.
Journal of the American College of Cardiology (Impact Factor: 16.5). 04/2005; 45(5):637-51. DOI: 10.1016/j.jacc.2004.12.005
Source: PubMed


Observational studies indicate that psychologic factors strongly influence the course of coronary artery disease (CAD). In this review, we examine new epidemiologic evidence for the association between psychosocial risk factors and CAD, identify pathologic mechanisms that may be responsible for this association, and describe a paradigm for studying positive psychologic factors that may act as a buffer. Because psychosocial risk factors are highly prevalent and are associated with unhealthy lifestyles, we describe the potential role of cardiologists in managing such factors. Management approaches include routinely screening for psychosocial risk factors, referring patients with severe psychologic distress to behavioral specialists, and directly treating patients with milder forms of psychologic distress with brief targeted interventions. A number of behavioral interventions have been evaluated for their ability to reduce adverse cardiac events among patients presenting with psychosocial risk factors. Although the efficacy of stand-alone psychosocial interventions remains unclear, both exercise and multifactorial cardiac rehabilitation with psychosocial interventions have demonstrated a reduction in cardiac events. Furthermore, recent data suggest that psychopharmacologic interventions may also be effective. Despite these promising findings, clinical practice guidelines for managing psychosocial risk factors in cardiac practice are lacking. Thus, we review new approaches to improve the delivery of behavioral services and patient adherence to behavioral recommendations. These efforts are part of an emerging field of behavioral cardiology, which is based on the understanding that psychosocial and behavioral risk factors for CAD are not only highly interrelated, but also require a sophisticated health care delivery system to optimize their effectiveness.

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Available from: Karina W Davidson
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    • "The scientific literature suggests that the link between PTSD and CVD may be causal in nature and related to the numerous cardiovascular abnormalities observed in PTSD patients. For instance, people with PTSD exhibit lower heart rate variability (HRV), reduced baroreflex sensitivity and increased QT variability (Cohen et al., 1998, 2000; Rozanski et al., 2005), each of which has been linked to greater CVD incidence or cardiovascular-related mortality (Bigger et al., 1992; Piccirillo et al., 2007; Rozanski et al., 2005). PTSD patients also demonstrate abnormally elevated heart rate (HR), blood pressure (BP) and norepinephrine (NE) levels at baseline and in response to emotional stimuli or events (for a review, see Zoladz & Diamond, 2013). "
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    ABSTRACT: Individuals with post-traumatic stress disorder (PTSD) experience many debilitating symptoms, including intrusive memories, persistent anxiety and avoidance of trauma-related cues. PTSD also results in numerous physiological complications, including increased risk for cardiovascular disease (CVD). However, characterization of PTSD-induced cardiovascular alterations is lacking, especially in preclinical models of the disorder. Thus, we examined the impact of a psychosocial predator-based animal model of PTSD on myocardial sensitivity to ischemic injury. Male and female Sprague-Dawley rats were exposed to psychosocial stress or control conditions for 31 days. Stressed rats were given two cat exposures, separated by a period of 10 days, and were subjected to daily social instability throughout the paradigm. Control rats were handled daily for the duration of the experiment. Rats were tested on the elevated plus maze (EPM) on day 32, and hearts were isolated on day 33 and subjected to 20 min ischemia and 2 h reperfusion on a Langendorff isolated heart system. Stressed male and female rats gained less body weight relative to controls, but only stressed males exhibited increased anxiety on the EPM. Male, but not female, rats exposed to psychosocial stress exhibited significantly larger infarcts and attenuated post-ischemic recovery of contractile function compared to controls. Our data demonstrate that predator stress combined with daily social instability sex-dependently increases myocardial sensitivity to ischemic injury. Thus, this manipulation may be useful for studying potential mechanisms underlying cardiovascular alterations in PTSD, as well as sex differences in the cardiovascular stress response.
    Full-text · Article · Oct 2015 · Stress (Amsterdam, Netherlands)
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    • "Accumulating evidence suggests that psychosocial factors, particularly psychological distress [9] [10] [11], are associated with increased risk of HF [12] [13]. Adverse effects of distress are also observed for other adverse cardiovascular health outcomes such as incident MI and post-MI mortality [14] [15] [16] [17]. These elevated cardiovascular risks are observed following prolonged psychological distress such as distress experienced during exhaustion [18] [19] and depression [13] [20] [21] as well as milder forms of chronic distress [22] [23]. "
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    ABSTRACT: Background: Heart failure (HF) prognosis is negatively influenced by adverse environmental conditions associated with psychological distress and depression. The underlying mechanisms are not well understood because of insufficient experimental control in prior clinical and epidemiological studies. Using a validated animal model we examined whether distress-producing environmental manipulations (social isolation and crowding) increase HF progression following myocardial infarction (MI). Methods: MI was induced using coronary artery ligation in 8-week old male Wistar rats (N=52) and results were compared to sham surgery (N=24). Housing conditions were randomly assigned at 5days post MI or sham surgery (1/cage=isolation, 2/cage=standard reference condition, or 4/cage=crowding) and continued for 17weeks until the end of observation. The open field test was used to test behavioral responses. Echocardiograms were obtained at weeks 8 and 16, and left ventricular (LV) weight at week 17. Results: Housing conditions increased behavioral markers of distress (p=0.046) with the strongest effects for the isolated (1/cage) (p=0.022). MI did not increase distress-related behaviors compared to sham. MI-surgery resulted in characteristic HF indices (left ventricular ejection fraction (LVEF) at week 16=46±12% vs. 80±7% in sham, p<0.001). Housing condition was not related to LVEF or LV weight (p>0.10). Conclusions: Adverse environmental conditions, particularly isolated housing, produce increases in some of the behavioral indicators of distress. No effects of housing were found on post-MI progression of HF. The distress-HF associations observed in humans may therefore reflect common underlying factors rather than an independent causal pathway. Stronger environmental challenges may be needed in future animal research examining distress as related HF progression.
    Full-text · Article · Oct 2015 · Physiology & Behavior
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    • "and genetic and behavioural psychological factors [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31]. Field specific knowledge and experience can be applied to determine the best proxy outcome for estimating effects of such unmeasured confounders. "
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    ABSTRACT: Background. Experimental studies suggest that alcohol can lead to aggression in laboratory settings; however, it is impossible to test the causal relationship between alcohol use and real-life violence among humans in randomized clinical trials. Objectives. (i) To examine the relationship between heavy alcohol use and assaults in a population based study; (ii) to demonstrate the proxy outcome method, as a means of controlling the effects of unknown/unmeasured confounders in observational studies. Methods. This study used data collected from three waves of the National Survey on Drug Use and Health (NSDUH). The effects of heavy alcohol use on assault were measured using multivariable logistic regressions in conjunction with the proxy outcome method. Results. Application of the proxy outcome method indicated that effect sizes of heavy alcohol use on the risk of assault were overestimated in the standard models. After adjusting for the effects of unknown/unmeasured confounders, the risk of assault remained 43% and 63% higher P < 0.05 among participants who consumed 5+ drinks/day for 5–8 days/month and 9–30 days/month, respectively. Conclusions. Even after adjustment for unknown/unmeasured confounders the association between heavy alcohol use and risk of violence remained significant. These findings support the hypothesis that heavy alcohol use can cause violence.
    Full-text · Article · Aug 2015
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