Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Review article: Biomedical intelligence

Vol. 142 No. 0304 (2012)

Psychosocial stress and cardiovascular risk – current opinion

  • Roland von Känel
DOI
https://doi.org/10.4414/smw.2012.13502
Cite this as:
Swiss Med Wkly. 2012;142:w13502
Published
15.01.2012

Summary

Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. Epidemiologic research of the last half-century has clearly shown that psychosocial factors related to the social environment, personality characteristics, and negative affect increase the risk of incident CVD and also impact prognosis of cardiac patients. Several mechanisms may explain this link, including a genetic predisposition, poor lifestyle choices, low adherence to health recommendations, and direct pathophysiologic perturbations. The latter include alteration of the hypothalamic-pituitary adrenal axis and autonomic dysfunction resulting in endothelial dysfunction, inflammation, and a prothrombotic state further downstream. Screening for psychosocial factors seems appropriate as part of the standard history and based on the clinician's knowledge of the patient and the purpose of the visit. Psychological interventions generally alleviate distress in cardiac patients, but whether they reduce the risk of hard cardiovascular endpoints and all-cause mortality is less evident. Cardiac patients with more severe depression may particularly profit from antidepressant medications. Due to their pharmacologic properties, selective serotonin reuptake inhibitors were shown to improve cardiovascular outcome. The most effective psychosocial treatment is multicomponent therapy that combines elements of cognitive behaviour therapy (“stress management”) and changes in health behaviours, including the adoption of a regular exercise regimen. Gender-specific issues should probably be considered. The field of behavioural cardiology has accumulated a wealth of epidemiological, mechanistic and clinical knowledge that undoubtedly has furthered our understanding about the important role of psychosocial risk factors in patients with a heart disease.

References

  1. Zahlen und Daten über Herz-Kreislauf-Krankheiten in der Schweiz. Schweizerische Herzstiftung. Ausgabe 2008, Tabelle 2.4.1 (Todesursachen in der Schweiz 2005), p. 38.
  2. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–52.
  3. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. 2005;45(5):637–51.
  4. Friedmann E, Thomas SA, Liu F, Morton PG, Chapa D, Gottlieb SS; Sudden Cardiac Death in Heart Failure Trial Investigators. Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality. Am Heart J. 2006;152(5):940.e1-8.
  5. Matchett M, Sears SF, Hazelton G, Kirian K, Wilson E, Nekkanti R. The implantable cardioverter defibrillator: its history, current psychological impact and future. Expert Rev Med Devices. 2009;6(1):43–50.
  6. Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352(6):539–48.
  7. Van Den Broek KC, Habibović M, Pedersen SS. Emotional distress in partners of patients with an implantable cardioverter defibrillator: a systematic review and recommendations for future research. Pacing Clin Electrophysiol. 2010;33(12):1442–50.
  8. Frasure-Smith N, Lespérance F. Depression and cardiac risk: present status and future directions. Heart. 2010;96(3):173–6.
  9. von Känel R. Psychological distress and cardiovascular risk: what are the links? J Am Coll Cardiol. 2008;52(25):2163–5.
  10. Cacioppo JT, Berntson GG, Malarkey WB, Kiecolt-Glaser JK, Sheridan JF, Poehlmann KM, et al. Autonomic, neuroendocrine, and immune responses to psychological stress: the reactivity hypothesis. Ann N Y Acad Sci. 1998;840:664–73.
  11. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York, NY: Springer, 1984.
  12. McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease. Ann N Y Acad Sci. 2010;1186:190–222.
  13. Leor J, Poole WK, Kloner RA. Sudden cardiac death triggered by an earthquake. N Engl J Med. 1996;334(7):413–9.
  14. Steinberg JS, Arshad A, Kowalski M, Kukar A, Suma V, Vloka M, et al. Increased incidence of life-threatening ventricular arrhythmias in implantable defibrillator patients after the World Trade Center attack. J Am Coll Cardiol. 2004;44(6):1261–4.
  15. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442.
  16. Charlson FJ, Stapelberg NJ, Baxter AJ, Whiteford HA. Should global burden of disease estimates include depression as a risk factor for coronary heart disease? BMC Med. 2011;9:47.
  17. Kudielka BM, von Känel R, Gander ML, Fischer JE. The interrelationship of psychosocial risk factors for coronary artery disease in a working population: do we measure distinct or overlapping psychological concepts? Behav Med. 2004;30(1):35–43.
  18. von Känel R, Mausbach BT, Dimsdale JE, Mills PJ, Patterson TL, Ancoli-Israel S, et al. Regular physical activity moderates cardiometabolic risk in Alzheimer’s caregivers. Med Sci Sports Exerc. 2011;43(1):181–9.
  19. Surwit RS, Williams RB, Siegler IC, Lane JD, Helms M, Applegate KL, et al. Hostility, race, and glucose metabolism in nondiabetic individuals. Diabetes Care. 2002;25(5):835–9.
  20. Shen BJ, Countryman AJ, Spiro A 3rd, Niaura R. The prospective contribution of hostility characteristics to high fasting glucose levels: the moderating role of marital status. Diabetes Care. 2008;31(7):1293–8.
  21. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation. 1999;99(16):2192–217.
  22. Low CA, Thurston RC, Matthews KA. Psychosocial factors in the development of heart disease in women: current research and future directions. Psychosom Med. 2010;72:842–54.
  23. Marmot G. Status syndrome: a challenge to medicine. JAMA. 2006;295(11):1304–7.
  24. Kerr GD, Slavin H, Clark D, Coupar F, Langhorne P, Stott DJ. Do vascular risk factors explain the association between socioeconomic status and stroke incidence: a meta-analysis. Cerebrovasc Dis. 2011;31(1):57–63.
  25. Wilkinson RG, Pickett KE. Income inequality and socioeconomic gradients in mortality. Am J Public Health. 2008;98(4):699–704.
  26. Kornerup H, Osler M, Boysen G, Barefoot J, Schnohr P, Prescott E. Major life events increase the risk of stroke but not of myocardial infarction: results from the Copenhagen City Heart Study. Eur J Cardiovasc Prev Rehabil. 2010;17(1):113–8.
  27. Dong M, Giles WH, Felitti VJ, Dube SR, Williams JE, Chapman DP, et al. Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circulation. 2004;110(13):1761–6.
  28. Orth-Gomér K, Wamala SP, Horsten M, Schenck-Gustafsson K, Schneiderman N, et al. Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. JAMA. 2000;284(23):3008–14.
  29. Lee S, Colditz GA, Berkman LF, Kawachi I. Caregiving and risk of coronary heart disease in U.S. women: a prospective study. Am J Prev Med. 2003;24(2):113–9.
  30. Mausbach BT, Patterson TL, Rabinowitz YG, Grant I, Schulz R. Depression and distress predict time to cardiovascular disease in dementia caregivers. Health Psychol. 2007;26(5):539–44.
  31. Williams VP, Bishop-Fitzpatrick L, Lane JD, Gwyther LP, Ballard EL, Vendittelli AP, et al. Video-based coping skills to reduce health risk and improve psychological and physical well-being in Alzheimer’s disease family caregivers. Psychosom Med. 2010;72(9):897–904.
  32. Theorell T, Karasek RA. Current issues relating to psychosocial job strain and cardiovascular disease research. J Occup Health Psychol. 1996;1(1):9–26.
  33. Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996;1(1):27–41.
  34. Kivimäki M, Virtanen M, Elovainio M, Kouvonen A, Väänänen A, Vahtera J. Work stress in the etiology of coronary heart disease--a meta-analysis. Scand J Work Environ Health. 2006;32(6):431–42.
  35. Aboa-Éboulé C, Brisson C, Maunsell E, Bourbonnais R, Vézina M, Milot A, et al. Effort-reward imbalance at work and recurrent coronary heart disease events: a 4-year prospective study of post-myocardial infarction patients. Psychosom Med. 2011;73(6):436–47.
  36. Barth J, Schneider S, von Känel R. Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis. Psychosom Med. 2010;72(3):229–38.
  37. Williams RB, Barefoot JC, Califf RM, Haney TL, Saunders WB, Pryor DB, et al. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA. 1992;267(4):520–4.
  38. Lett HS, Blumenthal JA, Babyak MA, Strauman TJ, Robins C, Sherwood A. Social support and coronary heart disease: epidemiologic evidence and implications for treatment. Psychosom Med. 2005;67(6):869–78.
  39. Friedmann M, Rosenman RH. Association of specific overt behavior pattern with blood and cardiovascular findings; blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease. J Am Med Assoc. 1959;169(12):1286–96.
  40. Myrtek M. Meta-analyses of prospective studies on coronary heart disease, type A personality, and hostility. Int J Cardiol. 2001;79(2-3):245–51.
  41. Chida Y, Steptoe A. The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol. 2009;53(11):936–46.
  42. Denollet J. DS14: standard assessment of negative affectivity, social inhibition, and type D personality. Psychosom Med. 2005;67(1):89–97.
  43. Denollet J, Schiffer AA, Spek V. A general propensity to psychological distress affects cardiovascular outcomes: evidence from research on the type D (distressed) personality profile. Circ Cardiovasc Qual Outcomes. 2010;3(5):546–57.
  44. Smith TW. Toward a more systematic, cumulative, and applicable science of personality and health: lessons from type D personality. Psychosom Med. 2011;73(7):528–32.
  45. O’Dell KR, Masters KS, Spielmans GI, Maisto SA. Does type-D personality predict outcomes among patients with cardiovascular disease? A meta-analytic review. J Psychosom Res. 2011;71(4):199–206.
  46. Shipley BA, Weiss A, Der G, Taylor MD, Deary IJ. Neuroticism, extraversion, and mortality in the UK Health and Lifestyle Survey: a 21-year prospective cohort study. Psychosom Med. 2007;69(9):923–31.
  47. Dong JY, Zhang YH, Tong J, Qin LQ. Depression and risk of stroke: a meta-analysis of prospective studies. Stroke. 2012;43(1):32–7.
  48. Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48(8):1527–37.
  49. Ormel J, de Jonge P. Unipolar depression and the progression of coronary artery disease: toward an integrative model. Psychother Psychosom. 2011;80(5):264–74.
  50. Dantzer R, O’Connor JC, Freund GG, Johnson RW, Kelley KW. From inflammation to sickness and depression: when the immune system subjugates the brain. Nat Rev Neurosci. 2008;9(1):46–56.
  51. Roest AM, Martens EJ, de Jonge P, Denollet J. Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol. 2010;56(1):38–46.
  52. Roest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med. 2010;72(6):563–9.
  53. Guler E, Schmid JP, Wiedemar L, Saner H, Schnyder U, von Känel R. Clinical diagnosis of posttraumatic stress disorder after myocardial infarction. Clin Cardiol. 2009;32(3):125–9.
  54. von Känel R, Hari R, Schmid JP, Wiedemar L, Guler E, Barth J, et al. Non-fatal cardiovascular outcome in patients with posttraumatic stress symptoms caused by myocardial infarction. J Cardiol. 2011;58(1):61–8.
  55. Appels A. Exhaustion and coronary heart disease: the history of a scientific quest. Patient Educ Couns. 2004;55(2):223–9.
  56. Phillips B, Mannino DM. Do insomnia complaints cause hypertension or cardiovascular disease? J Clin Sleep Med. 2007;3(5):489–94.
  57. Kivimäki M, Batty GD, Hamer M, Ferrie JE, Vahtera J, Virtanen M, et al. Using additional information on working hours to predict coronary heart disease: a cohort study. Ann Intern Med. 2011;154(7):457–63.
  58. Honkonen T, Ahola K, Pertovaara M, Isometsä E, Kalimo R, Nykyri E, et al. The association between burnout and physical illness in the general population--results from the Finnish Health 2000 Study. J Psychosom Res. 2006;61(1):59–66.
  59. Ahola K, Väänänen A, Koskinen A, Kouvonen A, Shirom A. Burnout as a predictor of all-cause mortality among industrial employees: a 10-year prospective register-linkage study. J Psychosom Res. 2010;69(1):51–7.
  60. Buerki S, Adler RH. Negative affect states and cardiovascular disorders: a review and the proposal of a unifying biopsychosocial concept. Gen Hosp Psychiatry. 2005;27(3):180–8.
  61. Everson SA, Kaplan GA, Goldberg DE, Salonen R, Salonen JT. Hopelessness and 4-year progression of carotid atherosclerosis. The Kuopio Ischemic Heart Disease Risk Factor Study. Arterioscler Thromb Vasc Biol. 1997;17(8):1490–5.
  62. Williams JR Jr. Depression as a mediator between spousal bereavement and mortality from cardiovascular disease: appreciating and managing the adverse health consequences of depression in an elderly surviving spouse. South Med J. 2005;98(1):90–5.
  63. Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med. 2008;70(7):741–56.
  64. Barefoot JC, Brummett BH, Williams RB, Siegler IC, Helms MJ, Boyle SH, et al. Recovery expectations and long-term prognosis of patients with coronary heart disease. Arch Intern Med. 2011;171(10):929–35.
  65. Binder RK, Barth J, Schmid JP, Saner H. Burden of abdominal obesity in cardiac rehabilitation patients: Results from the Swiss CaRe study. Swiss Med Wkly. 2011;141:w13153.
  66. Scherrer JF, Xian H, Bucholz KK, Eisen SA, Lyons MJ, Goldberg J, et al. A twin study of depression symptoms, hypertension, and heart disease in middle-aged men. Psychosom Med. 2003;65(4):548–57.
  67. Williams RB, Surwit RS, Siegler IC, Ashley-Koch AE, Collins AL, Helms MJ, et al. Central nervous system serotonin and clustering of hostility, psychosocial, metabolic, and cardiovascular endophenotypes in men. Psychsom Med. 2010;72(7):601–7.
  68. Brummett BH, Siegler IC, Ashley-Koch A, Williams RB. Effects of 5HTTLPR on cardiovascular response to an emotional stressor. Psychosom Med. 2011;73(4):318–22.
  69. Chida Y, Steptoe A. Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: a meta-analysis of prospective evidence. Hypertension. 2010;55(4):1026–32.
  70. Kuzawa CW, Sweet E. Epigenetics and the embodiment of race: developmental origins of US racial disparities in cardiovascular health. Am J Hum Biol. 2009;21(1):2–15.
  71. Hänsel A, Hong S, Cámara RJ, von Känel R. Inflammation as a psychophysiological biomarker in chronic psychosocial stress. Neurosci Biobehav Rev. 2010;35(1):115–21.
  72. von Känel R, Mills PJ, Fainman C, Dimsdale JE. Effects of psychological stress and psychiatric disorders on blood coagulation and fibrinolysis: a biobehavioral pathway to coronary artery disease? Psychosom Med. 2001;63(4):531–44.
  73. von Känel R, Orth-Gomér K. Autonomic function and prothrombotic activity in women after an acute coronary event. J Womens Health. 2008;17(8):1331–7.
  74. Steptoe A, Brydon L. Emotional triggering of cardiac events. Neurosci Biobehav Rev. 2009;33(2):63–70.
  75. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction – executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110(5):588–636.
  76. Lichtman JH, Bigger JT Jr, Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lespérance F, et al. American Heart Association Prevention Committee of the Council on Cardiovascular Nursing; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Epidemiology and Prevention; American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research; American Psychiatric Association. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation. 2008;118(17):1768–75.
  77. Ziegelstein RC, Thombs BD. Is routine screening a parachute for heart disease patients with depression? J Psychosom Res. 2011;71(1):3–5.
  78. Albus C, Jordan J, Herrmann-Lingen C. Screening for psychosocial risk factors in patients with coronary heart disease-recommendations for clinical practice. Eur J Cardiovasc Prev Rehabil. 2004;11(1):75–9.
  79. Whooley MA. Depression and cardiovascular disease: healing the broken-hearted. JAMA. 2006;295(24):2874–81.
  80. Löwe B, Gräfe K, Zipfel S, Spitzer RL, Herrmann-Lingen C, Witte S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians’ diagnosis. J Psychosom Res. 2003;55(6):515–9.
  81. Prins A, Ouimette PC, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, et al. The Primary Care PTSD Screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry. 2003;9(1):9–14.
  82. Herrmann-Lingen C. Steps towards integrated psychosomatic medicine – the example of psychocardiology. J Psychosom Res. 2011;70(2):111–5.
  83. Whalley B, Rees K, Davies P, Bennett P, Ebrahim S, Liu Z, et al. Psychological interventions for coronary heart disease. Cochrane Database Syst Rev. 2011;(8):CD002902.
  84. Linden W, Phillips MJ, Leclerc J. Psychological treatment of cardiac patients: a meta-analysis. Eur Heart J. 2007;28(24):2972–84.
  85. Orth-Gomér K, Schneiderman N, Wang HX, Walldin C, Blom M, Jernberg T. Stress reduction prolongs life in women with coronary disease: the Stockholm Women’s Intervention Trial for Coronary Heart Disease (SWITCHD). Circ Cardiovasc Qual Outcomes. 2009;2(1):25–32.
  86. Gulliksson M, Burell G, Vessby B, Lundin L, Toss H, Svärdsudd K. Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Arch Intern Med. 2011;171(2):134–40.
  87. Welton NJ, Caldwell DM, Adamopoulos E, Vedhara K. Mixed treatment comparison meta-analysis of complex interventions: psychological interventions in coronary heart disease. Am J Epidemiol. 2009;169(9):1158–65.
  88. Blumenthal JA. New frontiers in cardiovascular behavioral medicine: Comparative effectiveness of exercise and medication in treating depression. Cleve Clin J Med. 2011;78(Suppl 1):S35–43.
  89. Williams RB. Psychosocial and biobehavioral factors and their interplay in coronary heart disease. Annu Rev Clin Psychol. 2008;4:349–65.
  90. Blumenthal JA, Sherwood A, Babyak MA, Watkins LL, Waugh R, Georgiades A, et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial. JAMA. 2005;293(13):1626–34.
  91. Bishop GD, Kaur D, Tan VL, Chua YL, Liew SM, Mak KH. Effects of a psychosocial skills training workshop on psychophysiological and psychosocial risk in patients undergoing coronary artery bypass grafting. Am Heart J. 2005;150(3):602–9.
  92. Koçer O, Wachter M, Zellweger M, Piazzalonga S, Hoffmann A. Prevalence and predictors of depressive symptoms and wellbeing during and up to nine years after outpatient cardiac rehabilitation. Swiss Med Wkly. 2011;141:w13242.
  93. Mazza M, Lotrionte M, Biondi-Zoccai G, Abbate A, Sheiban I, Romagnoli E. Selective serotonin reuptake inhibitors provide significant lower re-hospitalization rates in patients recovering from acute coronary syndromes: evidence from a meta-analysis. J Psychopharmacol. 2010;24(12):1785–92.
  94. von Känel R. Platelet hyperactivity in clinical depression and the beneficial effect of antidepressant drug treatment: how strong is the evidence? Acta Psychiatr Scand. 2004;110(3):163–77.
  95. Vieweg WV, Julius DA, Fernandez A, Wulsin LR, Mohanty PK, Beatty-Brooks M, et al. Treatment of depression in patients with coronary heart disease. Am J Med. 2006;119(7):567–73.

Most read articles by the same author(s)