Stress and heart disease: a few basics a model and

evidence on triggering heart attacks

Kop provides a readable account of psychological risk factors for CAD. His model provides a useful way of organising the material on stress and CVD & the material on “vital exhaustion” will be covered later in the lecture on depression.Kop, WJ (1999) Chronic and acute psychological risk factors for clinical manifestations of coronary artery disease. Psychosomatic Medicine, 61, 476-487.

Black and Garbutt are not for the feint hearted. They offer a very complex physiological model of stress, inflammation and CVD. Incorporates a lot of important new information but only for those with background in biology. I shall use model illustratively

Black, PH., & Garbutt, LD (2002). Stress, inflammation and cardiovascular disease. J. of Psychosomatic Res., 52, 1-23

Rozanski paper is very up to date account of stress and heart disease written for cardiologists. I strongly recommend it.

Rozanski, A., Blumenthal, JA., Davidson, KW, Saab, PC., Kubzansky, L (2005). The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice. J. American College of Cardiology., 45, 637-651.

Process of build up of atherosclerotic plaque, plaque rupture and thrombus formation.

What causes a Myocardial Infarction: Plaque rupture and blocked coronary artery

No MI, plaque remains

Unstable situation

Artery blocked, MI results

Heart Rate SBP DBP50

70

90

110

130

150H

R (

bp

m)a

nd

BP (

mm

Hg

)

CV effects of Active Coping taskPatterson et al 1994

Baseline

Stroop

Mental Arithmetic

Psychological stress and platelet activation: Differences in platelet reactivity in healthy men during active and passive stressors. Patterson, S. M.; Zakowski, SG.; Hall, Martica H.;

Health Psychology, Vol 13, 1994. pp. 34-38.

Heart Rate SBP DBP50

70

90

110

130

150H

R (

bp

m)a

nd

BP (

mm

Hg

)

CV effects of Passive Coping taskPatterson et al 1994

Baseline

Combat surgery

Heart surgery

Active Stressor Passive Stressor No Stressor

0

10

20PF4

act

ivit

y (

ng

/ml)

Effects of stress on platelet activityPatterson et al, 1994

Baseline

Stroop

MA

Baseline

Surgery

Surgery

Baseline

Travel film

Travel film

Effects of stress on platelets, and hence clotting & process of atherogenesis. See particularly PF (Platelet Factor) 4

Low work demand High work demand0.06

0.12

0.17

0.23

0.28

0.34p

rog

ress o

f m

axim

al in

tim

al th

ickn

ess

Everson et al, 1997, BMJ, 314, 558-65Work demand, reactivity and progress of athersclerosis

Small BP reaction

Large BP reaction

The diathesis model: stress plus vulnerability

The Triggering of Acute Coronary syndromes: Findings and possible mechanisms

The main reference is Strike & Steptoe (2005) Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique. Psychosomatic Medicine, 67, 179-186.

This reviews all the studies of triggering. It mentions mechanism in passing but does not cover it in detail.

There is not a lot of empirical information on mechanism but many of the acute effects of stress (see earlier lectures & Kop) are likely to be involved.

Strike and Steptoe’s review finds evidence for following triggers:

•Physical exertion

•Sexual activity

•Earthquakes

•Sporting events

•War

•Emotional Distress and Anger

Population-Based Analysis of the Effect of the Northridge Earthquake on Cardiac Death in Los Angeles County, California Robert A. Kloner MD, et al J American College of Cardiology, 1997, 30, 1174-1180

Effects of an earthquake on BP and HR. Parati et al, (2001), Cardiovascular effects of an earthquake: Direct evidence by ambulatory blood pressure monitoring. Hypertension, 38, 1093-1095.

Matsuo T et al (1998) Hemostatic activation and cardiac events after the 1995 Hanshin-Awaji earthquake. Iny. J. Hematology, 67, 123-9

Mittleman MA et al (1995) Triggering of acute myocardial infarction onset by episodes of anger. Circulation, 92, 1720-1725

1623 patients interviewed average of 4 days (range 0-30) after MI

7 point anger scale (1 calm; 5 Very angry, body tense clenched fists or teeth ; 7 Enraged!. Lost control, throwing objects

Case-cross design. 2 hours prior to onset of MI compared with

1) Usual frequency of anger in last year

2) in a 2 hour period 24 hours previously

Using anger of 5 or more 36 patients angry in 2 hours after MI compared to 9 in control period.

Relative risk of 4 (CI 1.9- 9.4) (NB low frequency of anger means absolute risk low)

Period after MI compared to average anger over preceding year. Effect of exertion only seen for first hour

Strike & Steptoe identify methodological issues in studies of triggers

•Retrospective reporting bias

•Memory decay

•Premonitory or prodromal symptoms

•Clinical presentation bias

Possible mechanisms involved in triggering Acute Coronary Syndromes