Stress en Cardiovascular Diseases PDF

CoRPS Stress en Cardiovascular Diseases Department of Medical and Clinical Psychology Center of Research on Psychology in Somatic diseases Prof. dr. Willem J. Kop CoRPS Outline Overview of cardiovascular disease Psychological factors an...

CoRPS Stress en Cardiovascular Diseases Department of Medical and Clinical Psychology Center of Research on Psychology in Somatic diseases Prof. dr. Willem J. Kop CoRPS Outline Overview of cardiovascular disease Psychological factors and heart disease Acute Psychological Risk Factors for Cardiac Events Need for the study of myocardial ischemia (lab studies) Episodic Factors: Depression and CVD (epidemiological studies) Mechanisms: inflammation and ANS dysregulation The biopsychosocial approach in cardiovascular health CoRPS Cardiovascular Physiology is Important to Biological Psychology In the Netherlands Cardiovascular diseases (CVDs) Cardiovascular The leading cause of death globally,. Disease is still the Responsible for 17.9 million deaths in 2019, leading cause of death in women Tha is 32% of all global deaths Cancer is the overall Cardiovascular diseases (CVDs)https://www.who.int/news- leding cause of death room/fact-sheets/detail/cardiovascular-diseases-(cvds) (2 September 2024) CoRPS Cardiovascular Physiology is Important to Biological Psychology In the Netherlands Cardiovascular Disease is still the leading cause of death in women Cancer is the overall leding cause of death In the USA CVD the leading cause of death (data from 2020) CoRPS CoRPS My life is in the hands of any rascal who chooses to put me in a passion Sir John Hunter (1728-1793) His death in 1793 followed a heart attack during an argument at St George's Hospital over the admission of students. Sir Hunter’s nature was kindly and generous, though outwardly rude and repelling (Fielding H. Garrison. 1913) 6  Anger as Trigger of Acute MI CoRPS (the ONSET study) N=1623, 39 pts reported anger in 24 hr prior to MI; 36 in 2 hr period RR = 2.3 (95%CI=1.7-3.2; compared to usual frequency Mittleman et al., Circulation, 1995 7 CoRPS Outline Overview of cardiovascular disease Psychological factors and heart disease Acute Psychological Risk Factors for Cardiac Events Need for the study of myocardial ischemia (lab studies) Episodic Factors: Depression and CVD (epidemiological studies) Mechanisms: inflammation and ANS dysregulation The biopsychosocial approach in cardiovascular health CoRPS Red = artery Blue = vein From Wikipedia (2010) CoRPS The Cardiovascular system consists of LA The heart (pump) LV and The blood vessels To supply all tissues of the body with oxygen and nutrients) Systemic circulation Pulmonary circulation Coronary arteries  The inside of the heart CoRPS The heart is a ‘pump’ is pumps oxygenated blood out of the left ventricle (LV) It pumps ‘used blood’ through the lungs via the RV It needs blood supply from coronary arteries to function (contract) properly  The heart from the outside CoRPS Coronary arteries lie ‘on top’ of the heart muscle They supply the heart muscle with blood CoRPS Main Types of Cardiovascular Disease (CVD) 1. Coronary Heart Disease (CHD) Coronary Artery Disease (CAD) / Myocardial Infarction (MI) Other (coronary spasm, coronary microvascular disease) Symptoms are typically chest pain (angina pectoris), shortness of breath and fatigue 2. Heart Failure (HF) 3. Valve Disease 4. Arrhythmias / Sudden Cardiac Death (SCD) 5. Stroke / CVA (and TIA) 6. Other (e.g., endocarditis) CoRPS Main Types of Cardiovascular Disease (CVD) Cardiovascular Disease Hyper- Peripheral Ischemic Heart Cardio- Valve Arrhythmias Stroke tension Disease Disease myopathy Disease PAD VT&VI CMD CAD Supra Ventricular Ischemic Hemor- Ventricular archic CHD HF Stable Unstable Myocardial HFrEF HFpEF AF Other VT VF Angina Angina Infarction SVT Acute Coronary Syndrome Terminal pump Cardiac arrest failure Sudden cardiac death CoRPS Coronary Atherosclerosis and Myocardial Infarction 1. Arteries on the heart muscle 2. Healthy (non- atherosclerotic artery 3. Narrowed coronary artery; tissue damage develops “behind” a complete narrowing  Atherosclerotic Coronary Heart Disease: CoRPS Pathology, Manifestations, and Timeline Complicate Fatty Fibrous d Streak Atheroma Plaque Lesion/ Rupture Risk Factors/ Preclinical CAD Ischemia/Angina MI/Sudden Death From First From Third From Fourth Decade Decade Decade 17 Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104). CoRPS Risk Factors for Coronary Artery Disease Modifiable Hypertension Diabetes Mellitus Elevated lipid levels (cholesterol ,LDL,low HDL) Smoking Overweight Psychosocial factors Non-modifiable Age Sex (male) Genetic Factors / family hx CVD CoRPS Treatment of coronary artery disease Percutaneous coronary intervention (PCI: coronary angioplasty /“Dotter behandeling”; used to re-open narrowed coronary arteries) Coronary Artery Bypass Graft (CABG) surgery (used to ”bypass” a narrowed segment(s) in one or more coronary arteries) Thrombolysis (used to re-open a (nearly) completely blocked coronary artery in the setting of myocardial infarction) CoRPS Outline Overview of cardiovascular disease Psychological factors and heart disease Acute Psychological Risk Factors for Cardiac Events Need for the study of myocardial ischemia (lab studies) Episodic Factors: Depression and CVD (epidemiological studies) Mechanisms: inflammation and ANS dysregulation The biopsychosocial approach in cardiovascular health CoRPS Psychosocial Risk Factors for Coronary Artery Disease (1) Acute Factors (triggers) (e.g., anger, mental arousal) (2) Episodic Factors (e.g., Major Depressive Disorder; Exhaustion) Transient (2 weeks – 2 years) Recurring (3) Chronic Factors (traits) (e.g., trait anxiety, hostility, Type D/negative affectivity, low SES) Associations with disease progression depend on severity of underlying coronary disease CoRPS Psychosocial Risk Factors for Coronary Artery Disease Most psychosocial risk factors for CVD are “sub- threshold” = not meeting diagnostic criteria for psychological or psychiatric disorder CoRPS Prevalence of Depression in Patients with Medical Conditions General Distress Subclinical Depression Major Depression CoRPS Stress Psychologic distress can be broadly defined as a negative internal state of the individual that is dependent on interpretation or appraisal of threat, harm, or demand (Cohen & Rodriguez, Health Psychology, 1995) CoRPS What is Stress? Process that unfolds over time and involves the whole person “Stress” can refer to: a stressor, feeling, or consequence Distress response (what we typically mean by “stress”): How environmental events (stressors) threaten us, how they are interpreted, and how they make us feel 2 types (Selye, 1956) - Eustress: stress evoked by positive emotions or events (this term is not very common anymore) - Distress: stress evoked by negative feelings and events CoRPS Variables Affecting Stress Response Time Control Individual Vulnerability CoRPS Yerkes-Dodson Law Moderate arousal produces optimal Performance Arousal CoRPS Stressors: Life Events & Environmental Challenges Vulnerability Factors -Genetic factors -Low SES -Discrimination Buffering Factors -Adverse early life + Appraisal of - - Social support experiences threat & demand - Coping resources -Personality - Optimism -Lack of controllability Stress Response - Self-report: Perceived Stress, Exhaustion, Depression - Behavioral measures: Ambulatory monitoring & Interview - Physiological stress response: ANS/CNS, hemodynamics coagulation/inflammation Cardiac Disease Progression CoRPS Psychosocial Risk Factors for Coronary Artery Disease Psychological Distress Chronic Episodic Acute Risk Factors Personality Low SES Psychological Anger Hostility Discrimination Distress Mental activity Type D PTSD Depression low Optimism Exhaustion Acute Coronary Disease Outcome Coronary Artery Intermediate CAD Severe CAD Syndromes Early CAD minimal stenosis luminal narrowing & Myocardial Infarction no luminal narrowing inducible ischemia Sudden Cardiac Death foam cells, endothelial lipid, T-cell deposition dysfunction, cytokine plaque activation, resulting from plaque & macrophage activation, smooth thinning of fibrous activatoin, thrombus recruitment muscle cells over plaque cap formation & arrhythmias  Atherosclerotic Coronary Heart Disease: CoRPS Pathology, Manifestations, and Timeline Complicate Fatty Fibrous d Streak Atheroma Plaque Lesion/ Rupture Risk Factors/ Preclinical CAD Ischemia/Angina MI/Sudden Death From First From Third From Fourth Decade Decade Decade 17 Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104). CoRPS Psychological Coronary Disease Coronary Artery Risk Factors Outcome Pathology Acute Acute Coronary Anger Syndromes Mental activity Myocardial Infarction thrombus Sudden Cardiac Death thinning cap Episodic Severe CAD plaque Depression luminal narrowing activation SMC over Exhaustion plaque macro endothelial phages dysfunction Intermediate CAD foam cells, minimal stenosis cytokine activation Chronic monocyte Early CAD lumen deposition Low SES T-cell and macro- Personality phage recruitment Hostility Type D? low Optimism? 18 CoRPS Outline Overview of cardiovascular disease Psychological factors and heart disease Acute Psychological Risk Factors for Cardiac Events Need for the study of myocardial ischemia (lab studies) Episodic Factors: Depression and CVD (epidemiological studies) Mechanisms: inflammation and ANS dysregulation The biopsychosocial approach in cardiovascular health CoRPS Part 2 Acute Psychological Risk Factors for Cardiac Events CoRPS Psychological Coronary Disease Coronary Artery Risk Factors Outcome Pathology Acute Acute Coronary Anger Syndromes Mental activity Myocardial Infarction thrombus Sudden Cardiac Death thinning cap Episodic Severe CAD plaque Depression luminal narrowing activation SMC over Exhaustion plaque macro endothelial phages dysfunction Intermediate CAD foam cells, minimal stenosis cytokine activation Chronic monocyte Early CAD lumen deposition Low SES T-cell and macro- Personality phage recruitment Hostility Type D? low Optimism? 18 CoRPS Acute Psychological Factors Emotions Environment Anger Disaster (earthquake) Anxiety Acts of war / aggression Acute distress Major public events (sports, electoins) CoRPS  Anger as Trigger of Acute MI CoRPS (the ONSET study) N=1623, 39 pts reported anger in 24 hr prior to MI; 36 in 2 hr period RR = 2.3 (95%CI=1.7-3.2; compared to usual frequency Mittleman et al., Circulation, 1995 3 CoRPS ONSET Anger Scale 1. Calm 2. Busy but not hassled 3. Mildly angry, irritated, and hassled, but does not show 4. Moderately angry – so hassled, it shows in your voice 5. Very angry, body tense, clenching fists or teeth 6. Furious, almost out of control, very angry, pound table, slam door 7. Enraged! Lost control, throwing objects, hurting yourself or others Correlation with Spielberger State Anger (r=0.25). 3 CoRPS Myocardial Ischemia CoRPS CoRPS Mental stress ischemia: Mechanisms Decreased cardiac supply (narrowing coronary arteries) Increased cardiac demand (hemodymanic reactivity) (blood pressure, heart rate, contractility) CoRPS The ECG – the recording of a moving current Measure of the changes in electrical loading of extracellular fluid due to electrical changes that occur in all cardiac muscle cells together tachycardia bradycardia arrhythmia CoRPS The ECG represents all phases of the conduction pathway R mV P T Q T S Atria contract first, Time (sec) then the ventricles P Normal PR < 0.2 sec Q, R, S Normal QRS 0.06-0.1 sec CoRPS What does the ECG provide you with? HEART RATE: net effect of cardiac parasympathetic and sympathetic NS activation R-R interval time between two beats 60/R-R interval = heart rate R QT interval ST-segment P T (depression / elevation Q S < 60 beats per minute: Bradycardia > 100 beats per minute: Tachycardia CoRPS CoRPS Gullette et al., 1998  Daily Life Activities as Triggers of Myocardial Ischemia CoRPS N=63; 24-48 hr Holter; structured activity diary 2519 hrs ECG; 203 ischemic events; 85% symptomatic CoRPS Structured Diary Classification of Activities Examples of physical activity: 1: sleep 2: rest, reclining 3: eating, talking 4: washing, dressing 5: shopping 6: climbing stairs, heavy physical work Examples of mental activity: 1: sleep 2: rest, reading 3: talking, clerical work 4: waiting, driving 5: concentrating 6: anger or anxiety Entries made each time when activities changed (1-3/hr awake) Included when coinciding with ischemic event within 10 min Circadian Variation in Triggering Ambulatory Ischemia by CoRPS Physical Activity and Mental Stress 1=Morning; 2=Afternoon; 3=Evening; 4=Night Exercise OR=1.9 (CI=1.4-2.6); Mental OR=1.6 (CI=1.1-2.3) Krantz et al., 199  Ambulatory Monitoring Study of Pre-Ischemic CoRPS Reduced Parasympathetic Activity  Ischemia Nonischemic Control CoRPS hf-HRV * 5 a ln(msec2) * 4 110 a 100 HR bpm 90 a 80 70 60 20 10 4 2 Event 20 10 4 2 Event Hight Mental Activity Low Mental Activity 75 CoRPS Summary Part I and 2 The heart is a muscle that pumps oxygenated blood throughout the body (systemic circulation) The heart also pumps “used” blood through the lungs for re-oxygenation Like any muscle, the heart muscle also needs supply of oxygenated blood, this occurs via the coronary arteries (this is a different process than the heart’s pump function) Myocardial infarction (MI) and sudden cardiac death are the end-stage of progressive coronary artery disease Psychological stressors play a different role in the development of heart disease: acute, episodic and chronic risk factors Acute mental stress can trigger MI and myocardial ischemia during daily life – partially mediated by changes in autonomic nervous system activity CoRPS CoRPS Outline Overview of cardiovascular disease Psychological factors and heart disease Acute Psychological Risk Factors for Cardiac Events Need for the study of myocardial ischemia (lab studies) Episodic Factors: Depression and CVD (epidemiological studies) Mechanisms: inflammation and ANS dysregulation The biopsychosocial approach in cardiovascular health CoRPS Part 3 Laboratory Studies Related to Psychological Risk Factors for Cardiac Events  Studying Mental Stress Myocardial Ischemia in the Laboratory CoRPS Measure Various Markers of Myocardial Ischemia Wall motion Perfusion ECG Chest pain  Echocardiography and Radionuclide Ventriculography CoRPS 28  Case Study: Effect of Stressful Imagery on Ischemic LV Wall Motion CoRPS Patient with PTSD and angina equivalent (cough) 5 CoRPS Ischemia with SPECT (moderate/severe) 5 CoRPS Part II. Clinical issues Panic Disorder and Inducible Ischemia based on Perfusion Defects Inducibility of ischemia 90 Patient TP #34 ICM 80 70 81% 60 50 % 40 46% 30 20 Exercise L10 Rest L10 Panic L26 10 0 1 vital capacity inhalation of a gas mixture CAD Only CAD + PD p <.01 and panic containing 35% carbon dioxide and 65% oxygen Elicited panic in 26/35 PD pts and 2/30 CAD controls 224 Fleet et al., 2005 Am J Cardiology CoRPS Transient Coronary Occlusion in Response to Acute Mental Arousal 60 Coronary constriction common with acute mental stress (↓ supply) – this is an extreme case (1 in 200) Papademetriou et al., 1995 CoRPS Relation between Blood Pressure Response to Mental Stress and Coronary Constriction 59 CAD patients (age 60+10 yrs; 8 women) Repeated angiograms - baseline control - 3-min mental arithmetic - 200 micro g intracoronary NTG 18.6 % coronary constriction (>0.15 mm; p >0.10) BP responses associated with constriction in diseased segments 61 (rSBP=-0.26, rDBP=-0.30, p's < 0.05) not in nonstenotic segments. Kop et al., 2001 CoRPS Mental Stress-induced Ischemia Characteristic Features - Observed in 30%-70% of patients with coronary artery disease - Rarely detectable with ECG in the laboratory - Requires myocardial functional or perfusion imaging (echocardiography, SPECT, PET, Cardiac MR) - Often asymptomatic (silent ischemia) - More common in patients with exercise-inducible ischemia than in patients without exercise-induced ischemia - Effects in the lab vary in reproducibility - Associated with ambulatory ischemia - Occurs at lower heart rate (i.e., lower cardiac demand than with exercise - Reduced coronary supply plays an important role - Mental stress-induced ischemia is associated with poor prognosis and increased risk of mortality (in red are the most important features) CoRPS CoRPS Tako-tsubo cardiomyopathy (TTC) First described in 1990 (Sato et al. Kagakuhyouronsha 1990; 1990Dote et al. J Cardiol 1990) Name derived from Japanese “octopus pot” also known as: Apical ballooning syndrome (ABS) Transient left ventricular apical ballooning Broken heart syndrome Stress cardiomyopathy Ampulla cardiomyopathy Neurogenic stunning CoRPS Tako-tsubo cardiomyopathy (TTC) Diastole Diastole Systole Systole Contrast-enhanced ventriculography during diastole and systole demonstrates apical and midventricular akinesis, with relative sparing of the base of the heart (arrow). CoRPS Tako-tsubo cardiomyopathy (TTC) -Characteristic features -ECG suggesting acute myocardial infarction -Apical ballooning or other major ventricular dysfunction -Chest pain/dyspnea, pulmonary edema, cardiogenic shock -Short-term recovery of LV function typically fast; long-term prognosis similar to myocardial infarction (New Engl J Med. 2015, Templin et al.) But also: -Minimal coronary artery disease -Often triggered by emotional or physical distress (≈50% each) -High (supraphysiologic) circulating catecholamines on admission -≈80% female, mostly post-menopausal (mean age 63 yr) -Wittstein NEJM, 2005 CoRPS Tako-tsubo cardiomyopathy (TTC) Case U MD 59 yr old woman - trigger: family member died in car accident. Coronary angiography ejection fraction 10%-20% (anterolateral, apical, inferior, and posterobasal akinesia) but only moderate non-obstructive disease in the left anterior descending artery. Peak troponin 29.9 Hx: MI, AF, mitral valve repair, restless leg syndrome, idiopathic joint disease CoRPS Outline Overview of cardiovascular disease Psychological factors and heart disease Acute Psychological Risk Factors for Cardiac Events Need for the study of myocardial ischemia (lab studies) Episodic Factors: Depression and CVD (epidemiological studies) Mechanisms: inflammation and ANS dysregulation The biopsychosocial approach in cardiovascular health CoRPS Part 4 Episodic risk factors Biobehavioral Mechanisms Involved in Cardiac Events CoRPS Episodic Psychological Factors Examples: Major Depressive Disorder (Vital) Exhaustion Burn-out Features: Transient (2 weeks – 2 years) Recurring CoRPS INTERHEART Study Aim: Examine psychosocial factors as risk indicators for non-fatal MI Design: Case-control 11,119 MI and13,648 controls 52 countries; 262 sites Measures: Stress at work Depression Stress at home Loss of control Financial stress Stressful life events Response options: Never/Some periods/Several Periods/Permanent Little-none/Moderate/High-severe 71 Rosengren et al., 2004 CoRPS Reported stress during the past year and risk of MI 2,5 2 Odds Ratio 1,5 Home Work 1 General 0,5 0 Never Some pd Several pd Permanent * Odds ratio adjusted for age, sex, region, and smoking Rosengren et al., 2004  Conclusions INTERHEART CoRPS MI higher prevalence of all four stress factors (p