STATE-OF-THE-ART PAPER
The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice
The emerging field of behavioral cardiology
Alan Rozanski, MD, FACC*,*,
James A. Blumenthal, PhD ,
Karina W. Davidson, PhD ,
Patrice G. Saab, PhD and
Laura Kubzansky, PhD||
* 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
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
Division of General Medicine, Columbia College of Physicians and Surgeons, and Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York
Department of Psychology, University of Miami, Coral Gables, Florida
|| Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts
Manuscript received September 29, 2004;
accepted October 6, 2004.
* Reprint requests and correspondence: Dr. Alan Rozanski, Division of Cardiology, St. Luke's-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, New York 10025 (Email: AR77{at}columbia.edu).
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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Abbreviations and Acronyms
| | CAD = coronary artery disease | | HPA = hypothalamic-pituitary-adrenocorticol | | MI = myocardial infarction | | SES = socioeconomic status | | SSRI = selective serotonin reuptake inhibitor | | PET = positron emission tomography |
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