Stress and Its Effects on

the Heart
Nancy Selfridge, MD
Professor and Chair
Clinical Foundations
2019
Learning Objectives
1. Describe the epidemiology of cardiovascular disease (CVD) in the U.S.
2. Identify modifiable and non-modifiable risk factors for CVD: age,
gender, ethnic factors, comorbidities and social determinants of
health.
3. Identify evidence-based emotional and behavioral factors that affect
cardiovascular disease.
4. Explain how personality and other psychosocial factors influence
cardiovascular disease.
5. Describe and discuss occupational and other environment risk factors
for cardiovascular disease.
6. Describe the psychosocial management and treatment of acute and
chronic cardiac conditions
Reading: Fadem, B. (2012). Behavioral Science in Medicine, 2nd Edition. Baltimore.
Lippincott Williams & Wilkins. [Chapter 25]
1. Describe the epidemiology of cardiovascular disease.

Epidemiology of Cardiovascular Disease

• Leading cause of death for both
men and women
• 610,000 Americans die each year
(1 in every 4 deaths)
• Someone has a heart attack in the
U.S. every 42 seconds
• Leading cause of death for people
of most racial/ethnic groups
including African American,
Hispanic, and Caucasian
• 2nd leading cause of death (behind
cancer) for Asian and Native
Americans
• Heart disease costs the U.S. $207
billion each year
2. Identify modifiable and non-modifiable factors that influence cardiovascular disease

Risk Factors (Non-Modifiable)

Age
• Increases risk of damaged and narrowed arteries, weakened heart
muscle
Gender
• Men are generally at greater risk; women’s risk increases after
menopause
Heredity
• Family history increases risk, especially if a parent developed CAD at
an early age (i.e., <55 for male relative, <65 for female relative)
• People with African or Asian ancestry are at higher risk

http://www.mayoclinic.org/diseases-conditions/heart-disease/basics/risk-factors/con-20034056
2. Identify modifiable and non-modifiable factors that influence cardiovascular disease

Risk Factors (Modifiable)

• Diabetes
• Hypertension
o Can lead to heart failure by causing left ventricular hypertrophy and less effective muscle
relaxation between heart beats.
• Hyperlipidemia
o High levels of blood lipids (including cholesterol and triglycerides) increases risk for
coronary artery disease, cerebrovascular disease, and peripheral vascular disease.
• Tobacco use
o Raises blood pressure and HR, narrows arteries, and makes blood more likely to clot.
o Even light/occasional smoking and second hand smoke can lower HDL (good) cholesterol,
raise blood pressure, and damage heart tissues.
• Obesity and physical inactivity
o 29% increase in coronary heart disease for each 5 unit increase in BMI (Bogers et al., 2007)
• Substance abuse
o Cocaine users often present to ED with cardiovascular complaints
http://www.mayoclinic.org/diseases-conditions/heart-disease/basics/risk-factors/con-20034056
2. Identify modifiable and non-modifiable factors that influence cardiovascular disease

Risk Factors (Social Determinants of Health)

• Socioeconomic status (the “inverse social gradient”)
• Education
• Neighborhood
• Physical environment
• Social support network
• Employment
• Access to health care

How do social determinants of health exert influence on CVD risk?

http://www.mayoclinic.org/diseases-conditions/heart-disease/basics/risk-factors/con-20034056
3. Identify emotional and behavioral factors that affect cardiovascular disease

Stress and CVD

• Situations, events, experiences, memories, behaviors, beliefs, etc.
that may interact with:
• Personality traits
• Psychological defense mechanisms
• Genetic vulnerability
• Physical state of health
• Conscious vs. Unconscious
• Positive and negative stressors can impact health
• Severity or magnitude of stress as a predictor of illness
• Holmes and Rahe rating scale
3. Identify emotional and behavioral factors that affect cardiovascular disease

Social Readjustment Rating Scale

Relative Point
Stressfulness Life Events Value
Very High • Death of a spouse 100
• Divorce 73
• Marital separation 65
• Death of a close family member 63
High • Major personal loss of health, injury, or illness 53
• Marriage 50
• Job loss 47
• Retirement 45
• Major loss of health of close family member 44
• Birth or adoption of child 39
Moderate • Assuming major debt (e.g., mortgage) 31 Harmon, D. K., Masuda, M., &
• Promotion or demotion at work 29 Holmes, T. H. (1970). The social
• Child leaving home 29 readjustment rating scale: a cross-
cultural study of Western
Low • Changing residence 20 Europeans and Americans. Journal
• Vacation 15 of Psychosomatic Research, 14(4),
• Major holiday 12 391-400.
3. Identify emotional and behavioral factors that affect cardiovascular disease

How does stress mediate its disease evoking

effect?

Stressful Event
Release of cortisol and
adrenaline
• Increased heart rate
Cognitive Processes • Oxygen demand and
breathing rate
• Role of the amygdala • Tensed muscles
and hypothalamus
• Increased blood flow and
pressure
• Alertness and tunnel
vision
3. Identify emotional and behavioral factors that affect cardiovascular disease

Think back to what you learned before!

Endocrine 1 Module:
• Hypothalamus-pituitary histology and physiology
• Modulators of GH secretion
• Adrenal gland: Histology and physiology
• Effects of cortisol
• Glucocorticoids and inflammation
• Hormonal and neural signals in stress response
• Physiology of acute vs. chronic stress
• Adrenal Pathology
• The role of stress in Addison disease
3. Identify emotional and behavioral factors that affect cardiovascular disease

From: 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):637-651. doi:10.1016/j.jacc.2004.12.005

Pathophysiologic mechanisms by which chronic stress and affective disorders, such as depression, appear to promote atherosclerosis. These stressors activate
the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS) and affect behaviors. Multiple adverse peripheral effects can ensue
from this neuroendocrine, sympathetic, and behavioral activation, as shown. The neuroendocrine and neuroplastic changes emanating from these stressors can
also induce a state of heightened physiologic responsivity to acute stress which may interact with chronic stressors to cause more adverse effects. ANS =
autonomic nervous system; Endo. = endothelial.
3. Identify emotional and behavioral factors that affect cardiovascular disease

Psycho-physiological Reactivity
• Cardiovascular reactivity hastens the development of CAD
• More frequent, pronounced, and prolonged increases in BP
and HR
• Increased sympathetic stimulation of the myocardium
• Reduced parasympathetic dampening
• Increased cardiac output
• Peripheral resistance

Smith et al. Psychosocial Influences on the Development and Course of Coronary Heart Disease: Current Status and Implications for Research and Practice.
Journal of Consulting and Clinical Psychology. 2002;70(3):548-568.
3. Identify emotional and behavioral factors that affect cardiovascular disease
3. Identify emotional and behavioral factors that affect cardiovascular disease

From: 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):637-651. doi:10.1016/j.jacc.2004.12.005
3. Explain how personality and other psychosocial factors influence cardiovascular disease

Personality and CVD

Cardiologists Friedman and Rosenman conducted 8.5 year study of healthy men – found that Type A
behavior doubles risk of CAD in otherwise healthy individuals.

Type A Type B
Outgoing, ambitious, competitive, achievement- Contrast to Type A
oriented

Rigid, impatient, anxious, status-conscious, angry,
aggressive, “short-fused”
Free-floating hostility triggered by minor incidents
More relaxed, work steadily, enjoy achievement but
not as bothered when they do not achieve, less
focused on winning.
Gravitate towards careers of creativity, enjoy
exploring ideas and concepts, reflective

Associated with coronary artery disease (CAD) and

myocardial infarction (MI)
Friedman, M., & Rosenman, R. H. (1974). Type A behavior and your heart.
4. Explain how personality and other psychosocial factors influence cardiovascular disease

Personality and CVD – Negative Emotional

States
• Depression, increased risk of cardiac event, increased risk of
CVD mortality, decreased survival after acute MI
• Anger and hostility, increased incident of CVD and increased
risk of dying from CVD
• Anger-out = increased stroke
• Anger-out and anger-in = increased risk of HTN
• Anxiety and worry, increased risk (somewhat mixed results)
• Work dissatisfaction? Effort-reward imbalance associated
with increased risk (> for men than for women)
4. Explain how personality and other psychosocial factors influence cardiovascular disease

Psychosocial Factors and CVD - Isolation

• Socially isolated men have 2-fold greater risk of fatal CHD
compared to socially integrated men (social isolation defined as
not being married and by number of social contacts)
• Subjective isolation “I feel lonely” increased risk of mortality in
patients undergoing coronary bypass surgery
• Emotionally supportive relationships are cardio-protective
• Low levels of emotional support increase CVD risk (men and
women)
• Marital unhappiness and marital stress create increased risk of
CVD in women
4. Explain how personality and other psychosocial factors influence cardiovascular disease

Psychosocial Factors and CVD -

Depression
• Depressed mood, weight changes, sleep disturbance, fatigue, guilt,
worthless, hopelessness
• Affects course of illness (e.g., development, compliance with treatment, recovery)
• Increased risk for CHD in healthy individuals with depression (RR=2.69; Rugulies et al.,
2002)

• Significant risk factor for complications following myocardial infarction

• 4X increased mortality after 6 months (Frasure-Smith, et al., 1999)
• Large population-based case-control study found association between MI
and risk of suicide
• Patients w/MI and no history of psychiatric illness >3X as likely to commit suicide
within one month of MI
• Risk of suicide remained high for at least 5 years after an MI
4. Explain how personality and other psychosocial factors influence cardiovascular disease

From: 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):637-651. doi:10.1016/j.jacc.2004.12.005
• The risk ratios for traditional risk
factors are for death due to cardiac
disease, myocardial infarction,
coronary artery insufficiency, and
development of angina
• For depressive symptoms and
clinical depression, the risk ratios
are for death due to cardiac
disease and myocardial infarction
• CI = confidence interval; HT =
hypertension; LDL = low-density
lipoprotein; HDL = high-density
lipoprotein
4. Explain how personality and other psychosocial factors influence cardiovascular disease

New Onset Depression Linked with Increased Risk of

CVD and Mortality

• In men over 70 years of age,

the recent onset of
depression, but not chronic
depression, was associated
with an increased risk of a
cardiovascular disease event
and all cause mortality.
• This association was not seen
in women over 70 years.

Penninx BW, et al. Cardiovascular events and mortality in newly and chronically depressed
persons> 70 years of age. The American Journal of Cardiology. 1998;81(8):988-994.
4. Explain how personality and other psychosocial factors influence cardiovascular disease

Depression After a Myocardial Infarction

Predicts Mortality
Study of 887 patients:
• Baseline depression was measured
by the Beck Depression Inventory
(BDI)
• Higher levels of depression
associated with higher one year
mortality rate
• Relationship between mortality and
depression decreased with
increasing levels of perceived social
Data from Frasure-Smith, N, Lesperance, F, Gravel, G, et al, Circulation 2000;
support.
101:1919.
5. Describe and discuss occupational and environmental risk factors for cardiovascular disease

Psychosocial Factors: Anxiety

• Heightened levels of perceived fear and nervousness
• Panic disorder, social phobia, OCD, acute stress disorder, PTSD, GAD
- Autonomic nervous system
- Heart palpitations, tachycardia, chest pain
- Ventricular arrhythmia and decreased heart rate variability
- Mitral valve prolapse
- Paroxysmal atrial tachycardia (PAT)
• Normal aging study (32-year follow-up) – individuals with 2 or more
anxiety symptoms had a 3.2-fold increased risk of fatal CHD and 5.7-
fold increased risk of sudden death
Kawachi I, Colditz GA, Ascherio A, et al. Prospective study of phobic anxiety and risk of coronary
heart disease in men. Circulation. 1994;89(5), 1992-1997.
5. Describe and discuss occupational and environmental risk factors for cardiovascular disease

Chronic Stress
• Work stress (particularly high demand but low control jobs)
• Marital stress and dissatisfaction
• Individuals with high levels of marital conflict more than 3 times as
likely to experience recurrent coronary event (Orth-Gomer et al., 2000)
• Social isolation, lack of social support
• Particularly unhealthy in patients with preexisting coronary heart
disease
• Caregiver strain
• Low socio-economic status
• Actual and perceived injustice
5. Describe and discuss occupational and environmental risk factors for cardiovascular disease

Post-Traumatic Stress Disorder

Hyper-arousal and avoidance following
traumatic event
• Military veterans – retrospective study
demonstrates stepwise relationship
between PTSD symptoms and nonfatal
MI as well as cardiac death (Kubzansky et al., 2007)
• Study of 1059 women shows relationship
between PTSD and incident coronary
heart disease (Kubzansky et al., 2009)
6. Describe the psychosocial management and treatment of cardiac conditions

Case Study
A 55-year-old man who works as the chief executive officer for
a large corporation, presents after two distinct episodes of
squeezing substernal chest pain that occurred when he was
moving into a new apartment last week. Both episodes
resolved with rest after about 15 minutes.
• Recently divorced
• Self-described “perfectionist” and “workaholic”
• Described by friends as “very competitive”
• Low frustration tolerance
• Quick to anger, even in the context of mild frustrations
6. Describe the psychosocial management and treatment of cardiac conditions

Suggested open-ended questions to screen for

psychosocial risk factors
• How would you describe your energy level?
• How have you been sleeping?
• How has your mood been recently?
• Do you feel anxious or worried?
• Are you under a lot of pressure at work or home?
• Do you have difficulty unwinding after work or at the end of
the day? Modified from Rozanski A, et al. The
epidemiology, pathophysiology and
• Who do you turn to for support? management of psychosocial risk factors in
cardiac practice: the emergent field of
behavioral cardiology. J Am Coll Cardiol
2005;45:637
6. Describe the psychosocial management and treatment of cardiac conditions

Clinical Management
Determining cardiovascular risk of an individual and using behavioral
modification strategies can help prevent cardiovascular events
• Stress reduction training (eg, MBSR)
• Biofeedback
• Relaxation training
• Anxiety management
• Anger management / stress inoculation therapy
• Exercise
• Reducing alcohol
• Patient education
6. Describe the psychosocial management and treatment of cardiac conditions

Stress Response in Cardiovascular

Disease
6. Describe the psychosocial management and treatment of cardiac conditions

Demonstration – Stress Response Reduction

• http://www.heartmath.com
• Heart rate variability is a reflection of autonomic nervous system
balance
• Optimum autonomic balance is reflected by increased heart rate
variability and “coherence” of the HR with breathing and blood
pressure that shows up in HM as high amplitude regular sine-wave
like activity
• This increased heart rate variability subsequently is reflected by
improvement in a lot of other domains: perceived stress, mental and
physical performance, emotional balance, well-being, blood pressure,
sleep, etc.
6. Describe the psychosocial management and treatment of cardiac conditions

Heart Rate Variability

• Is a key indicator of autonomic function

• Decreases with age

• Low HRV is predictive of MI and sudden death

Circulation, 1996;93:1043-1065
6. Describe the psychosocial management and treatment of cardiac conditions

Heart Rate Variability

Is affected by:
• Your thoughts
• Your emotions
• Your breathing
• Your ability to regulate your attention
• Maybe other people (intention?)
6. Describe the psychosocial management and treatment of cardiac conditions

HeartMath Demonstration
Heart Math Recording Dr. Selfridge