The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice
Open accessAbstract
Observational studies indicate that psychologic factors strongly influence the course of coronary artery disease (CAD). In this review, we examine new epidemiologic evidence for the association between psychosocial risk factors and CAD, identify pathologic mechanisms that may be responsible for this association, and describe a paradigm for studying positive psychologic factors that may act as a buffer. Because psychosocial risk factors are highly prevalent and are associated with unhealthy lifestyles, we describe the potential role of cardiologists in managing such factors. Management approaches include routinely screening for psychosocial risk factors, referring patients with severe psychologic distress to behavioral specialists, and directly treating patients with milder forms of psychologic distress with brief targeted interventions. A number of behavioral interventions have been evaluated for their ability to reduce adverse cardiac events among patients presenting with psychosocial risk factors. Although the efficacy of stand-alone psychosocial interventions remains unclear, both exercise and multifactorial cardiac rehabilitation with psychosocial interventions have demonstrated a reduction in cardiac events. Furthermore, recent data suggest that psychopharmacologic interventions may also be effective. Despite these promising findings, clinical practice guidelines for managing psychosocial risk factors in cardiac practice are lacking. Thus, we review new approaches to improve the delivery of behavioral services and patient adherence to behavioral recommendations. These efforts are part of an emerging field of behavioral cardiology, which is based on the understanding that psychosocial and behavioral risk factors for CAD are not only highly interrelated, but also require a sophisticated health care delivery system to optimize their effectiveness.
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Mechanisms linking psychosocial factors to increased CVD risk include unhealthy lifestyle, increased healthcare utilization, and low adherence to behaviour-change recommendations or cardiac medications.
“Mechanisms that link psychosocial factors to increased CVD risk include unhealthy lifestyle (more frequent smoking, unhealthy food choice, and less physical exercise), increased healthcare utilization, and low adherence to behaviour-change recommendations or cardiac medications.88,90,116 -119”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [118]
Persons and patients with depression and/or chronic stress show alterations in autonomic function, hypothalamic-pituitary axis, and other endocrine markers, affecting haemostatic and inflammatory processes, endothelial function, and myocardial perfusion.
“In addition, persons and patients with depression and/or chronic stress show alterations in autonomic function (including reduced heart rate variability) in the hypothalamic-pituitary axis and in other endocrine markers, which affect haemostatic and inflammatory processes, endothelial function, and myocardial perfusion.117,118,120”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [118]
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European Guidelines on cardiovascular disease prevention in clinical practice (version 2012)
Authors/Task Force Members:, Perk, J., De Backer, G., Gohlke, H., Graham, I., Reiner, Ž., Verschuren, M., Albus, C., Benlian, P., Boysen, G., et al. (2012) · European Heart Journal · doi:10.1093/eurheartj/ehs092 · Cited by 8,490 · see citing works
European guidelines on cardiovascular disease prevention in clinical practice: executive summary
Graham, I., Atar, D., Borch‐Johnsen, K., Boysen, G., Burell, G. K., Cífková, R., Dallongeville, J., Backer, G. D., Ebrahim, S. B. J., Gjelsvik, B., et al. (2007) · European Heart Journal · doi:10.1093/eurheartj/ehm316 · Cited by 3,840 · see citing works
“There is increasing scientific evidence that psychosocial factors contribute independently to the risk of CHD even after statistical control for the effects of standard risk factors.(159) In addition to increasing the risk of a first event and worsening the prognosis in CHD, these factors may act as barriers to treatm…”
Authors Task Force Members, de Werf, F. V., Bax, J. J., Betriu, A., Blomström‐Lundqvist, C., Crea, F., Falk, V., Filippatos, G. S., Fox, K. A. A., Huber, K., et al. (2008) · European Heart Journal · doi:10.1093/eurheartj/ehn416 · Cited by 2,294 · see citing works
Graham (2007) · doi:10.1097/01.hjr.0000277983.23934.c9 · Cited by 1,647 · see citing works
Havranek, E. P., Mujahid, M. S., Barr, D. A., Blair, I. V., Cohen, M. S., Cruz-Flores, S., Davey-Smith, G., Dennison-Himmelfarb, C. R., Lauer, M. S., Lockwood, D. W., et al. (2015) · Circulation · doi:10.1161/cir.0000000000000228 · Cited by 1,472 · see citing works
“Furthermore, there is evidence that reductions in these negative emotions can improve CVD risk factor profile and disease end points.(152) More general measures of stress and resources have shown less consistent evidence with cardiovascular risk.”
Background2016 European Guidelines on cardiovascular disease prevention in clinical practice
Authors/Task Force Members, Piepoli, M. F., Hoes, A. W., Agewall, S., Albus, C., Brotons, C., Catapano, A. L., Cooney, M. T., Corrà, U., Cosyns, B., et al. (2016) · European Journal of Preventive Cardiology · doi:10.1177/2047487316653709 · Cited by 1,409 · see citing works
Effects of stress on the development and progression of cardiovascular disease
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State of the art review: depression, stress, anxiety, and cardiovascular disease
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Exercise for the Treatment of Depression
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The Association of Anger and Hostility With Future Coronary Heart Disease
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Epidemiology of Sudden Cardiac Death: Clinical and Research Implications
Chugh, S. S., Reinier, K., Teodorescu, C., Evanado, A., Kehr, E. L., Samara, M. A., Mariani, R., Gunson, K., & Jui, J. (2008) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2008.06.003 · Cited by 732 · see citing works
“Risk factors for coronary artery disease such as lack of physical activity, smoking, hyperlipidemia, hypertension, obesity, and DM are more common among individuals with lower socioeconomic status (81,84,85).”
BackgroundEuropean guidelines on cardiovascular disease prevention in clinical practice: Executive summary
Graham, I. M. (2007) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2007.08.024 · Cited by 715 · see citing works
“There is increasing scientific evidence that psychosocial actors contribute independently to the risk of CHD even after tatistical control for the effects of standard risk factors [159].”
BackgroundRyan, R. M., & Deci, E. L. (2008) · Social and Personality Psychology Compass · doi:10.1111/j.1751-9004.2008.00098.x · Cited by 732 · see citing works
“Subjective vitality has been linked with specific configurations of brain activation and positive response mechanisms (e.g., Barrett, Della-Maggiore, Chouinard & Paus, 2004; Rozanski, Blumenthal, Davidson, Saab, & Kubzansky, 2005 ).”
BackgroundInfluentialEuropean Guidelines on cardiovascular disease prevention in clinical practice (version 2012)
Perk, J., Backer, G. D., Gohlke, H., Graham, I. M., Reiner, Ž., Verschuren, W. M. M., Albus, C., Benlian, P., Boysen, G., Cífková, R., et al. (2012) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2012.05.007 · Cited by 693 · see citing works
Anxiety disorders and comorbid medical illness
Roy-Byrne, P. P., Davidson, K. W., Kessler, R. C., Asmundson, G. J. G., Goodwin, R. D., Kubzansky, L., Lydiard, R. B., Massie, M. J., Katon, W., Laden, S. K., et al. (2008) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2007.12.006 · Cited by 668 · see citing works
“[92] Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L.”
BackgroundSelf-citationVitalizing effects of being outdoors and in nature
Ryan, R. M., Weinstein, N., Bernstein, J. H., Brown, K. W., Mistretta, L., & Gagné, M. (2009) · Journal of Environmental Psychology · doi:10.1016/j.jenvp.2009.10.009 · Cited by 620 · see citing works
Barth, J., Schneider, S., & von Känel, R. (2010) · Psychosomatic Medicine · doi:10.1097/psy.0b013e3181d01611 · Cited by 597 · see citing works
“A bundant evidence suggests that psychosocial factors like depression, anxiety, personality characteristics, chronic life stress, and social isolation predict the development, the course, and negative prognosis of coronary heart disease (CHD) (1,2).”
BackgroundSocial determinants of breast cancer risk, stage, and survival
Coughlin, S. S. (2019) · Breast Cancer Research and Treatment · doi:10.1007/s10549-019-05340-7 · Cited by 570 · see citing works
Positive interventions: An emotion regulation perspective.
Quoidbach, J., Mikolajczak, M., & Gross, J. J. (2015) · Psychological Bulletin · doi:10.1037/a0038648 · Cited by 546 · see citing works
A meta-analysis of heart rate variability in major depression
Koch, C., Wilhelm, M., Salzmann, S., Rief, W., & Euteneuer, F. (2019) · Psychological Medicine · doi:10.1017/s0033291719001351 · Cited by 489 · see citing works
“medical conditions, drugs, nutrition, smoking, physical activity) (Rozanski et al., 2005; Eller et al., 2011; Nemeroff and Goldschmidt-Clermont, 2012; Elderon and Whooley, 2013; Shaffer et al., 2014; Cohen et al., 2015; Pieritz et al., 2016; Kemp et al., 2017; Gidron et al., 2018; Young and Benton, 2018).”
BackgroundSocioeconomic status and cardiovascular disease: risks and implications for care
Clark, A. M., DesMeules, M., Luo, W., Duncan, A. S., & Wielgosz, A. (2009) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2009.163 · Cited by 533 · see citing works
Sudden cardiac death: epidemiology and risk factors
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Positive Psychological Well-Being and Cardiovascular Disease
Kubzansky, L. D., Huffman, J. C., Boehm, J. K., Hernandez, R., Kim, E. S., Koga, H. K., Feig, E. H., Lloyd-Jones, D. M., Seligman, M. E. P., & Labarthe, D. R. (2018) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2018.07.042 · Cited by 429 · see citing works
“Previous state-of the-art reviews on psychological distress and CVD (131,132) outlined an approach to such screening and potential next steps in clinical management of mental health conditions.”
BackgroundSelf-citationKubzansky, L. D., Koenen, K. C., Spiro, A., Vokonas, P., & Sparrow, D. (2007) · Archives of General Psychiatry · doi:10.1001/archpsyc.64.1.109 · Cited by 425 · see citing works
Self-citationSocially Isolated Children 20 Years Later: Risk of Cardiovascular Disease
Caspi, A., Harrington, H., Moffitt, T. E., Milne, B. J., & Poulton, R. (2006) · Archives of Pediatrics & Adolescent Medicine · doi:10.1001/archpedi.160.8.805 · Cited by 414 · see citing works
“The experience of social isolation may be a form of chronic stress that activates the sympathetic nervous and hypothalamic-pituitary-adrenocortical systems and induces a variety of pathophysiologic responses that contribute to the clustering of risk factors for coronary artery disease (hypertension, insulin resistance…”
BackgroundBlumenthal, J. A., Sherwood, A., Babyak, M. A., Watkins, L. L., WAUGH, R. A., Georgiades, A., Bacon, S., Hayano, J., Coleman, R. E., & Hinderliter, A. L. (2005) · JAMA · doi:10.1001/jama.293.13.1626 · Cited by 414 · see citing works
Self-citationvon Känel, R., Hepp, U., Kraemer, B., Traber, R., Keel, M., Mica, L., & Schnyder, U. (2007) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2006.06.009 · Cited by 408 · see citing works
Affective science and health: The importance of emotion and emotion regulation.
DeSteno, D. A., Gross, J. J., & Kubzansky, L. D. (2013) · Health Psychology · doi:10.1037/a0030259 · Cited by 417 · see citing works
Self-citationA prospective evaluation of the directionality of the depression–inflammation relationship
Stewart, J. C., Rand, K. L., Muldoon, M. F., & Kamarck, T. W. (2009) · Brain, Behavior, and Immunity · doi:10.1016/j.bbi.2009.04.011 · Cited by 390 · see citing works
“Importantly, the predictive value of depression is similar to that of many traditional cardiovascular risk factors (Rozanski et al., 2005), with relative risk ratios in the 1.”
ResultInfluentialStress, Visceral Obesity, and Metabolic Complications
Kyrou, I., Chrousos, G. P., & Tsigos, C. (2006) · Annals of the New York Academy of Sciences · doi:10.1196/annals.1367.008 · Cited by 379 · see citing works
Posttraumatic stress disorder and risk for coronary heart disease: A meta-analytic review
Edmondson, D. E., Kronish, I. M., Shaffer, J. A., Falzon, L., & Burg, M. M. (2013) · American Heart Journal · doi:10.1016/j.ahj.2013.07.031 · Cited by 366 · see citing works
“There is also evidence of autonomic dysfunction in both PTSD and CHD development, as evidenced by decreased heart rate variability, baroreflex dysfunction, and increased QT variability on the electrocardiogram.(33) Reduced heart rate variability has been shown to predict mortality after myocardial infarction (MI),(34)…”
BackgroundPsychological stress and wound healing in humans: A systematic review and meta-analysis
Walburn, J., Vedhara, K., Hankins, M. C., Rixon, L., & Weinman, J. A. (2009) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2009.04.002 · Cited by 353 · see citing works
Gulliksson, M., Burell, G., Vessby, B., Lundin, L., Toss, H., & Svärdsudd, K. (2011) · Archives of Internal Medicine · doi:10.1001/archinternmed.2010.510 · Cited by 349 · see citing works
“CHD even after adjustment for the effects of traditional risk factors.(8,9) Psychosocial factors have been shown to account for ap-”
BackgroundImpact of Cardiac Rehabilitation on Depression and Its Associated Mortality
Milani, R. V., & Lavie, C. J. (2007) · The American Journal of Medicine · doi:10.1016/j.amjmed.2007.03.026 · Cited by 347 · see citing works
Post-traumatic stress disorder and cardiovascular disease
Edmondson, D. E., & von Känel, R. (2017) · The Lancet Psychiatry · doi:10.1016/s2215-0366(16)30377-7 · Cited by 346 · see citing works
Lavie, C. J., Thomas, R. J., Squires, R. W., Allison, T. G., & Milani, R. V. (2009) · Mayo Clinic Proceedings · doi:10.4065/84.4.373 · Cited by 340 · see citing works
Davidson, K. W., Mostofsky, E., & Whang, W. (2010) · European Heart Journal · doi:10.1093/eurheartj/ehp603 · Cited by 334 · see citing works
“3 However, there has been little research to address the question of whether positive affect protects against CHD.(2,4,10) We therefore examined whether clini-”
BackgroundInfluentialSelf-citationWomen, Loneliness, and Incident Coronary Heart Disease
Thurston, R. C., & Kubzansky, L. D. (2009) · Psychosomatic Medicine · doi:10.1097/psy.0b013e3181b40efc · Cited by 313 · see citing works
“For example, whereas the simple presence of a spouse is linked to salubrious cardiovascular outcomes among men (2), marital quality seems important for women, with poor quality marriages linked to poor physical and mental health outcomes among women (1,2).”
BackgroundMethodInfluentialSelf-citationEuropean Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012)
Perk, J., Backer, G. D., Gohlke, H., Graham, I. M., Reiner, Ž., Verschuren, W. M. M., Albus, C., Benlian, P., Boysen, G., Cífková, R., et al. (2012) · International Journal of Behavioral Medicine · doi:10.1007/s12529-012-9242-5 · Cited by 313 · see citing works
“In addition, persons and patients with depression and/or chronic stress show alterations in autonomic function (including reduced heart rate variability) in the hypothalamic–pituitary axis and in other endocrine markers, which affect haemostatic and inflammatory processes, endothelial function, and myocardial perfusio…”
“Shift-and-Persist” Strategies: Why Low Socioeconomic Status Isn’t Always Bad for Health
Chen, E., & Miller, G. E. (2012) · Perspectives on Psychological Science · doi:10.1177/1745691612436694 · Cited by 359 · see citing works
“…high blood pressure, systemic inflammation, and endothelial dysfunction that drive CVD (Brotman et al., 2007; Everson-Rose & Lewis, 2005; Hashimoto et al., 2001; Pradhan et al., 2002; Ridker, Rifai, Stampfer, & Hennekens, 2000; Rozanski et al., 2005; Seeman et al., 1997; Vasan et al., 2001).”
BackgroundRainforth, M. V., Schneider, R. H., Nidich, S. I., Gaylord‐King, C., Salerno, J. W., & Anderson, J. W. (2007) · Current Hypertension Reports · doi:10.1007/s11906-007-0094-3 · Cited by 304 · see citing works
Maas, A. H. E. M., van der Schouw, Y. T., Regitz‐Zagrosek, V., Swahn, E., Appelman, Y., Pasterkamp, G., Cate, H. T., Nilsson, P. M., Huisman, M. V., Stam, H. C. G., et al. (2011) · European Heart Journal · doi:10.1093/eurheartj/ehr048 · Cited by 290 · see citing works
Sumner, J. A., Kubzansky, L. D., Elkind, M. S. V., Roberts, A. L., Agnew‐Blais, J. C., Chen, Q., Cerdá, M., Rexrode, K. M., Rich-Edwards, J. W., Spiegelman, D. L., et al. (2015) · Circulation · doi:10.1161/circulationaha.114.014492 · Cited by 290 · see citing works
Self-citationPogosova, N., Saner, H., Pedersen, S. S., Cupples, M. E., McGee, H., Höfer, S., Doyle, F., Schmid, J.-P., von Känel, R., & on behalf of the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology (2015) · European Journal of Preventive Cardiology · doi:10.1177/2047487314543075 · Cited by 292 · see citing works
“Therefore, this position paper applies an umbrella concept to the definition of PSRFs of CVD as is common practice in behavioural cardiology.(3) Three categories of PSRFs for a poor prognosis in patients with uncomplicated CHD (the largest group treated in CR) can usually be distinguished.”
BackgroundMethodVaccarino, V., Badimón, L., Corti, R., de Wit, C., Dorobanţu, M., Hall, A. S., Koller, Á., Marzilli, M., PRIES, A. R., Bugiardini, R., et al. (2010) · Cardiovascular Research · doi:10.1093/cvr/cvq394 · Cited by 287 · see citing works
Graham, I. D., Atar, D., Borch‐Johnsen, K., Boysen, G., Burell, G. K., Cífková, R., Dallongeville, J., Backer, G. D., Ebrahim, S. B. J., Gjelsvik, B., et al. (2007) · European Journal of Cardiovascular Prevention & Rehabilitation · doi:10.1097/01.hjr.0000277984.31558.c4 · Cited by 286 · see citing works
“There is increasing scientific evidence that psychosocial factors contribute independently to the risk of CHD even after statistical control for the effects of standard risk factors.(159) In addition to increasing the risk of a first event and worsening the prognosis in CHD, these factors may act as barriers to treatm…”
Lemay, K. R., Tulloch, H. E., Pipe, A. L., & Reed, J. L. (2019) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000379 · Cited by 280 · see citing works
Depressive Symptoms and Stressful Life Events Predict Metabolic Syndrome Among Middle-Aged Women
Räikkönen, K., Matthews, K. A., & Kuller, L. H. (2007) · Diabetes Care · doi:10.2337/dc06-1857 · Cited by 276 · see citing works
“First, psychosocial factors related to deleterious health behaviors, such as smoking and nonadherence to medical regimens, are more common among individuals with low socioeconomic backgrounds and may vary according to age (8,9).”
BackgroundMethodBlumenthal, J. A., Sherwood, A., Smith, P. J., Watkins, L., Mabe, S., Kraus, W. E., Ingle, K., Miller, P., & Hinderliter, A. (2016) · Circulation · doi:10.1161/circulationaha.115.018926 · Cited by 257 · see citing works
“Heart failure, n (%) 5 (7) 3 (4) 5 (7)”
Self-citationPredicting relapse in Crohn’s disease: a biopsychosocial model
Bitton, A., Dobkin, P. L., Edwardes, M. D., Sewitch, M. J., Meddings, J. B., Rawal, S., Cohen, A., Vermeire, S., Dufresne, L., Franchimont, D., et al. (2008) · Gut · doi:10.1136/gut.2007.134817 · Cited by 254 · see citing works
Kubzansky, L. D., & Thurston, R. C. (2007) · Archives of General Psychiatry · doi:10.1001/archpsyc.64.12.1393 · Cited by 252 · see citing works
“We further consider specific behavioral and biologic pathways through which emotional vitality may influence CHD risk.(9) Finally, given the many studies that have found an association between negative emotions and CHD,(9) we also evaluate the likelihood that observed effects are merely caused by the absence of negati…”
BackgroundSelf-citationLucini, D., Fede, G. D., Parati, G., & Pagani, M. (2005) · Hypertension · doi:10.1161/01.hyp.0000185147.32385.4b · Cited by 252 · see citing works
Kim, E. S., Sun, J. K., Park, N., Kubzansky, L. D., & Peterson, C. (2013) · Journal of Behavioral Medicine · doi:10.1007/s10865-012-9406-4 · Cited by 244 · see citing works
Self-citationSuarez, E. C. (2008) · Brain, Behavior, and Immunity · doi:10.1016/j.bbi.2008.01.011 · Cited by 248 · see citing works
“, 2004) biomarkers, as well as indicators of psychosocial distress (hostility, anger, depression and social support) (Krantz and McCeney, 2002; Rozanski et al., 1999; Rozanski et al., 2005), are associated with an increased risk of cardiovascular and metabolic disorders.”
Prognostic Significance of Dyspnea in Patients Referred for Cardiac Stress Testing
Abidov, A., Rozanski, A., Hachamovitch, R., Hayes, S. W., Aboul-Enein, F., Cohen, I., Friedman, J. D., Germano, G., & Berman, D. S. (2005) · New England Journal of Medicine · doi:10.1056/nejmoa042741 · Cited by 297 · see citing works
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- Authors
- Rozanski, A., Blumenthal, J. A., Davidson, K. W., Saab, P. G., & Kubzansky, L.
- Affiliations
- St. Luke's-Roosevelt Hospital Center (US)
- Duke Medical Center (US)
- Columbia University (US)
- University of Miami (US)
- Harvard University (US)
- Corresponding author
- Rozanski, Alan
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2005-03
- Volume
- 45
- Issue
- 5
- Pages
- 637-651
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2144716474
- Cited by
- 1,238
- References
- 113
- Citations by year
- 2026: 27 · 2025: 16 · 2024: 19 · 2023: 28 · 2022: 30 · 2021: 48 · 2020: 42 · 2019: 46 · 2018: 48 · 2017: 48 · 2016: 72 · 2015: 72 · 2014: 72 · 2013: 82 · 2012: 84
- FWCI
- 12.83
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hc25197-0-0-0)
- National Heart, Lung, and Blood Institute (R24HL076857, N01 HC025197)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Keywords
- psychosocial risk factors, coronary artery disease, psychological distress, behavioral interventions, cardiac rehabilitation, physical activity, screening, patient adherence, lifestyle risk factors
- MeSH terms
- Affective Symptoms, Arousal, Behavior Therapy, Combined Modality Therapy, Coronary Artery Disease, Heart, Humans, Hypothalamo-Hypophyseal System, Life Style, Myocardial Infarction, Patient Care Team, Pituitary-Adrenal System, Psychotherapy, Brief, Psychotropic Drugs, Risk Factors, Social Support, Stress, Psychological, Sympathetic Nervous System, Comorbidity
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