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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 4  |  Page : 109-115

Novel comprehensive cardiac rehabilitation to combat the dose-dependent relationship between psychosocial stress and cardiovascular disease

1 Department of Internal Medicine, Tulane Medical Center, New Orleans, LA, USA
2 Department of Internal Medicine, Tulane Medical Center; Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, New Orleans, LA, USA
3 Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, New Orleans, LA, USA

Date of Submission25-Aug-2020
Date of Acceptance23-Nov-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Carl J Lavie
John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA 70121 2483

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_32_20

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The association of cardiovascular disease (CVD) and psychosocial stress (PSS) is a bidirectional function, whereby the two conditions create a self-reinforcing feedback loop. Either can incite and/or magnify the other, prognosis consequently deteriorates and spontaneous remission is unlikely. Several studies show that even subclinical PSS increases mortality. Recent evidence suggests that stress exhibits a strong dose–response toxicity on cardiovascular health with increased levels of PSS directly correlating to additional morbidity and mortality. As such, it will be important that future research considers PSS as a continuous variable capable of causing a spectrum of disease. This article proposes targeted exercise routines as the most efficient therapy for both arms of the feedback loop. A consistent body of data indicates that regular physical activity eases the PSS burden while simultaneously lowering CVD risk. Exercise therapy, mindfulness training, and interventions targeting positive psychological well-being stress management are indispensable therapies, particularly for at-risk and already established cardiovascular patients. Indeed, comprehensive cardiac rehabilitation and exercise training programs inclusive of education, lifestyle, and psychological measures in addition to fitness training are a potent multifaceted therapy for improving quality of life and overall prognosis.

Keywords: Cardiac rehabilitation, cardiovascular disease, dose–response, exercise, physical activity, psychosocial stress

How to cite this article:
OKeefe EL, Lavie CJ, Kachur SM. Novel comprehensive cardiac rehabilitation to combat the dose-dependent relationship between psychosocial stress and cardiovascular disease. Heart Mind 2020;4:109-15

How to cite this URL:
OKeefe EL, Lavie CJ, Kachur SM. Novel comprehensive cardiac rehabilitation to combat the dose-dependent relationship between psychosocial stress and cardiovascular disease. Heart Mind [serial online] 2020 [cited 2023 Feb 6];4:109-15. Available from: http://www.heartmindjournal.org/text.asp?2020/4/4/109/304805

  Introduction Top

Psychosocial stress (PSS), often manifested as depression, anxiety, and hostility, is known to place a significant burden on population health. Indeed, depression and anxiety are currently ranked among the top ten leading causes of global disability.[1] Moreover, it is now largely understood that cardiovascular disease (CVD) exists in a bidirectional relationship with PSS, whereby the two conditions create a self-reinforcing feedback loop – the presence of either incites and worsens the prognosis of the other.[2] This enormous population of CVD patients is uniquely vulnerable to bear the brunt of this malicious relationship, as they persistently display rates of PSS far above those of the general population. Up to 65% of patients after acute myocardial infarction (MI) have reported depressive symptoms, 22% will be diagnosed with major depression. Moreover, PSS-triggered CVD is an underdiagnosed condition.[3],[4],[5],[6]

While it is a known risk factor for CVD, inactivity is also associated with additional PSS, and more recent evidence suggests that this stress exhibits a strong dose–response toxicity on CV health.[7],[8],[9] If left untreated, PSS, especially in the CVD populace, is an insidious, persistent condition that is unlikely to resolve without intervention.[10] The most effective remedy would be one that addresses both arms of a bidirectional association; reintroduction of regular physical activity (PA) would ease the PSS burden while simultaneously lowering CVD risk [Figure 1].[2] For those with established CVD, especially, cardiac rehabilitation (CR) should play an increased role in the years to come. Yet, the state-of-the-art has progressed past the currently practiced, outdated model of CR, and exercise training (CRET), and the time has come to adopt a more comprehensive approach inclusive of mind and lifestyle targeted interventions, in addition to physical training for the body.
Figure 1: The complex interactions among stress, cardiovascular disease,
and exercise (information from Exercise Counteracts the Cardiotoxicity
of Psychosocial Stress published in Mayo Clinic Proceedings 2019)

Click here to view

  Psychosocial Stress as a Cardiovascular Risk Factor Top

PSS is posited to strain the CV system through inappropriate overactivation of the sympathetic branch of the autonomic nervous system (ANS). Chronic ANS imbalance with a sustained sympathetic response spikes blood pressure, inhibits heart rate (HR) variability, blunts peak exercise HR, impairs HR recovery, lowers the arrhythmic threshold, and predisposes the CV system to inflammation, endothelial dysfunction, hypercoagulability, platelet dysfunction, insulin resistance, left ventricular hypertrophy, and coronary spasm.[2],[11] Ultimately, this excessive adrenergic tone is a major determinant of CV health as many of these markers are known to not only increase the risk for CVD but also all-cause mortality.[11] For example, in a study of 9500 adults, the data associated with failure to lower HR by more than 12 beats/min during the 1st min after exercise – noted in 20% of apparently healthy subjects – revealed a fourfold mortality risk over the next 5 years.[12] In those with established CVD, high levels of self-reported PSS were associated with a 5-fold increased risk of major CVD events within 6 months, a 4-fold increase in medical costs, and a 2.5-fold increased risk of additional hospitalizations.[13]

PSS is a particularly nebulous risk factor, whereby rarely do any two patients have the same trigger and subsequent experience. Although this difficulty in objective definition often diminishes its clinical consideration in comparison to other widely recognized and more readily quantitated CVD risk factors, several markers of stress have long been associated with the development of coronary heart disease (CHD) in otherwise healthy populations.[14],[15] For example, evidence from 11,000 patients enrolled in the INTERHEART trial demonstrated that PSS is the third most important modifiable risk factor for MI.[16],[17] PSS had an odds ratio (OR) of 2.67 in that landmark study, making it a stronger risk factor for acute MI than that of diabetes (2.37), hypertension (1.91), and abdominal obesity (1.62) and is comparable to that of smoking (2.87) [Figure 2].[2],[15],[17],[18] Not surprisingly, recovery for patients who continue to report PSS and Type A behavior following an MI is hampered, as these patients are fraught with significantly higher rates of morbidity and mortality.[19] CVD patients battling major depressive disorder are 3.9 times more likely to die of CVD causes compared to their nondepressed counterparts. CVD patients are twofold more likely to experience future adverse CVD-related events if they struggle with concomitant anxiety, and high levels of hostility are linked to a fourfold and fivefold increased incidences of symptomatic CHD and adverse CVD events, respectively.[20],[21],[22],[23],[24],[25]
Figure 2: The odds of experiencing a MI for individuals in the INTERHEART
study stratified by risk factor: An OR >1 indicates an increased risk of
MI versus an OR <1 indicates a reduction in MI risk (information from
Exercise Counteracts the Cardiotoxicity of Psychosocial Stress published
in Mayo Clinic Proceedings 2019). OR: Odds ratio, MI: Myocardial

Click here to view

One of the exceptional characteristics of PSS, however, is that its physiological effects are not isolated to neurohormonal impacts but are also compounded by the provocation of self-destructive behaviors. Those displaying elevated PSS have been shown to engage in such maladaptive practices as serious substance abuse, smoking, noncompliance with medical regimens, and an unhealthy diet and lifestyle.[18],[26] In comparison, those displaying a high level of psychological well-being are more likely to engage in regular exercise, consume more fruits and vegetables and fewer sweets and processed meats, and are less likely to smoke.[27],[28]

  Dose–Response Relationship between Stress and Cardiovascular Disease Top

PSS, and depression in particular, negatively affects prognosis in a categorical fashion.[10],[29],[30],[31],[32] Then, in 1996, Barefoot et al. presented robust evidence that when assessed as a continuous variable, the level of depression demonstrates a dose–response effect on cardiac and all-cause mortality.[33] With 1200 participants and an average of 15 years of follow-up, in comparison to the nondepressed cohort, the adjusted mortality risk for cardiac death was 38% higher in the mildly depressed group and 69% higher in the moderate/severely depressed group, with all-cause mortality demonstrating even stronger correlations at 57% and 78%, respectively.[33] Using the beck depression inventory, Lespérance et al. corroborated those results showing increased mortality risks for those with mild (HR 2.80, P < 0.00) (HR 2.35, P < 0.001) and with moderate/severe depression (HR 4.32, P < 0.001) (HR 3.57, P < 0.001) for cardiac and all-cause mortality, respectively.[9] Interestingly, there was evidence of an increased risk of cardiac mortality in the cohorts displaying only low normal and high normal levels of depression. These early data suggest that such stress even within normal limits for a healthy population may confer added risk to those suffering from CVD.[34]

While the field of PSS has been dominated by research into depressive symptomatology, there is still a significant body of evidence proposing that all serious mental disorders carry an increased risk of premature death from both natural and unnatural causes.[35] Affective disorders, in particular, have been shown to confer a mortality risk from unnatural causes up to 7.9 times that of expected and as seen with depression, evidence of another dose–response relationship.[35],[36] The meta-analysis from Russ et al. concluded that affective disorders and PSS as measured by the 12-item General Health Questionnaire (GHQ-12) demonstrate a dose–response relationship with all-cause mortality, CVD death, and even cancer death at the higher levels of PSS.[37] Puustinen et al. bolstered that data with evidence that each additional point documented on the GHQ-12 increased the mortality hazard ratio by 16%.[38] Remarkably, data once again showed that after adjustment, the subclinically symptomatic group still retained a 20% increased risk of mortality.[37]

PSS often has multiple points of origin both internally and externally. Socioeconomic status is a major determinant of health, whereby cohorts with more economic and personal resources tend to have healthier coping strategies, a longer life expectancy, and less disease.[39],[40],[41] Socioeconomic status is already a risk factor for CVD and all-cause mortality, but when assessed in the light of preexisting PSS, researchers have hypothesized that the result is derived from a multiplicative effect, not a mere additive one.[42],[43] Indeed, PSS in combination with low socioeconomic status amplifies mortality rates (HR 1.46 [95% confidence interval: 1.33–1.59; P = 0.001]).[42] Internal PSS can have a similar effect. For example, affective disorders often occur together, whereby one can have either depression, anxiety, posttraumatic stress disorder, panic disorder, or any combination thereof. When this phenomenon occurs, depression with comorbid PSS (HR 1.98, P = 0.03) demonstrates increased mortality over depression alone (HR 1.73, P = 0.04).[8] Hostility often accompanies and compounds PSS, and mortality once again jumps when the former is found in conjunction with anxiety and depression (HR 2.41, P = 0.04), further representing the presence of a dose–response relationship.[8]

  Therapeutic Effects of Cardiac Rehabilitation Top

Just as the severity of PSS lies on a spectrum, so too does its detrimental effect on health outcome – PSS is a known cause and result of CVD, and health outcomes and premature mortality are ostensibly dependent on a dose–response effect. Exercise training is a powerful weapon in the therapeutic arsenal against CVD and PSS alike, and it remains one of the most powerful countermeasures a patient can take to alleviate mental suffering and physical disability. Cardiorespiratory exercise training programs improve ANS function, blood rheology, inflammation, metabolic syndrome, brain plasticity, mood, and cognition as well as mitigate standard CVD risk factors through reductions in body weight, blood pressure, and an improvement in insulin sensitivity.[44],[45] Accordingly, compared with an inactive control group, those patients who consistently obtain the recommended levels of exercise post-MI are at half the risk of dying during follow-up.[46] The improvements seen in ANS functioning and blood rheology may be due, at least in part, to an amelioration of psychological and behavioral factors.[44] Nonetheless, sufficient levels of PA have the power to reverse many of the systemic derangements associated with depression, including improvements in HR variability, baroreflex reactivity, QT prolongation, autonomic balance, inflammation, hypercoagulability, and endothelial function while also curbing the emotional distress associated with not only depression but also anxiety, hostility, and other forms of PSS.[47],[48]

There is a substantial body of data to support the efficacy of exercise programs for improving CVD risk factors, measures of PSS, quality of life (QoL), and overall prognosis.[49],[50] The Aerobics Center Longitudinal Study reported that when low levels of negative emotions are matched with high levels of cardiorespiratory fitness (CRF), all-cause mortality drops 63%.[51] Milani and Lavie showed in 522 patients that high levels of oxygen consumption (VO2) after CRET are associated with the lowest levels of mortality (4%) and the best reduction in depressive symptoms (18% to 5%, P < 0.0001), followed closely by the mild VO2 gain cohort with a mortality of 6% and a fall in depressive symptoms from 17% to 5% (P = 0.004) with the VO2 loss group demonstrating a mortality rate of 15% and a nonsignificant reduction in depressive symptoms [Figure 3].[52],[53] Depressive symptoms fell 63% in patients who successfully completed their CRET program. Furthermore, as compared with their depressed counterparts who at least completed CRET, those in the depressed control group without CRET demonstrated a nearly fourfold elevation in mortality (30% vs. 8%, P = 0.0005).[52] Yet, at CRET program completion, those who remained depressed retained a more than fourfold higher mortality risk (22% vs. 5%, P = 0.0004).[52],[54] Even within the control cohort – those who dropped out within 2 weeks of program entry – the depressed subjects exhibited a nearly threefold higher mortality risk as compared with nondepressed subjects (30% vs. 11%, P = 0.003).[52] CRET is shown not only to prevent depression and CVD-related depression but also actively to treat it as well as antidepressant medication. As compared to the medication intervention, CRET participants have even been shown to suffer lower rates of depression relapse over extended periods of follow-up.[53],[54],[55],[56]
Figure 3: Prevalence of depression and subsequent mortality based
on changes in peak VO2 during cardiac rehabilitation and exercise
training (information from Impact of Cardiac Rehabilitation on Depression
and Its Associated Mortality published in the American Journal of

Click here to view

  Power of Positive Psychosocial Behavior Top

Effective strategies to mitigate PSS are important for not only avoiding the direct cardiotoxic effects of stress but also reducing detrimental lifestyles and self-destructive behaviors. However, the reduction of PSS is not sufficient to maximize longevity as the absence of negative emotion does not predicate an ideal psychological state. While clear PSS is an independent risk factor for CVD, several previously discussed studies have correlated subclinical psychological distress to premature mortality. Conversely, data support an active, positive psychological state, which is a protective factor for CV health [Figure 4].[57],[58],[59]
Figure 4: The various biological and psychosocial mechanisms by which
psychological well-being improves cardiovascular health (figure adapted
from The Mind-Heart-Body Connection published in Circulation 2019)

Click here to view

Positive psychological well-being has been associated with a lower incidence of smoking, greater likelihood of regular exercise, and elevated consumption of fruits and vegetables in lieu of sweets and processed meats.[27],[28] In a study of 70,000 women, those in the highest quartile for the level of optimism showed a 38% and 39% reduction in CVD and stroke mortality risk, respectively.[60] In a large meta-analysis of ten studies and 125,000 patients, a sense of purpose in life conferred a 17% reduction in CVD events.[61] Positive affect and psychological well-being have also been linked to lower levels of atherogenic lipid and glycosylated hemoglobin, with a decreased incidence of metabolic syndrome.[62],[63],[64]

Programs targeting mindfulness and interventions focusing on fostering positive psychological well-being have been shown to improve depressive symptoms, stress, anxiety, QoL, physical functioning, PA, healthy eating, and smoking cessation.[65],[66],[67],[68] In groups suffering from existing CVD, mindfulness training has led to improvements in QoL, depression, anxiety, PA, and biological markers including blood pressure, inflammation, and HR variability.[69],[70],[71],[72] Blumenthal et al. demonstrated, however, that while stand-alone programs for stress management and CR training were each useful therapies for CVD patients, when combined, they produced a 47% reduction in clinical events as compared to CR alone [Figure 5].[53],[73] Comprehensive cardiac prevention and rehabilitation programs focused on a patient's entire health-care picture – lifestyle, associated risk factors, medication, and fitness – have demonstrated better outcomes as compared to less inclusive programs or those that regularly defer certain aspects of risk reduction to outside health-care providers. In particular, those comprehensive programs addressing at least six risk factors reduced all-cause mortality by 37%, prescribing and monitoring medication within the program was associated with a reduction in all-cause mortality by 65%, and such rehabilitation programs also reduced cerebrovascular events, CV mortality, and MI by 60%, 58%, and 30%, respectively.[74]
Figure 5: Cumulative time-to-event curves for CR + SMT, CR alone, and
no CR groups. Clinical events included all-cause mortality, myocardial
infarction, cardiac or peripheral vascular intervention, stroke/transient
ischemic attack, or unstable angina requiring hospitalization (information
from Enhancing Cardiac Rehabilitation with Stress Management Training:
A Randomized, Clinical Efficacy Trial published in Circulation). CR + SMT:
Cardiac rehabilitation + stress management training

Click here to view

PSS will provoke exaggerated adrenergic responses which cause physiologic derangements including elevations in blood pressure, sometimes during sleep hours, and elevations in resting HR – both often in response to even mundane, generally nonthreatening stimuli. Such a chronic ANS imbalance and sympathetic predominance will invariably lower CV vagal tone, induce higher levels of circulating catecholamines, also can cause coronary vasoconstriction, increase inflammation, and activate platelets, all of which could trigger MI, stroke, or CV death.[2] While PA is known to combat each of these triggers and responses individually, it is not the activity done in solitude that derives the most benefit. Recent evidence has shown simple alterations to PA such as engaging in activities that require two or more individuals to play together, such as racquet sports, golf, and soccer, and engaging in those activities among green space offers the most PSS reduction and opportunity to increase longevity and optimize psychological well-being.[75]

  Conclusion Top

In summary, CV patients are unique positioned as they suffer from elevated rates PSS, and PSS, in turn, predisposes patients back to CVD. Alone, higher PSS is not only associated with physiological derangements but also increased tendencies toward maladaptive behavior. CRET has been long known to treat CVD and those physiological derangements, but it also curbs emotional distress and PSS. Moreover, the comprehensive CRET described here goes farther by focusing on lifestyle and mental well-being in addition to exercise training. This promotes psychological well-being which, in turn, is related to increased PA and an overall healthier diet and lifestyle.

Furthermore, it is now becoming clear that future research will not be able to simply address PSS as a categorical variable but will need to consider it on a spectrum of disease with appropriate health consequences. PSS, unfortunately, is shown to be a persistent condition that is unlikely to resolve spontaneously. CRET as a therapy has the ability to treat and prevent both CVD and PSS simultaneously and interrupt this self-reinforcing feedback loop. Yet, simply reducing levels of PSS is not enough to optimize health; cultivating positive psychological well-being is a potent protective factor for longevity. This proposed comprehensive CRET, mindfulness training, and interventions targeting positive psychological well-being, as adjuncts to stress management, are indispensable long-term therapies for CVD patients.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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