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
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Figure 1 Post-myocardial infarction (MI) patients were recruited and assigned to one of four categories based on the Beck Depression Inventory (BDI), ranging from no depressive symptoms (BDI <5) to moderate to severe depressive symptoms (BDI  19). During the five-year follow-up period, a gradient relationship was observed between the magnitude of depressive symptoms and the frequency of deaths, with increased events occurring even in patients with mild depressive symptoms (BDI 5 to 9) (2).
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Figure 2 Two leading conceptual models of work stress. In the job strain model (left), the amount of job demand and decision latitude determines the degree of job strain. High demand but low decision latitude characterizes job strain. In the effort-reward imbalance model (right), increased job effort may result from either extrinsic demands or personal overcommitment, and "reward" may occur in the form of money, recognition, prestige, security, or career opportunities. High effort with low reward characterizes job imbalance.
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Figure 3 Postmenopausal females (n = 390) were divided into those in satisfying marriages (left of each panel), unmarried (middle of each panel), and in low-satisfying marriages (right of each panel). After 11 years of follow-up, the women in satisfied marriages had the lowest and the women in unsatisfying marriages had the highest percentage of significant plaque (left panel). Serial carotid ultrasonography was performed after three years in a subgroup of this patient population (n = 206) and revealed that women in low-satisfying marriages also had the greatest progression of plaque during follow-up (right panel). Reprinted with permission from Gallo et al. Psychosom Med 2003;65:952–62 (34). *Groups differ significantly at p < 0.05.
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Figure 4 The risk ratios for traditional risk factors reported for men in the Framingham study (28). The risk ratios for depressive symptoms and clinical depression are from a recent meta-analysis by Rugulies et al. (3). The risk ratios for traditional risk factors are for death due to cardiac disease, myocardial infarction, coronary artery insufficiency, and development of angina. For depressive symptoms and clinical depression, the risk ratios are for death due to cardiac disease and myocardial infarction. CI = confidence interval; HT = hypertension; LDL = low-density lipoprotein; HDL = high-density lipoprotein.
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Figure 5 Risk of acute myocardial infarction for men and women for each of nine coronary artery disease (CAD) risk factors evaluated in the international INTERHEART case-control study. Results are adjusted for age, gender, and geographic location. The prevalence of each CAD risk factor is presented for controls and cases in the third and fourth columns; prevalence rates are not calculated for the psychosocial (PS) index as it is derived from a statistical model. Reprinted with permission from Yusuf et al. Lancet 2004;364:937–52 (43). Abd = abdominal; CI = confidence interval; Curr = current; OR = odds ratio; PAR = population-attributable risk; Smok = smoking; Veg = vegetables.
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Figure 6 The mental health paradigm in which individuals who have a strong sense of purpose coupled with a sense of self-worth derive benefit in terms of a greater sense of vitality. The positive emotion associated with vitality provides energy needed to develop and maintain greater emotional competence and positive response mechanisms. In turn, the presence of emotional competence and positive response mechanisms provide a stabilizing force for maintaining a sense of vitality.
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Figure 7 Pathophysiologic mechanisms by which chronic stress and affective disorders, such as depression, appear to promote atherosclerosis. These stressors activate the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS) and affect behaviors. Multiple adverse peripheral effects can ensue from this neuroendocrine, sympathetic, and behavioral activation, as shown. The neuroendocrine and neuroplastic changes emanating from these stressors can also induce a state of heightened physiologic responsivity to acute stress which may interact with chronic stressors to cause more adverse effects. ANS = autonomic nervous system; Endo. = endothelial.
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Figure 8 Six reasons that promote interest in the evaluation and management of psychosocial stress in cardiac practice.
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Figure 9 Proposed three-stage approach for developing behavioral intervention trials. Stage 1 consists of a single-center evaluation of a specific behavioral intervention. If successful, this intervention would be repeated at multiple centers to assess the reproducibility of findings (stage 2). In both stages, intermediate end points, such as change in carotid intimal wall thickening or plaque size during carotid ultrasonography, would be used to minimize necessary sample size and follow-up time. If reproducible results are obtained during stage 2, a multicenter intervention trial would be performed in stage 3, during which subjects would be observed for the occurrence of hard cardiac events. IMT = intima medial thickness.
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Figure 10 Stepped collaborative care for cardiac patients depending on the degree of psychological distress. Patients with mild psychologic distress (step 1) would generally be treated by cardiologists without additional collaborative intervention. The greater the degree of psychosocial distress, the greater the need for collaborative intervention.
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Figure 11 Approaches to promoting treatment adherence commonly make use of techniques that involve external regulation, such as the use of incentives or external network support. An alternative motivational paradigm to such controlled behavior regulation focuses on attempts to promote autonomy by fostering greater intrinsic motivation. Health providers can foster this motivational process through a variety of steps, including promoting patient ownership over recommended behavioral changes (i.e., getting patients to voice their own reasons for initiating change), helping patients to find a meaningful purpose for suggested changes, formatting the specifics of behavior recommendations in a manner most consistent with patients' personal preferences, and recognizing what coping mechanisms were best served by the old adverse behaviors (e.g., eating to decrease a sense of tension) and finding alternative solutions. At the same time it is important to avoid ignoring a sense of conflict (which can occur if behavioral recommendations are made without considering the relationship of physician advice to patients' internal values and preferences), fostering a sense of coercion, or setting goals that are not readily achievable.
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Copyright © 2005 by the American College of Cardiology Foundation.
