Lecture 4: Stress and cardiovascular disease Flashcards
How can psychological conditions influence myocardial infarction and cardiac death?
- Can be trigged by emotional distress
- Vulnerability determined by CAD, myocardial damage and chronic psychiatric, psychological and social conditions which can enhance the likelihood of emotion-related triggers
Phases of acute coronary syndromes
- Gradual subclinical disease progression
- Vulnerable disease stage
- Acute coronary syndromes
- Cardiac symptoms like chest pain and angina occur later in the disease process
What are the 3 categories of classification of cardiovascular risk factors?
- Acute psychological risk factors like outbursts of anger, mental activity and acute distress can trigger within 1 hour
- Episodic psychologic risk factors which lasts from several weeks to two years which can be depression, exhaustion, job loss
- Chronic psychological risk factors which can increase progression of CAD like personality traits and socioenvironmental factors
What is the role of chronic psychologic risk factors?
Chronic psychologic risk factors linked to increased reactivity to acute stressors and greater risk of development of episodic risk factors. Greater emotional and biologic response to acute stressors
What is the definition of psychological distress?
Negative internal state of the individual that is dependent on interpretation or appraisal of threat, harm or demand. Stress has some definitional problems but distress is used to indicate the reaction to stressors. It incorporates a large portion of predictive values of cardiovascular risk like depression, anxiety, hostility and low social support. Severe and uncontrollable distress can result in clinical and subclinical states which have negative affect
How can psychological distress be evaluated?
By environmental precipitants, and factors that can increase vulnerability to these events as well as psychological and social factors which act as buffers (social support, coping resources, optimism). To detect this distress can lead to referral and intervention
What is the role of acute distress in triggering cardiac events?
- potential trigger of acute coronary syndromes and cardiac arrhythmias
- prolonged and repeated exposures to short term stress can lead to more cardiac and vascular disease progression
- acute coronary syndromes preceded by acute trigger
- increase in central and ANS activity is linked to psychological events which result in cardiac pathologies
- acute distress plays a role in clinical syndromes with no anatomical or structural disease
What is the difference between panic disorder and non-cardiac chest pain?
- Can be complicated
- Angina can be the result of abnormal microvascular vessels with normal coronary arteries
Cases which highlight importance of psychological distress as a trigger of acute coronary syndromes
- development of left ventricular dysfunction after suicide hanging due to intense emotions and physical challenge
- spouse found to die after other one dies due to heart causes-> acute coronary occlusion due to structure mental challenge task during coronary angiography
- anger preceded patients in 2 hours preceding the MI with a high relative risk
Myocardial ischemia
This is when cardiac demand exceeds coronary blood supply to heart muscle, causing infarctions. Exercise and psychologic distress can induce transient myocardial ischemia by increasing cardia demand. Psychologic stress can cause decreased supply due to constriction.
Features of ischemia induced by acute psychological distress
- occurs in 40-70% of CAD patients with exercise-inducible ischemia
- not detectable by ECG ST-segment changes
- asymptomatic
- occurs at lower heart rates and similar blood pressure
- linked to lower ischemic thresholds during exercise testing and monitoring
- more than two fold risk of negative CVD outcomes
Cardiac arrhythmias
- arrhythmic vulnerability can be linked to myocardial ischemia
- severe to moderate distress was linked to ventricular fibrillation
- more patients with defibrillators after 9/11, but media could have played a role too
- acute mental stress induced by angerl recall and mental arithmetic was linked to increases in T-wave alterations with defibrillator.
- These T-waves were predictive of future arrhythmias
- mental arithmetic can induce prolongation or QT interval
Acute heart failure
Lots of overlap of acute heart failure with MI, but less evidence.
Takotsubo syndrome clinical characteristics
- left ventricular dysfunction
- apical ballooning
- minimal CAD
- limited cardiac damage
- develops in post-menopausal women
- catecholamine increase plays a role
What is different about takotsubo syndrome?
Can result to normal or near normal LV function. The treatments are patient education, counselling, pharmacologic therapy. There can be substantial cardiac responses to distress like LV function impaired, life-threatening arrhythmias with no CAD.
What are most common psychological risk factors in cardiology?
Depression and exhaustion which could be due to psychological distress (includes marital distress, natural disaster, job loss and job strain). MI is associated with higher prevalence in work stress, home stress, financial stress, major life stress, lower locus of control and more depression (retrospective bias could play a role in results to find an explanation). But high predictive value of distress for adverse CVD outcomes
What can precipitate depressive episodes?
- psychologic reactions to having a life threatening disease with symptoms, functional limitations, CVD changes that can alter the CNS
- mild to moderate episodes linked to adverse life events but not for severe episodes
- dysfunctional cognitions/maladaptive responses to loss and health play a role
- functional severity, social factors and biological all play a role
Link between depression and cardiology
It predicts the first and recurrent MI and cardiac death. Untreated depression can significantly increase the risk of cardiac events.
Fatigue and lack of energy, irritability more often observed in cardiac patients than other symptoms like sadness, guilt, low self-esteem. Prior diagnoses seen to be stronger predictor of post-MI mortality than during.
What is the role of fatigue in acute coronary syndromes?
Known as vital exhaustion which is a lack of energy, increased irritability and demoralization. Vital is seen as the long-term consequences of this condition on daily life functioning. Depression and exhaustion seen as not fully overlapping conditions. Somatic depressive symptoms seen as better predictors of MI than cognitive-affective depressive symptoms.
