Year : 2017 | Volume
: 1 | Issue : 1 | Page : 4--7
Heart and mind: A research update of heart diseases caused by psychological factors
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029
Although it has been proposed in scholarly works for centuries that psychological factors play a role in the pathophysiology of somatic disease, this belief has not been validated mechanistically until relatively recently. This article discusses one specific instance of this general phenomenon: psycho-cardiology. Combining insights from epidemiological research, which has been prolific in showing associations between cardiovascular and psychological diseases, and the basic science research that has recently begun elucidating the biological mechanisms that may underlie those associations, the aim of this article is to provide a broad overview of the field of psycho-cardiology as it is presently understood. Beginning with a history of the development of psycho-cardiology, the article proceeds through separate sections that discuss contemporary research in the field under the following categories: epidemiology, clinical manifestations, structural and functional derangements, induction mechanisms, the impact of technological and diagnostic changes, and the practical implications for treatment. Taken together, the body of work that this article surveys points clearly to the need to integrate the evaluation for and treatment of psychological disease into the scope of clinical cardiology.
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Liu M. Heart and mind: A research update of heart diseases caused by psychological factors.Heart Mind 2017;1:4-7
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Liu M. Heart and mind: A research update of heart diseases caused by psychological factors. Heart Mind [serial online] 2017 [cited 2023 Jun 10 ];1:4-7
Available from: http://www.heartmindjournal.org/text.asp?2017/1/1/4/206970
Psycho-cardiology (also referred to as psychological or psychiatric cardiology) is a discipline that investigates the influence of social, behavioral, and physiological factors on the onset, treatment, and prognosis of diseases of the cardiovascular system. The concept of mind–body disease under which this discipline operates has a long history. It was first proposed by Dr. Heinroth, a German psychiatrist, in 1818. Later in the 19th century, Dr. Jacobi elaborated the concept with his theory of psychosomatic disease (1884), which emphasized the importance of psychological factors in the onset of disease. In 1943, when his laboratory produced the evidence of pathological vascular changes brought on by psychological factors, neurologist Dr. Harold Wolff became the first to bring the psychosomatic theoretical framework to fruition within the field of cardiology. Findings such as these, and the mechanistic understanding of psychosomatic disease to which they would contribute, ultimately produced the development of psycho-cardiology. In 1980, the American Psychosomatic Disease Research Institute formally defined psychosomatic disease as psychological stress, caused by environmental stress, that would aggravate somatic diseases. These diseases included much of what would become the scope of psycho-cardiology: primary hypertension, primary hypotension, coronary heart disease, coronary artery spasm, neurogenic angina, paroxysmal tachycardia, primary bradycardia, functional premature contraction, and cardiac neurosis. A meeting in 1998 of the community of specialists working on the psychological aspects of these conditions incorporated them into a consensus definition of psycho-cardiology. Since then, psycho-cardiological research has proliferated, with reports regarding clinical aspects, pathophysiological origins, and experimental treatments appearing in succession. Recent years have witnessed a surge in the production and popularization of this work, and have, accordingly, been notable for the consolidation of clinical practice and clinician–patient consensus that has emerged from them. In China, the concept of psycho-cardiology was first proposed by Dayi Hu in 1995. In 2006, after years of clinical practice and research, Hu went on to find the discipline formally in our country.
Psycho-cardiological inquiry has become more and more prominent in the recent years in the field of cardiovascular disease research. One particularly long-lived focus has been the psychological factors that may precipitate or worsen cardiac ischemia. It has emerged that unhealthy emotions and psychological problems are the primary causes and risk factors for cardiovascular diseases, both precipitating their onset and worsening their outcome. An illustrative case of a patient with multiple myocardial infarctions was encountered in clinical practice 1 year ago. At the outpatient clinic, the patient was found with five cardiac stents that were placed at the onset of myocardial infarction. Even though all patients were strictly compliant with medical orders and the levels of blood glucose and cholesterol were recovered to the normal levels, this patient sustained multiple subsequent myocardial infarction that led to serious psychological problems. After consultations with collaborating psychologists, however, the patient's infarction prognosis was changed. The patient's medical history included depression at the age of 16, but contained no record of enrollment for treatment at the hospital. It was agreed that this untreated depression was linked to the patient's multiple onsets of cardiac ischemia and myocardial infarction, and this link was substantiated when the patient recovered from both cardiac and psychological symptoms after the latter were addressed in tandem with the former. This case demonstrates the need for all clinicians, and not just psychologists, to pay attention to the psychological issues that are often concomitant with physiological disease. In addition to significantly augmenting their suffering on its own, cases such as this demonstrate that depression, possibly by means of inducing damage to coronary endothelial cells, poses real risk for exacerbating cardiovascular disease in patients afflicted with it.
Psychological factors, such as unhealthy emotions or fluctuations in mood due to unanticipated stressful events, are also closely linked with cardiovascular diseases that lead to sudden death. This has been shown in the context of natural disasters (e.g., earthquakes and floods), during which increased psychological stress is considered to cause cardiac disease coincident with these events.,,
Cardiac Ischemia Caused by Psychological Stresses
The variety and extent of cardiac damage shown to be induced by psychological factors has far exceeded than what was predicted. Data from clinical practice have demonstrated the link between psychological factors and cardiac ischemia, and coronary diseases have been observed to co-exist with anxiety and depression.,, The EUROASPIRE III study showed that the incidence of patients with depression was 8.2%–25.7% in males and 10.3%–62.5% in females after diagnosis of hospital anxiety and depression in a total of 850 patients hospitalized with chronic heart disease. A study conducted in ten secondary and tertiary hospitals showed that the incidence of anxiety was 42.5%, and the incidence of depression was 7.1%, among a population of 3260 patients in cardiovascular clinics. In a survey conducted in 14 large hospitals distributed across five cities, the prevalence rates and lifetime prevalence rates for depression in 2123 patients enrolled in cardiology clinics were 14.37% and 17.00%, respectively. The reasons for the onset of depression were complex, and incidence in female patients outweighed incidence in males by 3:2.
Cardiac ischemia in the clinic
In patients with coronary disease, psychological stress can induce cardiac ischemia. Unhealthy emotions and psychological stress diminish blood supply even further in vessels that are already stenotic, causing deterioration in disease status. In the 2 weeks preceding its onset, approximately two-thirds of patients who would develop myocardial infarction complained of tiredness, stresses, and insomnia. Cardiac damage was observed to be correlated with psychological stresses. Depression and anxiety brought about by chronic stress induced deterioration of the coronary endothelial system, and endothelial impairment rendered patients prone to atherosclerosis. Patients who had atherosclerotic plaques experienced rupture due to shear action, leading to acute coronary syndrome.
The clinical symptoms of cardiac ischemia include abnormal systolic and diastolic function in microvessels; these symptoms have been observed acutely in patients with sudden anxieties or unhealthy emotions. Increased stress burdens the psychological status of these patients, who then go on to develop cardiac ischemia.
Studies that have investigated the intervening pathophysiological mechanism have emphasized a progressive stress-brain-emotions-heart model in which neuroendocrine factors play an important role. Overstimulation of the sympathetic nervous system is thought, through mediation by the renin-angiotensin-aldosterone system, the adrenergic system, and others, to bring about cardiac damage by modulating viscosity, vasomotor tone, as well as other pathophysiologically relevant parameters. By this mechanistic work, psychological factors have been linked with heart disease in a precise cause and effect relationship.
Changes of cardiac structure and function and cardiac ischemia
Patients who were diagnosed with coronary stenosis by chance in clinical practice have complained, after the placement of medical stents, of a sensation of foreign bodies. The sensitivity to 5-hydroxytryptamine (5-HT) of coronary microvessels was observed to be changed in these patients, who presented with arteriosclerosis after psychological issues were observed, but before cardiac disease was diagnosed. Similarly, patients with multiple myocardial infarctions have been diagnosed with heart disease after being diagnosed with depression. This succession is accounted for by changes in 5-HT levels in depression, which influence circulatory homeostasis in a manner that changes the systolic and diastolic functions of microvessels or their associated receptors. Thus, 5-HT system dysregulation may be involved in the co-occurrence of depression and myocardial infarction. However, manifestations of heart disease are not limited to structural abnormalities (such as blood vessel stenosis, changes in ventricular walls, and ventricular enlargement). In fact, functional neuroendocrine changes have been observed by clinicians before any evidence of structural abnormality: patients with cardioneurosis who were not treated have been found with cardiac insufficiency, cardiac ischemia, or cardiac arrhythmia in concordance with progression of their disease.
In patients with panic attacks, recurrent attacks over time can result in damage to the coronary system, such as angiostenosis and myocardial infarction. Symptoms of panic attacks, when worked up in an emergency clinic, have been observed to coincide with the structural and functional changes consistent with the onset of myocardial infarction. These changes included impairment of the coronary endothelial system sufficient to precipitate incidental or multiple atherosclerosis, and the histiocytes and macrophages observed with oxidative stress and inflammatory chemotaxis that are definitive of the mechanism of angiostenosis; as stated above, psychological stresses cause this damage.
Cardiac ischemia induced by both psychological and physical stresses
Rather than by excessive physical activity, death from overwork is caused by intense psychological stress. Patients with stable coronary diseases have been observed with cardiac ischemia by electrocardiogram after physical overload. However, these patients were also observed to have cardiac ischemia at rest when overloaded with psychological stress. Interestingly, psychological stress seemed to induce ischemia in locations that differed from those induced by physical overload.
In a study of rats with myocardial ischemia and comorbid depression, changes in 5-HT levels in the peripheral blood and in the central nervous system were observed when stress was induced. Changes in the levels of the 5-HT2A receptor showed a linear relationship with the progress of depression and myocardial infarction. Similar significant changes occurred for levels of the 5-HT transporter (serotonin transporter). Although the significance of these changes with respect to the co-occurrence of heart disease and depression is not fully understood, most depressed patients are observed to have changes in the concentration and receptors associated with 5-HT.
Advance in stable coronary disease guidelines
Over the past 20 years, there have been a number of technological achievements that have proven important for the field of psycho-cardiology. Patients with coronary diseases who received cardiac stents were found to develop psychological issues and were therefore designated as psycho-cardiological patients. Damages in the modulatory system of the affected blood vessels were observed, and the European Guidelines on Heart Diseases (2006 version) reflected this when they emphasized, while describing the indications for stent placement, both the extent of stenosis (categories were <75% or >75%), as well as the abnormalities in the micro-circulation that are influenced by psychological and emotional factors.
In addition, a study conducted in Sweden was designed to compare patients with chest pain using a contrast examination. Totally 60% of females and 30% of males were diagnosed with coronary diseases due to symptoms of chest pain, but no stenosis was shown on angiography with contrast. The reason for the chest pain was not due to coronary disease, but rather to microvascular pathology that was defined as nonobstructive coronary heart disease, for which incidence was high. The worst case recorded was coronary artery disease complicated by as-yet undetected microvascular disease. Of interest to psycho-cardiology were the multiple mechanisms of cardiac ischemia reported in the treatment guidelines, which included dysfunction of microvessels caused by psychological factors and coronary vasospasm. Similarly, psychological stress could be observed in patients with variant angina pectoris, and in patients with myocarditis, damage to cardiomyocytes was shown to be caused by emotional stress in a manner that was analogous to the precipitation of sudden deaths due to myocardial infarction in the context of acute emotional stress.
Perspective on solutions to psycho-cardiological disease
Mechanistic studies on cardiac ischemia induced by psychological factors
In the presence of the following risk factors, cardiac ischemia may have been caused by the platelet and microcirculation dysfunctions secondary to psychological disease: (a) Blood vessels with significant angiostenosis; (b) inflammatory changes in blood vessels; (c) dysfunction of micro-circulation; (d) disturbance of blood coagulation and defects in platelets; and (e) endothelial damage caused by dysfunction of platelets and microvessels.
It is important for clinicians to distinguish the coronary structural changes from functional changes that indicate pathological transformation as soon as possible. Ample evidence has shown that both physical and psychological stresses can lead to the onset of cardiac ischemia. Early training in stress reduction, lifestyle changes, and pharmacotherapy for potential psychological stresses have all significantly lowered the risk of cardiac ischemia caused by psychological factors, improved the prognosis of the patients with coronary diseases, and prevented damages to the microcirculation, platelets, and endothelial function that are associated with psychological stress.
Over the past 20 years, the ascendency of evidence-based medicine has required the verification of scientific theories with clinical data. This has been done in the field of psycho-cardiology, in which it has been demonstrated that effective treatment of cardiac disease often depends on the concurrent treatment of psychological factors. Psycho-cardiological research has shown that screening for psychological and emotional issues alongside evaluation for physiological disease is crucial for effective clinical practice.
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Conflicts of interest
There are no conflicts of interest.
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