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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 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]
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“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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Höfer, S., Kullich, W., Graninger, U., Wonisch, M., Gaßner, A., Klicpera, M., Laimer, H., Marko, C., Schwann, H., & Müller, R. W. (2009) · Health and Quality of Life Outcomes · doi:10.1186/1477-7525-7-99 · Cited by 25
“Since there is presently a controversial discussion about depression as a potential risk factor or a significant comorbidity [30-32] influencing the outcome [33], special attention needs to be paid to the diagnosis of anxiety/depression in patients attending inpatient CR [34].”
Felice, F., Stefano, R. D., Pini, S., Mazzotta, G., Bovenzi, F., Bertoli, D., Abelli, M., Borelli, L., Cardini, A., Lari, L., et al. (2015) · Human Psychopharmacology Clinical and Experimental · doi:10.1002/hup.2470 · Cited by 25
“Inflammation has been involved as a biological mechanism common to depression and ACS (Rozanski et al., 2005; Lippi et al., 2009).”
BackgroundPsychotherapy with cardiac patients: Behavioral cardiology in practice.
Dornelas, E. A. (2008) · American Psychological Association eBooks · doi:10.1037/11809-000 · Cited by 26
Pedersen, S. S., Spindler, H., Johansen, J. B., & Mortensen, P. T. (2008) · Pacing and Clinical Electrophysiology · doi:10.1111/j.1540-8159.2009.02173.x · Cited by 25
“Other independent associates were symptomatic heart failure (F (1,437) = 27.”
BackgroundMethodInfluentialAssessment of endothelial function in patients with fibromyalgia—cardiac ultrasound study
Cho, K. I., Lee, J. H., Kim, S. M., Lee, H. G., & Kim, T. I. (2010) · Clinical Rheumatology · doi:10.1007/s10067-010-1599-8 · Cited by 25
“Converging evidence from both experimental and epidemiological studies indicates that there is an association between chronic psychological distress and cardiovascular disease [7–10].”
BackgroundTriggers and the Onset of Acute Myocardial Infarction
Hammoudeh, A. J., & Alhaddad, I. A. (2009) · Cardiology in Review · doi:10.1097/crd.0b013e3181bdba75 · Cited by 27
“Interventions that incorporate regular exercise, multifactorial secondary preventive measures, and psychosocial interventions may attenuate the occurrence of cardiovascular events in patients with cardiac disease.(6,90) Thus, individuals with cardiovascular disease should avoid confrontational situations and heavy phy…”
BackgroundHintsa, T., Puttonen, S., Toivonen, L., KONTULA, K. K., Swan, H., & Keltikangas‐Järvinen, L. (2010) · Heart · doi:10.1136/hrt.2009.190868 · Cited by 25
“There are several reasons that promote interest in evaluation and management of stress in cardiac practice.(36) The practical implications of this study, irrespective of the direction of the causal link between a history of stressful life events, prolonged mental stress and arrhythmias in LQTS, are that major stressfu…”
BackgroundAssociation between social isolation and left ventricular mass
Rodriguez, C. J., Elkind, M. S. V., Clemow, L., Jin, Z., Di Tullio, M., Sacco, R. L., Homma, S., & Boden-Albala, B. (2011) · The American Journal of Medicine · doi:10.1016/j.amjmed.2010.09.011 · Cited by 24
“Within the past few years, there has been renewed interest in social isolation and its relationship to cardiovascular health and well-being.(6) The hypothesis that health can be affected by supportive interactions with individuals within one’s social network has now been strengthened by evidence on the relationship be…”
Backgroundvan Montfort, E., Kupper, N. H. M., Widdershoven, J. W. M. G., & Denollet, J. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.04.072 · Cited by 24
Cardiovascular disease and meaning in life: A systematic literature review and conceptual model
Vos, J. (2021) · Palliative & Supportive Care · doi:10.1017/s1478951520001261 · Cited by 24
“Some reviews describe meaning amongst other factors (Rozanski et al., 2005; Leegaard and Fagermoen, 2008; Cohen et al., 2016; Sin, 2016).”
BackgroundLindgren, H. I. V., & Bergman, S. (2010) · BMC Musculoskeletal Disorders · doi:10.1186/1471-2474-11-127 · Cited by 25
“Observational studies have also linked psychosocial factors to cardiovascular disease [22].”
BackgroundGreeson, J. M., Lewis, J. G., Achanzar, K., Zimmerman, E. A., Young, K. H., & Suarez, E. C. (2008) · Brain Behavior and Immunity · doi:10.1016/j.bbi.2008.09.015 · Cited by 24
“We and others have posited that the relation of state and trait measures of psychological distress to ACVD may be due, in part, to inflammation (Black, 2006; Kop et al., 2003; Suarez, 2003; Suarez et al., 2004b, 2006) and particularly the effects of stress on monocyte function.”
BackgroundInfluentialWang, X., Wen, K., Yang, X., Li, L., & Yu, X. (2017) · Journal of Materials Chemistry B · doi:10.1039/c7tb02090b · Cited by 24
Association of Psychosocial Factors With Risk of Chronic Diseases: A Nationwide Longitudinal Study
Sahle, B. W., Chen, W. L., Melaku, Y. A., Akombi-Inyang, B. J., Rawal, L. B., & Renzaho, A. M. N. (2020) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.09.007 · Cited by 27
Fumagalli, C., Maurer, M. S., Fontana, M., Fine, N. M., Gillmore, J. D., Goyal, P., Nakagawa, S., Musumeci, B., Grogan, M. A., Marfella, R., et al. (2024) · JACC Advances · doi:10.1016/j.jacadv.2024.101123 · Cited by 23
“54 Chronic diseases, chronic pain, socioeconomic disadvantage, or recent widowing are all risk factors for depression with relative increase in CV risk.”
BackgroundStress als Risikofaktor für körperliche und psychische Gesundheitsbeeinträchtigungen
Gerber, M., & Schilling, R. (2017) · Springer eBooks · doi:10.1007/978-3-662-49322-9_5 · Cited by 23
Qiao, L., Ding, S., Zhong, Z., Liu, X., Lai, L., & Zheng, F. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.705783 · Cited by 23
Jayakodi, S., Senthilnathan, R., Swaminathan, A., Shanmugam, V., Shanmugam, R., Krishnan, A., Ponnusamy, V., Tsai, P.-C., Lin, Y., & Chen, Y.-H. (2023) · International Journal of Biological Macromolecules · doi:10.1016/j.ijbiomac.2023.125025 · Cited by 22
Emotional Triggering of Cardiac Dysfunction: The Present and Future
Jiang, W. (2015) · Current Cardiology Reports · doi:10.1007/s11886-015-0635-3 · Cited by 22
Kornerup, H., Marott, J. L., Schnohr, P., Boysen, G., Barefoot, J. C., & Prescott, E. (2009) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2009.08.009 · Cited by 23
“Several pathways have been suggested to explain the link between depression and cardiovascular disease [28,29].”
BackgroundGrenier, S., Potvin, O., Hudon, C., Boyer, R., Préville, M., Desjardins, L., & Bherer, L. (2011) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.09.052 · Cited by 23
“Our results are also in agreement with studies indicating that the association between low SES and the risk of having a CVD is increased by other factors such as psychological distress or anxiety (Clark et al., 2009; Rozanski et al., 2005).”
ResultVujcic, I. S., Vlajinac, H., Dubljanin, E., Vasiljević, Z., Matanović, D., Maksimovic, J. M., Grujičić, S. Š., & Marinković, J. (2014) · Irish Journal of Medical Science (1971 -) · doi:10.1007/s11845-014-1079-2 · Cited by 23
Grewal, K., Gravely‐Witte, S., Stewart, D. E., & Grace, S. L. (2010) · Anxiety Stress & Coping · doi:10.1080/10615806.2010.546838 · Cited by 27
“Suls and Bunde (2005) called for the examination of multiple psychosocial risk factors and their relationship to one another, as opposed to investigating individual risk factors (Bleil, Gianaros, Jennings, Flory, & Manuck, 2008; Rozanski et al., 2005; Suls & Bunde, 2005).”
BackgroundMeyer, F. A., von Känel, R., Saner, H. E., Schmid, J., & Stauber, S. (2014) · European Journal of Preventive Cardiology · doi:10.1177/2047487314549745 · Cited by 23
Berard, D. M., VanDenKerkhof, E. G., Harrison, M., & Tranmer, J. E. (2012) · Cardiology Research and Practice · doi:10.1155/2012/616372 · Cited by 23
“Given that high levels of social support may promote psychological and physical well-being and good health behaviours, it is unclear whether gender differences and varying levels of social support or a combination of these factors influence functional well-being and other health outcomes for older persons with HF [11].”
Coronary Heart Disease and Emotional Intelligence
Vlachaki, C., & Maridaki‐Kassotaki, K. (2013) · Global Journal of Health Science · doi:10.5539/gjhs.v5n6p156 · Cited by 22
“…studies have demonstrated that emotion regulation may promote cardiovascular health, reduce the risk for coronary heart disease and contribute to greater well-being (Côté, 2010; Kubzansky & Thurston, 2007; Rozanski et al., 2005; Pennebaker, 1995; Urry & Gross, 2010; Cornelius, 2001; Bushman, 2002).”
Backgroundde Werf, F. V., Bax, J. J., Betriu, A., Blomström‐Lundqvist, C., Crea, F., Falk, V., Filippatos, G. S., Fox, K. A. A., Huber, K., Kastrati, A., et al. (2009) · Rational Pharmacotherapy in Cardiology · doi:10.20996/1819-6446-2009-5-5-73-89 · Cited by 24
Emotional predictors and behavioral triggers of acute coronary syndrome.
Davidson, K. W. (2008) · Cleveland Clinic Journal of Medicine · doi:10.3949/ccjm.75.suppl_2.s15 · Cited by 23
Self-citationRisk Factors for Cardiovascular Disease
Kucia, A. M., & Hartley, A. (2022) · Wiley eBooks · doi:10.1002/9781119117810.ch5 · Cited by 26
Risk of Coronary Heart Disease in Men With Poor Emotional Control
Potijk, M. R., Janszky, I., Reijneveld, S. A., & Falkstedt, D. (2015) · Psychosomatic Medicine · doi:10.1097/psy.0000000000000254 · Cited by 22
“Conceivably, better emotion regulation capacity could attenuate stress reactions associated with certain mental disorders and personality characteristics (8,13,15,17).”
BackgroundInfluentialRandomized controlled trial of a well-being intervention in cardiac patients
Nikrahan, G. R., Eshaghi, L., Massey, C. N., Hemmat, A., Amonoo, H. L., Healy, B. C., & Huffman, J. C. (2019) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2019.06.005 · Cited by 23
Versorgungsforschung in der psychosozialen Medizin
Schulz, H., Barghaan, D., Harfst, T., Dirmaier, J., Watzke, B., & Koch, U. (2006) · Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz · doi:10.1007/s00103-005-1217-0 · Cited by 22
Metadata
- 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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