Psychological Aspects of Cardiovascular Diseases Notes

Lecture Outline

• Risk factors & measurement- Psychological factors

• Associations with health outcomes- Cardiovascular disease, mortality

• Mechanisms- Behavioural, biological

• Interventions- Pharmacological, behavioural, psychosocial

CVD Risk Factors

• Demographic:

  • Family history: Genetic predisposition to CVD.

  • Male: Generally higher risk than females before menopause.

  • Older age: Risk increases with age.

• Clinical risk factors:

  • Elevated blood pressure: Hypertension increases the risk of heart disease and stroke. Optimal blood pressure is typically below 120/80 mmHg.

  • Elevated serum cholesterol: High LDL cholesterol and low HDL cholesterol levels.

  • Diabetes: Both type 1 and type 2 diabetes increase CVD risk.

• Behavioral risk factors:

  • Smoking: Damages blood vessels and increases blood clot formation.

  • Alcohol: Excessive alcohol consumption increases blood pressure and triglyceride levels.

  • Diet/obesity: High intake of saturated fats, cholesterol, and sodium. Obesity leads to insulin resistance and increased inflammation.

  • Physical inactivity: Lack of exercise contributes to obesity and other risk factors.

  • Psychological stress: Chronic stress elevates blood pressure and promotes unhealthy behaviors.

• Fixed: non-modifiable

• Partially modifiable

• Largely modifiable

Psychological Factors

• Psychological factors are also known to be important.

• What are they?-

  • Stress: Acute and chronic stress.

  • Mood & mood disorders: Depression, anxiety.

  • Personality: Type A personality, hostility.

• These factors are also thought to be modifiable.

Stress

• Multi-component response to threat/challenge

  • Acute stressors

    • Natural disasters: Earthquakes, floods.

    • Death of a loved one: Grief and bereavement.

  • Chronic stressors

    • Work stress (high demand/low control): Job strain.

    • Financial strain: Economic hardship.

    • Family/caregiver stress: Caring for elderly or disabled family members.

• ‘Fight-or-flight’ response: Activation of the sympathetic nervous system.

Measurement

• Self-report

  • Validated scales: Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HAM-A), Depression Anxiety Stress Scales (DASS).

• Physiological

  • Startle response: Measures anxiety and reactivity.

  • Brain activity (EEG, fMRI): Electroencephalography, functional magnetic resonance imaging.

• Behavioural

  • Vocal, facial, whole body: Observable expressions and movements.

Health Outcomes

• Definitions & measurement- Psychological factors

• Associations with health outcomes- Cardiovascular disease, mortality

• Mechanisms- Behavioural, biological

• Interventions- Pharmacological, behavioural, psychosocial

Health Outcomes: Acute Stressors

• On the day of the Northridge Earthquake (1994) there was a sharp increase in the number of sudden deaths due to cardiac causes. Leor et al. (1996).

Egypt’s Earthquake 1992

• Populations in areas closest to the epicenter experienced increased death and injury rates (4.6 deaths per 100,000 and 80.6 injuries per 100,000) compared to those located further from the epicenter (0.8 deaths per 100,000 and 23.7 injuries per 100,000)

Health Outcomes: Acute Stressors

• On days of World Cup matches involving the German team, the incidence of cardiac emergencies was 2.66 times that during the control period (95% CI, 2.33 to 3.04; P<0.001).

Health Outcomes: Chronic Stressors

• Socially stressed adult male monkeys developed more extensive coronary artery atherosclerosis than unstressed controls over 2 years. Kaplan et al. (1983)

Risk of Acute MI Associated with Exposure to Psychosocial Factors

• Odds ratio for MI: - Hypertension: 1.9 (1.7-2.1)

  • Plus smoking, diabetes mellitus, ApoB: ApoA1 ratio: 42.3 (33.2-54.0)

  • Plus obesity: 68.5 (53.0-88.6)

  • Plus psychosocial factors: 182.9 (132.6-252.2)

  • Combined risk factors

Health Outcomes: Psychological Distress

• Dose-response association between psychological distress and cardiovascular disease death across the full-range of distress. Russ et al. (2012)

Health Outcomes: Anger and Hostility

• Recent meta-analysis (Chida & Steptoe, 2009).

• Anger and hostility were associated with:

  • Increased CHD events in the healthy population studies (HR: 1.19; 95% CI: 1.05 to 1.35, p = 0.008).

  • Poor prognosis in the CHD population studies (HR: 1.24; 95% CI: 1.08 to 1.42, p = 0.002).

Depression & Stroke

• Stroke is the 3rd leading cause of death (after Coronary heart disease & Cancer)

• Depression after stroke is usually under- diagnosed & untreated

• The overall prevalence of depression is around 30 % in the first few weeks after stroke

• 2/3 of the patients fit the criteria for MDD

Depression & Stroke

• Depression tend to negatively affect the stroke recovery through the following mechanisms:

  • 1- Loss of motivation for rehabilitation (Hopeless or fatigue)

  • 2- Cognitive impairment (non-adherence)

• Patients with CHD should be routinely screened for depression AHA science advisory on depression & CHD recommendation 2008

Depression & Stroke

• In patients with CHD, depression predicts:

  • 1- Death

  • 2- Admissions

  • 3- Healthcare costs

  • 4- Healthcare service utilization

Depression & Stroke

• Evidence from recent clinical trials suggests that untreated depression may be associated with a particularly high risk of mortality or cardiac morbidity in patients following acute coronary syndrome

  • ENRICHD: Enhancing Recovery in Coronary Heart Disease, 2000

    • MDD= 30.2% of all mortality

    • Non-depressed=3.4%

Depression & Diabetes

• Meta-analysis revealed a bidirectional association between depression and diabetes:

  • Depression is associated with 60% increased risk of type 2 diabetes

  • Type 2 diabetes is associated with modest increased risk of depression

Depression & Diabetes

• Depression affects negatively the glycemic control

ADA Recommendations

• Advises regular screening throughout the course of diabetes management: at diagnosis, routine management visits, hospitalizations, when complications develop, or when problems with glucose control, quality of life, or adherence to self-care are identified. The American Diabetes Association (2008)

Health Outcomes: Positive Well-Being

• Is the presence of positive well-being simply synonymous with the absence of negative affect?

• WHO definition of health?

Health Outcomes: Positive Well-Being

• Recent meta-analysis found positive psychological well- being was associated with:

  • Reduced CVD mortality in the healthy population (HR 0.71; 95% CI 0.52–0.98; p = 0.038).

  • Reduced CVD mortality in the disease population (e.g. HIV, cancer, renal failure) (HR 0.93; CI 0.86–1.01; p = 0.065).

• Independent of negative affect

Health Outcomes: Positive Well-Being

• Optimism was associated with lower risk of cardiovascular mortality in elderly men during 15 years follow-up Association remained after controlling for cardiovascular risk factors and depressive symptoms

Mechanisms

• Definitions & measurement- Psychological factors

• Associations with health outcomes- Cardiovascular disease, mortality

• Mechanisms- Behavioural, biological

• Interventions- Pharmacological, behavioural, psychosocial

Mechanisms - Factors

• Health behaviour

• Psychobiological processes

• Cardiac events

  • Recurrent event/death- indirect effect

    • prognostic factor

• Psychological factor

  • trigger- direct effect

    • Predisposing Factors Precipitating Perpetuating

Health Behaviors

• Maladaptive behaviors

  • Smoking: Increases heart rate and blood pressure.

  • Alcohol consumption: Heavy drinking leads to cardiomyopathy.

  • Physical activity: Lack of exercise promotes obesity.

  • Sleep: Poor sleep increases inflammation.

  • Adherence to medical regimens: Non-compliance worsens outcomes.

Personality Traits and Coping Styles

• –Hostile, pressured behaviors contributing to CVD (Type A personality)

• – Pathological denial of the need for investigations or interventions (surgery )

Mechanisms: Health Behaviours

• Proportion of non-adherent (aspirin taken 80% of days) patients in 3 groups: non-depressed (BDI score 0 to 4), mildly depressed (BDI 10 to 16), and moderately to severely depressed (BDI ≥16). Rieckmann et al. (2006)

Mechanisms: Biological

• Stressors - CNS

• Activation of:

  • Autonomic: Increased sympathetic activity.

  • Neuroendocrine: HPA axis activation.

  • Immune systems: Inflammatory response.

  • Hypothalamus

  • CRH

  • AVP

  • TRH

  • GnRH

  • ACTH

  • TSH

  • LH/FSH

  • Adrenal Glands

  • Gonads

  • Cytokines

  • immune Cells

Mechanisms: Biological

• Cardiovascular activity (heart rate, blood pressure).

Mechanisms: Biological

• Cortisol is vital to life, being involved in fat, protein and carbohydrate metabolism.

• Cortisol also regulates the immune system:

  • It causes an anti-inflammatory response.

• The negative feedback loop of the HPA axis is essential for regulating cortisol.

• If this feedback fails, this results in excess cortisol which can cause immune dysregulation.

Mechanisms: Biological - Cortisol and Health Outcomes

• CVD (Kumari et al., 2011)

• Diabetes (Rosmond, 2003)

• Infectious disease (Godbout, 2006)

• Asthma (Wright et al., 1998)

• Mental disorders (Goodyer et al., 2000)

Mechanisms: Biological - Cortisol Profiles

• Low PA High PA

• Mean cortisol sampled on waking, 30 min and 60 min later in young men with low (solid line) and high (dotted line) positive affect. Steptoe et al. (2007)

Interventions

• Definitions & measurement- Psychological factors

• Associations with health outcomes- Cardiovascular disease, mortality

• Mechanisms- Behavioural, biological

• Interventions- Pharmacological, psychosocial, life-style modifications

Intervention Modality

• Pharmacotherapy

  • e.g. SSRIs, SNRIs: Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors.

• Psychosocial

  • e.g. Cognitive Behavioural Therapy: CBT aims to change maladaptive thought patterns.

• Life-style changes

  • e.g. Physical exercise, mindfulness, meditation: Stress reduction techniques.

American Psychiatric Association Practice Guidelines – Therapy Options

• Recommendations for treatment of major depression in adults include:

  • Psychodynamic psychotherapy

  • Brief focused therapy

  • Behaviour therapy (BT)

  • Cognitive behaviour therapy (CBT)

  • Marital, family and group therapy

  • Interpersonal psychotherapy (IPT)

Supportive Psychotherapy

• –Give hope

• –Environmental changes

• –Scheduling

• –Postpone major life events

• –Social support (Group, Networks)

• –Encourage to new successful experiences

• –List of goals (realistic & attainable)

• –List of challenges

Psychosocial Interventions

• What are the effects of psychosocial interventions on disease and mortality risk?

Psychosocial Interventions: SUPRIM

• 362 adults ≤ 75 years who had had a CHD event within the past 12 months.

• Traditional care vs. traditional care plus CBT

• 20 2-hour group sessions during 1 year.

Psychosocial Interventions: SUPRIM

• During mean 94 months of follow-up, the intervention group had:

  • 41% lower rate of fatal and nonfatal first recurrent CVD events

  • 45% fewer recurrent acute MI

  • Non-significant 28% lower all-cause mortality (0.72 [0.40-1.30]; P=.28) than controls

• Adjustment for other outcome-affecting variables.

• Dose-response association between intervention group attendance and outcome.