Behavioral Cardiology

The connection between psychological and cardiovascular health

BEHAVIORAL CARDIOLOGY  
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In medical treatment today, heart health requires more than blood pressure control or the right pharmacologic therapy. Doctors advise lifestyle modifications in the form of diet and exercise yet may encounter resistance. Patients must be willing to comply with lifestyle modifications and often such motivation is tied to their psychological health. If a patient already has underlying depression, then news of serious cardiovascular disease may deepen such depression and dampen motivation.
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Behavioral cardiology looks at the links between behavioral and psychosocial factors and the origin and progression of coronary heart disease. Randal Thomas notes in Behavioral Cardiology: Where the Heart and Head Meet (U.S. Cardiology Review, 2006) “Results of recent clinical research have strengthened the understanding and management of the links between psychological health and heart health, and have moved the field of behavioral cardiology steadily closer into the mainstream of current clinical cardiology.” Thomas notes the importance of behavioral cardiology: Adverse psychosocial factors are common in persons with coronary artery disease and up to 50% of survivors of myocardial infarction present with significant anxiety and/or depressive disorders. These adverse psychosocial factors can significantly worsen coronary artery disease risk and prognosis. Moreover, psychosocial health status is generally responsive to behavioral and pharmacologic therapies.

CARDIOLOGISTS ALERT TO PSYCHOLOGICAL AND CARDIOVASCULAR FACTORS
Physical and emotional factors contribute to feelings of overwhelming depression and hopelessness in a vulnerable patient who has recently experienced a heart attack. This presents an unusual dilemma in current cardiovascular healthcare. The cardiologist must treat the underlying disease and the risk of heart disease and at the same time be aware of related psychosocial factors, such as hostility and anxiety. Treatments that effectively treat both psychosocial and coronary artery disease outcomes can be elusive.

The cardiologist is often the first to see a patient during and after cardiovascular events at a time when adverse psychosocial factors may become more visible and patients are more open to therapeutic recommendations. The cardiologist's challenge is to identify ​coexisting heart disease and psychological distress, and then successfully intervene and initiate the early steps of  psychosocial care.  ​

PSYCHOSOCIAL FACTORS THAT INCREASE THE RISK OF HEART DISEASE
As important as smoking, high blood pressure, obesity, and cholesterol, psychological factors may be the final insult resulting in a heart attack or stroke. Psychological factors contribute to atherosclerosis, the slow, corrosive process that damages artery walls. Depression, stress, loneliness, pessimistic outlook, and other psychosocial factors influence heart health. Conversely, heart disease affects the brain and the mind.

DEPRESSION
Symptoms of depression, as well as full-blown major depression, contribute to heart disease. The prognosis is worse for people who become depressed after a heart attack or stroke, heart surgery, or the onset of heart failure.

ANGER AND HOSTILITY
​Atherosclerosis seems to advance faster in people who score high on anger or hostility scales. Anger may even initiate heart attacks. In the Harvard-based Determinants of Myocardial Infarction Onset Study, one in every 40 heart attack survivors reported an "episode of anger" in the two hours before the attack.

ANXIETY
Intense anxiety associated with fear of enclosed places, heights, and crowds may set off a sudden cardiac arrest. These often-fatal heart attacks happen when the heartbeat abruptly turns fast and uncoordinated.

LACK OF SOCIAL SUPPORT
Among heart attack survivors, social isolation is almost as important as high cholesterol, high blood pressure, and smoking in the prediction of long-term survival.

CHRONIC STRESS
Constant stress from work, financial problems, a troubled marriage, taking care of sick family members, or even living in an unsafe neighborhood have been linked to the development of heart disease and poor prognosis.

SUDDEN EMOTIONAL STRESS
Sudden emotional turmoil can trigger a temporary but serious heart condition also known as  broken heart syndrome or stress cardiomyopathy, in which stress hormones stun the cells of the heart. Researchers have documented broken heart syndrome after a death in the family, a divorce, a surprise (even a good surprise), a robbery, a car accident, or other physically draining event.

HEALTHY BEHAVIOR IS GROUNDED IN EMOTIONAL STATE 
Healthcare providers agree that our health behaviors are grounded in the larger context of our emotions, moods, and even parts of our personality. Stress, loneliness, depression, and anxiety all exact a toll. Dr. Alan Rozanski divides the behavioral risk factors for coronary heart disease into physical health behaviors, negative emotions and negative mental mindsets, chronic stress, social isolation and poor social support, and lack of sense of purpose. "Negative psychosocial factors promote illness by fostering negative health behaviors and by their direct pathophysiological effects," he says. "These effects can vary according to the type of psychosocial stress, but as a group they include induction of autonomic dysfunction, heightened cardiovascular reactivity, insulin resistances, central obesity, increased risk for hypertension, endothelial and platelet dysfunction, and unfavorable alterations in brain plasticity and cognitive function.”

POSITIVE AND NEGATIVE FEEDBACK LOOPS OFFER TREATMENT OPPORTUNITY
Psychosocial factors form part of positive and negative feedback loops, which offer opportunities for overall approaches to treatment. Transforming one component of the negative feedback loop may create a positive feedback loop. For example, treating depression can improve health behaviors, reduce stress, improve social performance, and increase sense of purpose. Exercise reduces heart rate, blood pressure, and cortisol and glucose responses to psychosocial stress, and it buffers the relationship between depression and inflammation.   

​LIFESTYLE MODIFICATIONS FOR HEART HEALTH
​Primary prevention measures and lifestyle interventions offer hope for the heart patient.
They include:
Healthy and balanced diet
Reduced salt intake, increased potassium intake
Weight loss
Smoking cessation
Appropriate exercise (moderate intensity, such as a 30-minute daily walk)
Stress reduction
Lipid regulation
Aspirin
Behavioral interventions including talk therapy, antidepressant therapy, and mindfulness practices
 
Behavioral interventions such as talk therapy, antidepressant therapy, and mindfulness practices relieve mental stress and maintain emotional balance. Treating heart disease by treating mood and emotion holds promise. Lifestyle interventions offer both physical and emotional benefits, and success with one modification may improve the patient's outlook in other areas.

Habits good for the heart seem to be good for the mind and brain as well. Ask anyone who exercises regularly about the mental benefits of exercise!