Behavioral cardiology: Recognizing and addressing the profound impact of psychosocial stress on cardiovascular health

Psychosocial Risk Factors and Cardiovascular Disease and Death in a Population-Based Cohort From 21 Low-, Middle-, and High-Income Countries

IMPORTANCE

Stress may increase the risk of cardiovascular disease (CVD). Most studies on stress and CVD have been conducted in high-income Western countries, but whether stress is associated with CVD in other settings has been less well studied.

OBJECTIVE

To investigate the association of a composite measure of psychosocial stress and the development of CVD events and mortality in a large prospective study involving populations from 21 high-, middle-, and low-income countries across 5 continents.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used data from the Prospective Urban Rural Epidemiology study, collected between January 2003 and March 2021. Participants included individuals aged 35 to 70 years living in 21 low-, middle-, and high-income countries. Data were analyzed from April 8 to June 15, 2021.

EXPOSURES

All participants were assessed on a composite measure of psychosocial stress assessed at study entry using brief questionnaires concerning stress at work and home, major life events, and financial stress.

MAIN OUTCOMES AND MEASURES

The outcomes of interest were stroke, major coronary heart disease (CHD), CVD, and all-cause mortality.

RESULTS

A total of 118 706 participants (mean [SD] age 50.4 [9.6] years; 69 842 [58.8%] women and 48 864 [41.2%] men) without prior CVD and with complete baseline and follow-up data were included. Of these, 8699 participants (7.3%) reported high stress, 21 797 participants (18.4%) reported moderate stress, 34 958 participants (29.4%) reported low stress, and 53 252 participants (44.8%) reported no stress. High stress, compared with no stress, was more likely with younger age (mean [SD] age, 48.9 [8.9] years vs 51.1 [9.8] years), abdominal obesity (2981 participants [34.3%] vs 10 599 participants [19.9%]), current smoking (2319 participants [26.7%] vs 10 477 participants [19.7%]) and former smoking (1571 participants [18.1%] vs 3978 participants [7.5%]), alcohol use (4222 participants [48.5%] vs 13 222 participants [24.8%]), and family history of CVD (5435 participants [62.5%] vs 20 255 participants [38.0%]). During a median (IQR) follow-up of 10.2 (8.6-11.9) years, a total of 7248 deaths occurred. During the course of follow-up, there were 5934 CVD events, 4107 CHD events, and 2880 stroke events. Compared with no stress and after adjustment for age, sex, education, marital status, location, abdominal obesity, hypertension, smoking, diabetes, and family history of CVD, as the level of stress increased, there were increases in risk of death (low stress: hazard ratio [HR], 1.09 [95% CI, 1.03-1.16]; high stress: 1.17 [95% CI, 1.06-1.29]) and CHD (low stress: HR, 1.09 [95% CI, 1.01-1.18]; high stress: HR, 1.24 [95% CI, 1.08-1.42]). High stress, but not low or moderate stress, was associated with CVD (HR, 1.22 [95% CI, 1.08-1.37]) and stroke (HR, 1.30 [95% CI, 1.09-1.56]) after adjustment.

CONCLUSIONS AND RELEVANCE

This cohort study found that higher psychosocial stress, measured as a composite score of self-perceived stress, life events, and financial stress, was significantly associated with mortality as well as with CVD, CHD, and stroke events.

Women's participation in stress management interventions for chronic heart failure: a meta-analysis of randomized controlled trials

Stress management interventions (SMIs) can alleviate the psychosocial stress often experienced by women with heart failure. The purpose of this meta-analysis was to summarize women's participation rates, and predictors of participation, in SMIs for the management of psychosocial distress in women with chronic HF. Studies were retrieved from bibliographic databases, reference sections of relevant papers, and research registries. Included studies (a) evaluated a SMI approach for the management of chronic HF, (b) sampled chronic HF patients, and (c) used a randomized controlled trial (RCT) design. Independent coders extracted the relevant data. Thirty-five RCTs met inclusion criteria (N = 3,649; mean age = 63.5 ± 7.0 years). All studies sampled both men and women; the mean proportion of women who participated in the trials was 38.8% (95% confidence interval [CI] = 34.5-43.4; I² = 82.4, 95% CI = 81.0-83.6). Women's participation rates were higher in studies sampling more HF patients with hypertension (B = 1.01, SE = 0.45, P = .046) but fewer HF patients prescribed beta blockers (B = -1.10, SE = 0.33, P = .006), F (2,12) = 6.27, P = 0.014, adjusted R² = 61%. SMIs may offer women a complementary or integrative approach to standard treatment to help manage the psychological distress associated with HF. Future research should explore the potential benefits of offering stress management approaches to women as part of comprehensive HF care.

A Systematic Review of the Associations of Adult Sexual Abuse in Women with Cardiovascular Diseases and Selected Risk Factors

Aim

To systematically assess the association between adult sexual abuse (ASA) and cardiovascular diseases (CVDs) of heart attack and stroke, and their risk factors of hypertension, diabetes, dyslipidaemia and obesity.

Methods

Two authors conducted a PubMed, Scopus and Web of Science review of the literature published prior to 1 October 2019. Relevant English language studies irrespective of study design and data collection techniques were included. Included articles needed to have examined ASA per se independent of physical or psychological/emotional abuse, and childhood sexual abuse.

Results

Of the 3260 articles identified, nine were selected from 97 full-text articles assessed for eligibility (n = 855 206 women). Six studies were cross-sectional in design while three articles were from longitudinal studies; all emanated from the United States. One study only (n = 867) performed clinical assessments (heights and weights) to determine the relevant outcome (obesity), four presented self-reported outcomes (heart attack, stroke, hypertension, diabetes, obesity), two reviewed clinical records and two did not provide details on outcome assessments (obesity). Sexual abuse by an intimate partner was examined in five articles, three assessed military sexual trauma and a single study evaluated any perpetrator. A meta-analysis could not be conducted because of the heterogeneity across studies. The available evidence was insufficient to quantify the relationship, if any, between ASA and CVDs and their risk factors.

Conclusions

Currently, no longitudinal studies of ASA in general populations have objectively investigated the development of CVDs and their risk factors using clinical and biochemical measurements. In view of the high CVD burden, and the frequency of ASA, it is important to fully understand the relationship between the two.

An international comparison of factors affecting quality of life among patients with congestive heart failure: A cross-sectional study

OBJECTIVE

To explore associations among twenty formal and informal, societal and individual-level factors and quality of life (QOL) among people living with congestive heart failure (CHF) in two settings with different healthcare and social care systems and sociocultural contexts.

SETTING AND PARTICIPANTS

We recruited 367 adult patients with CHF from a single heart failure clinic within two countries with different national social to healthcare spending ratios: Minneapolis, Minnesota, United States (US), and Nijmegen, Netherlands (NL).

DESIGN

Cross-sectional survey study. We adapted the Social Quality Model (SQM) to organize twenty diverse factors into four categories: Living Conditions (formal-societal: e.g., housing, education), Social Embeddedness (informal-societal: e.g., social support, trust), Societal Embeddedness (formal-individual: e.g., access to care, legal aid), and Self-Regulation (informal-individual: e.g., physical health, resilience). We developed a survey comprising validated instruments to assess each factor. We administered the survey in-person or by mail between March 2017 and August 2018.

OUTCOMES

We used Cantril's Self-Anchoring Scale to assess overall QOL. We used backwards stepwise regression to identify factors within each SQM category that were independently associated with QOL among US and NL participants (p<0.05). We then identified factors independently associated with QOL across all categories (p<0.05).

RESULTS

367 CHF patients from the US (32%) and NL (68%) participated. Among US participants, financial status, receiving legal aid or housing assistance, and resilience were associated with QOL, and together explained 49% of the variance in QOL; among NL participants, financial status, perceived physical health, independence in activities of daily living, and resilience were associated with QOL, and explained 53% of the variance in QOL.

CONCLUSIONS

Four formal and informal factors explained approximately half of the variance in QOL among patients with CHF in the US and NL.

Emotion regulation moderates the association between chronic stress and cardiovascular disease risk in humans: a cross-sectional study

Chronic stress is a risk factor for incident cardiovascular (CV) disease. Emotion regulation is the ability to modulate one's state or behavior in response to a given situation or stressor, and may mitigate the effect of chronic stress on CV disease risk. Data from a cohort of 754 community-dwelling young to middle-aged adults who were assessed between 2007 and 2012 on stress, emotion regulation, and CV risk measures were used to test the hypothesis that emotion regulation mitigates the effect of chronic stress on CV risk. Emotion regulation was measured using the Difficulties in Emotion Regulation Scale (DERS). We created a composite stress score using data from the Cumulative Adversity Interview and the Perceived Stress Scale. Our outcomes included blood pressure, body mass index, and insulin resistance separately and combined into a composite CV risk score. Covariates included age, sex, race, years of education, and smoking status. We used multivariable logistic regression to evaluate associations between stress measures and CV risk among participants and the impact of emotion regulation (DERS scores) on this association. We found that composite stress interacted significantly with the DERS score to affect CV risk (p = .007). A median split of the DERS scores indicated that CV risk was associated with the composite stress score in the fully adjusted model (ß = 0.206; p = .005) among participants with low emotion regulation, but not among those with high emotion regulation (ß = 0.048; p = .59). Chronic stress was associated with CV risk only among participants with poor emotion regulation. Emotion regulation is a teachable skill, and may play a role in preventing CV disease.Lay summaryEmotion regulation is the ability to modify one's reaction to a negative or stressful event, and is a teachable skill. Effective emotion regulation dampens the negative effect of chronic stress on the body, which may reduce risk for cardiovascular disease.

Dog ownership and the risk of cardiovascular disease and death - a nationwide cohort study

Dogs may be beneficial in reducing cardiovascular risk in their owners by providing social support and motivation for physical activity. We aimed to investigate the association of dog ownership with incident cardiovascular disease (CVD) and death in a register-based prospective nation-wide cohort (n = 3,432,153) with up to 12 years of follow-up. Self-reported health and lifestyle habits were available for 34,202 participants in the Swedish Twin Register. Time-to-event analyses with time-updated covariates were used to calculate hazard ratios (HR) with 95% confidence intervals (CI). In single- and multiple-person households, dog ownership (13.1%) was associated with lower risk of death, HR 0.67 (95% CI, 0.65–0.69) and 0.89 (0.87–0.91), respectively; and CVD death, HR 0.64 (0.59–0.70), and 0.85 (0.81–0.90), respectively. In single-person households, dog ownership was inversely associated with cardiovascular outcomes (HR composite CVD 0.92, 95% CI, 0.89–0.94). Ownership of hunting breed dogs was associated with lowest risk of CVD. Further analysis in the Twin Register could not replicate the reduced risk of CVD or death but also gave no indication of confounding by disability, comorbidities or lifestyle factors. In conclusion, dog ownership appears to be associated with lower risk of CVD in single-person households and lower mortality in the general population.

Study protocol for a longitudinal study evaluating the impact of rape on women's health and their use of health services in South Africa

INTRODUCTION

South Africa is a country known for its high levels of HIV infection and sexual violence. Although the interface between gender-based violence, HIV and mental health has been described, there are substantial gaps in knowledge of the medium-term and long-term health impact. The 2010 Global Burden of Disease study excluded many health outcomes associated with rape and other forms of gender-based violence because systematic reviews revealed huge gaps in data and poor evidence of health effects. This study aims to describe the incidence and attributable burden of physical and mental health problems (including HIV acquisition) in adult women over a 2-year postrape period, through comparison with a cohort of women who have not been raped. The study will substantially advance our understanding of the impact of rape and will generate robust data to assist in the development of postrape health services and the delivery of evidence-based care.

METHODS AND ANALYSIS

This longitudinal study seeks to recruit 1008 rape-exposed and 1008 rape non-exposed women. Women were recruited from health services, and assessments were carried out at baseline, 3, 6, 9, 12, 18 and 24 months. Outcome measures include exposure to risk factors; mental health status; cardio-metabolic risks; and biomarkers for HIV, sexually transmitted infections, pregnancy and stress. The primary analysis will be to compare HIV incidence in the two groups using log-rank tests. Appropriate models to predict health outcomes over time will also be applied.

ETHICS AND DISSEMINATION

The South African Medical Research Council's Ethics Committee approved the study. As rape is a key element of the study, the safety and protection of participants guides the research process. We will adopt a research uptake strategy to ensure dissemination to policy makers, service providers and advocacy groups. Peer-reviewed journal articles will be published.

Exposure to Violence and Carotid Artery Intima-Media Thickness in Mexican Women

BACKGROUND

Violence against women has become a global public health threat. Data on the potential impact of exposure to violence on cardiovascular disease are scarce.

METHODS AND RESULTS

We evaluated the association between exposure to violence and subclinical cardiovascular disease in 634 disease-free women from the Mexican Teachers' Cohort who responded to violence-related items from the Life Stressor Checklist and underwent measures of carotid artery intima-media thickness in 2012 and 2013. We defined exposure to violence as having ever been exposed to physical and/or sexual violence. Intima-media thickness was log-transformed, and subclinical carotid atherosclerosis was defined as intima-media thickness ≥0.8 mm or plaque. We used multivariable linear and logistic regression models adjusted for several potential confounders. Mean age was 48.9±4.3 years. Close to 40% of women reported past exposure to violence. The lifetime prevalence of sexual violence was 7.1%, and prevalence of physical violence was 23.5% (7.7% reported both sexual and physical violence). Relative to women with no history of violence, exposure to violence was associated with higher intima-media thickness (adjusted mean percentage difference=2.4%; 95% confidence interval 0.5, 4.3) and subclinical atherosclerosis (adjusted odds ratio=1.60; 95% confidence interval 1.10, 2.32). The association was stronger for exposure to physical violence, especially by mugging or physical assault by a stranger (adjusted mean % difference=4.6%; 95% confidence interval 1.8, 7.5, and odds ratio of subclinical carotid atherosclerosis=2.06; 95% confidence interval 1.22, 3.49).

CONCLUSIONS

Exposure to violence, and in particular assault by a stranger, was strongly associated with subclinical cardiovascular disease in Mexican middle-aged women.

Association between pet ownership and coronary artery disease in a Chinese population

A number of studies have suggested the benefits of pet ownership to human health, including cardiovascular disease (CVD). However, there are few findings regarding pet ownership and coronary artery disease (CAD). The objective of this study is to investigate the association between pet ownership and CAD in a Chinese population. From October 2015 to May 2016, a survey consisting of 561 consecutive patients was done in Nanjing, China. Based on the results of coronary arteriography for the first time, participants were divided into 2 groups (non-CAD and CAD groups). Pet ownership information was collected by using a questionnaire. After multivariate adjustments, pet ownership was associated with a decreased CAD risk (odds ratios [OR]: 0.504, 95% confidence intervals [CIs]: 0.310-0.819). There was a reduced CAD risk among dog owners (OR: 0.420, 95% CI: 0.242-0.728) when compared with the cat group (OR: 0.738, 95% CI: 0.240-2.266) and the cat and dog group (OR: 1.052, 95% CI: 0.330-3.355). With the increase of pet ownership duration, there was a decreased tendency of CAD risk, including years of keeping pets (P for trend = 0.008) and time of playing with pets per day (P for trend = 0.001). In addition, similar dose-response relationship was observed for starting age of keeping pets (P for trend = 0.002). Pet ownership, especially dog ownership, can be a protective factor for CAD in Chinese patients.

Forensic Interviews for Child Sexual Abuse Allegations: An Investigation into the Effects of Animal-Assisted Intervention on Stress Biomarkers

The use of therapy animals during forensic interviews for child sexual abuse allegations is a recommendation by the Therapy Animals Supporting Kids Program to help ease children's discomfort during the forensic interview process. Based on this recommendation, this study incorporated a certified therapy canine into the forensic interview process for child sexual abuse allegations. This study investigated changes in salivary cortisol, immunoglobulin A, blood pressure, and heart rate as a result of forensic interview phenomenon (e.g., outcry) incorporating animal-assisted intervention versus a control condition in children (N = 42) interviewed for alleged child sexual abuse. The results supported significantly greater heart rate values for the control group (n = 23) who experienced sexual contact and/or indecency than the experience of aggravated sexual assault compared to no difference in HR for the intervention group (n = 19). The results suggest that the presence of the canine in the forensic interview may have acted as a buffer or safeguard for the children when disclosing details of sexual abuse. In the intervention group, children's HR was lower at the start of the forensic interview compared to the control group. Finding an effect of having a certified handler-canine team available during the forensic interview on physiological measures of stress has real-world value for children, child welfare personnel, and clinical therapists. It is suggested that animal-assisted intervention be expanded to children facing other types of trauma and to treatment programs for child survivors of sexual abuse.

Combined exercise circuit session acutely attenuates stress-induced blood pressure reactivity in healthy adults

Objective

To investigate the blood pressure (BP) responses to cardiovascular stress test after a combined exercise circuit session at moderate intensity.

Method

Twenty individuals (10 male/10 fem; 33.4± 6.9 years; 70.2± 15.8 kg; 170.4± 11.5 cm; 22.3± 6.8% body fat) were randomized in a different days to control session with no exercise or exercise session consisting of 3 laps of the following circuit: knee extension, bench press, knee flexion, rowing in the prone position, squats, shoulder press, and 5 min of aerobic exercise at 75-85% of age-predicted maximum heart rate and/or 13 on the Borg Rating of Perceived Exertion [scale of 6 to 20]. The sets of resistance exercise consisted of 15 repetitions at ~50% of the estimated 1 repetition maximum test. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured at rest and during 1h of recovery in both experimental sessions. After that, blood pressure reactivity (BP_R) was evaluated using the Cold Pressor Test.

Results

During 1h of exercise recovery, there was a reduction in SBP (3-6 mmHg) and DBP (2-5 mmHg) in relation to pre-session rest (p<0.01), while this reduction was not observed in the control session. A decline in BP_R (4-7 mmHg; p<0.01) was observed 1h post-exercise session, but not in the control session. Post-exercise reductions in SBP and DBP were significantly correlated with BP_R reductions (r=0.50-0.45; p<0.05).

Conclusion

A combined exercise circuit session at moderate intensity promoted subsequent post-exercise hypotension and acutely attenuated BP_R in response to a cardiovascular stress test. In addition, the post-exercise BP reduction was correlated with BP_R attenuation in healthy adults of both genders.

Neutralizing the adverse prognosis of coronary artery calcium

OBJECTIVES

To report and compare the outcomes and survival of patients with abnormal computed tomography-derived coronary artery calcium (CT-CAC) scores undergoing aggressive medical treatment at a cardiac prevention clinic.

PATIENTS AND METHODS

We conducted a retrospective analysis of 849 patients with intermediate risk based on the Framingham risk score and an abnormal CT-CAC score who were aggressively treated in a preventive cardiology risk factor modification program from June 23, 2000, to September 1, 2012. The primary outcome was a composite end point of myocardial infarction, resuscitated cardiac arrest, revascularization, and cardiovascular death. The effect of the CT-CAC subgroup on major adverse coronary heart disease events (MACEs) was evaluated by calculating hazard ratios with Cox proportional hazards regression modeling. The Centers for Disease Control and Prevention Wonder database was used to identify age- and sex-matched controls from the general population of Kansas and Missouri.

RESULTS

The mean age of the study patients was 65.4 years (58.4% men [496]). The median follow-up was 58 months, and the mean CT-CAC score was 336 Agatston units. Thirty-four patients (4.0%) reached the primary end point, including 4 deaths. The adjusted 10-year mortality rates were similar in the study group and control group (9.3 vs 10.6; P=.80). After adjustment, a CT-CAC score greater than 400 Agatston units correlated with a higher risk of MACEs (hazard ratio, 3.55; P=.01).

CONCLUSION

These results suggest that intermediate-risk patients with abnormal CT-CAC scores when treated with intensive risk factor reduction have lower rates of MACEs than predicted by the Framingham risk score and the presence of coronary artery calcium.

Emergency department patients self-report higher patient inertia, hopelessness, and harmful lifestyle choices than community counterparts

Patient inertia is defined as an individual's failure to take responsibility for proactive lifestyle change and health conditions including hypertension. Generalized and hypertension-specific patient inertia factors were compared in 110 patients (48% women; 52% African American) from a Forsyth County, NC, emergency department (ED) and 104 community members (79% women; 70% African American) using the patient inertia-facilitated survey Patient Inertia-36. Statistically, more ED than community participants added salt to food at the table and consumed fast foods 5 to 7 days a week. ED patients agreed less often with health literacy questions about salt and BP. Hypertension associated Patient inertia questions asked of 45 ED and 40 community participants with a personal history of hypertension revealed a statistically higher sense of hopelessness surrounding blood pressure management in ED participants. Past BP control experiences of family members had statistically greater impact on community participants regarding their own BP control. Using a logistic regression model, advancing age and being surveyed in the ED were correlated with hopelessness towards BP control. ED patients make unhealthier diet choices and possess heightened generalized and hypertension-specific patient inertia including hopelessness towards controlling their BP that increases with age. These factors may contribute to this population's poor BP control, particularly self-efficacy barriers.

Cardiologic side effects of psychotropic drugs

Psychotropic drugs can produce cardiovascular side effects associated with a degree of cardiotoxicity. The coexistence of a heart disease complicates the management of mental illness, can contribute to a reduced quality of life and a worse illness course. The co-occurrence of psychiatric disorders in cardiac patients might affect the clinical outcome and morbidity. Moreover, the complex underlying mechanism that links these two conditions remains unclear. This paper discusses the known cardiovascular complications of psychotropic drugs and analyzes the important implications of antidepressive treatment in patients with previous cardiac history.

The role of anxiety in metabolic syndrome

Metabolic syndrome (MS) seems to be associated with both depression and increased cardiovascular risk. This article emphasizes the most relevant findings on the link between MS and psychological cardiovascular risk factors, focusing on the impact of anxiety. There is evidence for an association between psychological disorders and the development of MS, which could eventually increase cardiovascular risk. However, the coexistence of anxiety in MS patients seems to be a byproduct of anxiety-depression comorbidity, stress and negative health behaviors. Endocannabinoid receptors, and hypothalamic-pituitary-adrenal axis dysregulation and sympathetic hyperactivation are the most commonly mentioned plausible underlying pathways.

Lowered omega-3 PUFAs are related to major depression, but not to somatization syndrome

BACKGROUND

Studies indicated a depletion of omega-3 fatty acid levels and an imbalance between omega-3 and omega-6 PUFAs in depressive patients. Depletion of omega-3 PUFAs may be related to the immune and serotonergic pathophysiologies of depression by alterations in membrane fluidity and modulation of membrane receptors, enzyme activities and carriers. Previous studies also found serotonergic and immunological disturbances in subjects with somatoform symptoms. Based on these findings we aimed to investigate PUFA concentrations and its relations to other biological systems in depressed patients and in patients with somatoform symptoms.

METHODS

We examined 150 subjects divided in 4 groups, i.e. somatization syndrome; depression; depression and somatization syndrome; controls. Blood samples were analyzed for fatty acids, markers of the serotonergic system and the immune system.

RESULTS

The study was able to replicate earlier findings in patients with depression (lowered omega-3 PUFAs, increased omega-6/omega-3 ratios in serum cholesteryl esters). The somatization syndrome group showed no abnormalities in the mentioned fatty acid levels. Only depressive patients revealed associations between fatty acids with serotonergic and immunological markers.

LIMITATIONS

We used current state diagnoses, and the consideration of lifetime diagnoses and longitudinal studies could highlight further aspects of the reported results.

CONCLUSIONS

The findings are further confirming that the concepts of depression and somatoform disorders should not be merged indiscriminately together, even though they often occur together. We conclude that in depression and somatoform syndrome different biological mechanisms seem to be involved.

The need for veterinarians in biomedical research

The number of veterinarians in the United States is inadequate to meet societal needs in biomedical research and public health. Areas of greatest need include translational medical research, veterinary pathology, laboratory-animal medicine, emerging infectious diseases, public health, academic medicine, and production-animal medicine. Veterinarians have unique skill sets that enable them to serve as leaders or members of interdisciplinary research teams involved in basic science and biomedical research with applications to animal or human health. There are too few graduate veterinarians to serve broad national needs in private practice; academia; local, state, and federal government agencies; and private industry. There are no easy solutions to the problem of increasing the number of veterinarians in biomedical research. Progress will require creativity, modification of priorities, broad-based communication, support from faculty and professional organizations, effective mentoring, education in research and alternative careers as part of the veterinary professional curriculum, and recognition of the value of research experience among professional schools' admissions committees. New resources should be identified to improve communication and education, professional and graduate student programs in biomedical research, and support to junior faculty. These actions are necessary for the profession to sustain its viability as an integral part of biomedical research.