Cardiologists should recognize and help manage depression, stress and other common psychosocial risk factors that play a powerful role in the wellbeing and health outcomes of heart disease patients, according to an article(PDF) in the March 1, 2005 issue of the Journal of the American College of Cardiology.
"Chronic stress, such as work or marital stress, and emotional problems, such as depression, constitute major risk factors for coronary artery disease and mandate attention in the context of cardiac practice. By effectively triaging sicker patients for outside help and utilizing office staff, as necessary, there are many practical steps cardiologists can take to help assist such patients," said Alan Rozanski, M.D., F.A.C.C., at St Luke's-Roosevelt Hospital Center and Columbia University in New York.
The authors highlighted studies that indicate the effects of psychosocial risk factors on coronary artery disease are perhaps even more powerful than well-recognized risk factors such as smoking, diabetes, obesity, cholesterol and high blood pressure. For instance, the authors cite the recent INTERHEART study, an international study that examined psychological stress and eight other coronary artery disease risk factors among patients in several countries. In that study, psychological stress was as strong as the most potent of the coronary artery disease risk factors.
Dr. Rozanski stated that he and his co-authors were compelled to write this article now because no one has addressed a very important issue that holds this field back: what should cardiologists do about the association of psychosocial risk factors and coronary artery disease, given that cardiologists are not trained as psychologists.
“We need a whole new behavioral health care delivery system that is modeled after work already done to treat some common problems that internists face but have limited time and skill to handle—the problems of depression and panic disorder. The model is called stepped collaborative care," he said.
Using a stepped collaborative care approach, cardiologists take the first step by regularly checking for depression, chronic stress and other psychosocial risk factors. In many cases, just talking about these issues can help patients cope and respond positively. The next step is to involve other staff, including nurses or counselors to advise and monitor patients. In more serious cases, cardiologists would refer the patient to a mental health care specialist.
Dr. Rozanski said he recognized that cardiologists may feel uncomfortable with or even resist grappling with psychosocial issues.
"They might also object by saying, 'I just don't have the time to deal with such things’ or ‘Show me the data where my attention to such matters will make a difference.' I would respond as follows: Just as we would want to alleviate any somatic symptom, depression and the like are painful. As physicians, if we can help assist in the alleviation of such suffering, we have an obligation to do so," Dr. Rozanski said.
The article cites practical steps cardiologists can take to help their patients.
Dr. Rozanski pointed out that the pathophysiologic relationship between psychosocial factors and coronary artery disease has been expanded through numerous recent studies. It is clear that the heart, blood vessels and other organs can suffer from the chronic stimulation of the sympathetic nervous system and the glands that regulate hormones, including the hypothalamus, pituitary and adrenal glands that are stimulated by chronic stress or chronic emotional distress. Such stimulation secondarily leads to inflammation within blood vessels, abnormalities in blood platelet function, abnormal heart rhythms and other physical effects that help promote atherosclerosis and/or adverse cardiac events.
Dr. Rozanski also noted that depression, stress, social isolation and other factors are linked to smoking, poor diet, lack of physical activity and other unhealthy behaviors. Thus psychosocial risk factors have both direct and indirect effects that can deliver a double whammy to the cardiovascular system.
The authors called for more research into how to treat these issues.
“Treatment: this is the new frontier. There are studies, for example, which show both the health and psychological benefit of exercise, but what needs to be assessed is whether we can develop a practical model for cardiologist-led behavioral interventions, and then show this improves patient outcomes. As in any situation, the more cardiologists believe they can make a difference in this arena, the more they are likely to get involved,” Dr. Rozanski said.
Anthony N. DeMaria, M.D., M.A.C.C., Editor in Chief of the journal said the point of this article is to emphasize how prevalent these problems are and the importance of addressing them.
“Increasing awareness has led to more studies and these additional studies have shown us that these psychosocial factors have an even greater impact than we had thought,” Dr. DeMaria said. “Cardiologists, by virtue of the highly technical nature of the discipline, with catheters, angioplasty, nuclear imaging and things of that nature, tend to be oriented toward the pathophysiological aspects of cardiovascular disease. But it’s clear that the interaction between psychosocial factors and the disease can account for many of the symptoms and can cause either deterioration of the condition, or conversely can be a means by which we can enhance the ability of a patient to function in the setting of heart disease.”
He said it was important for the journal to provide an update of recent research, as well as offer practical suggestions for how to incorporate the knowledge into busy cardiology practices in order to benefit patients.