Cardiology & StressCardiology & Stress

A force acting against some A force acting against some resistance(the Heart)resistance(the Heart)

Cardiology & StressCardiology & Stress

Hans Selye defined stress as Hans Selye defined stress as

““the rate of wear and tear in the the rate of wear and tear in the body”in this case the heartbody”in this case the heart

Stressor is an environmental Stressor is an environmental source of threat to the source of threat to the

organismorganism

Stressor Stressor Organism (Heart)

Stress

Cardiology & StressCardiology & Stress

Stress causes changes Stress causes changes that once they are that once they are perceived by the perceived by the

organism will disrupt the organism will disrupt the homeostatic balance homeostatic balance

within the heartwithin the heart

StressStressStressful Life EventsStressful Life Events

Locus of ControlLocus of ControlNeed for stimulationNeed for stimulationOpenness to change ( Flexibility)Openness to change ( Flexibility)Self - ActualizationSelf - ActualizationUse of DenialUse of DenialPresence of Social SupportsPresence of Social SupportsEmotional Self DisclosureEmotional Self Disclosure

Stress Example Stress Example • Men whose blood pressure rises in response Men whose blood pressure rises in response to stress have an increased chance (72%)of to stress have an increased chance (72%)of developing a stroke compared with men whose developing a stroke compared with men whose blood pressure does not react in stressful blood pressure does not react in stressful situations.situations.

–““Stress induced blood pressure reactivity and Stress induced blood pressure reactivity and incident stroke in middle-aged men.” incident stroke in middle-aged men.”

–StrokeStroke 2001, Everson et al. 2001, Everson et al.

Sudden Mental Stress Sudden Mental Stress • In the May 2002 – Journal of the A. Heart In the May 2002 – Journal of the A. Heart AssociationAssociation

–Sudden mental stress causes endothelial Sudden mental stress causes endothelial dysfunction.dysfunction.

–Endothelial dysfunction occurs when the Endothelial dysfunction occurs when the blood vessel’s ability to expand or contract blood vessel’s ability to expand or contract fails.fails.

StressStressCircadian Occurrences of Cardiac Circadian Occurrences of Cardiac

EventsEvents

Angina and sudden death occurAngina and sudden death occur

Mornings before noonMornings before noon

Early EveningsEarly Evenings

More on Mondays More on Mondays

StressStress

Figure 29 -1 Figure 29 -1

HandoutHandout

Diagnosis of StressDiagnosis of Stress

Three Main InvestigationsThree Main Investigations

Medical Interview - When, Where, HowMedical Interview - When, Where, How

Self ReportSelf Report

Direct measurement of Physiologic Direct measurement of Physiologic

ResponsesResponses

Physician InterventionsPhysician InterventionsCommunicate with patients about stress:Communicate with patients about stress:

Avoid “all in your head” “you are Avoid “all in your head” “you are responsible for your illness”responsible for your illness”

Avoid inducing guiltAvoid inducing guilt

Counsel about perception and copingCounsel about perception and coping

Non Pharm. & Pharm strategies for improving Non Pharm. & Pharm strategies for improving physiologic processesphysiologic processes

Arousal reduction StrategiesArousal reduction Strategies

Referral for psychotherapyReferral for psychotherapy

Multidimensional Stress ModelMultidimensional Stress Model

This model must include:This model must include:

Patient’s perceptionsPatient’s perceptions

Coping strategiesCoping strategies

Physiological arousal mechanismsPhysiological arousal mechanisms

Arousal reduction strategiesArousal reduction strategies

Biological DeterminantsBiological DeterminantsJust Right BalancesJust Right Balances

•Ask the questions about the individual’s “just Ask the questions about the individual’s “just right balances”right balances”

•““Is it too much in your life?”Is it too much in your life?”

•““Is it too little in your life?”Is it too little in your life?”

•““Is it just right in your life? Is it just right in your life?

Biological DeterminantsBiological Determinants

•NourishmentNourishment

•Waste DisposalWaste Disposal

•ActivitiesActivities

•ArousalArousal

•Rest/RelaxationRest/Relaxation

•CaringCaring

•StrokesStrokes

Biological DeterminantsBiological Determinants

•Nourishment Nourishment

Is the person properly nourished physically?Is the person properly nourished physically?

Is the person nourished emotionally?Is the person nourished emotionally?

Biological DeterminantsBiological Determinants

•Waste Disposal - Waste Disposal - –Does the person have regular kidney and bowel Does the person have regular kidney and bowel functioning?functioning?

–Does the person have regular removal of Does the person have regular removal of “emotional waste products?”“emotional waste products?”

Biological DeterminantsBiological Determinants

•ActivitiesActivities - Does the individual engage in a - Does the individual engage in a variety and diverse set of activities?variety and diverse set of activities?

Biological DeterminantsBiological Determinants

•CaringCaring - Does the individual have an even - Does the individual have an even balance in what he/she gives out in life and balance in what he/she gives out in life and what she /he receives in life?what she /he receives in life?

Biological DeterminantsBiological Determinants

•StrokesStrokes - The minimum amount of human - The minimum amount of human interaction needed to sustain one self. Strokes interaction needed to sustain one self. Strokes may be physical (hugs, touch) or emotional may be physical (hugs, touch) or emotional (praise, encouragement)(praise, encouragement)

Biological DeterminantsBiological Determinants

•Rest/ Relaxation - Rest/ Relaxation - Does the individual get Does the individual get sufficient amounts of rest and relaxation. This sufficient amounts of rest and relaxation. This category may include sleep.category may include sleep.

Biological DeterminantsBiological Determinants

•ArousalArousal - Are the individual’s sensory - Are the individual’s sensory systems sufficiently aroused?systems sufficiently aroused?

Reduce Mental Stress Reduce Mental Stress • In the April 23 2001 – Archives of Internal In the April 23 2001 – Archives of Internal Medicine by Linden & LenzMedicine by Linden & Lenz

–Individual Stress Management reduces high Individual Stress Management reduces high Blood PressureBlood Pressure

–Reduced blood pressure was reduced in the Reduced blood pressure was reduced in the experimental group and patients reported experimental group and patients reported reduction in physiological stress and reduction in physiological stress and improved anger coping mechanisms. improved anger coping mechanisms.

Stress in the WorkplaceStress in the Workplace• In the July 2001 issue of HypertensionIn the July 2001 issue of Hypertension

–““Perceived job stress but not individual Perceived job stress but not individual cardiovascular reactivity to stress is related cardiovascular reactivity to stress is related to higher blood pressure at work.” to higher blood pressure at work.” Fauvel et al.Fauvel et al.

–Study says that healthy individuals w/ no Study says that healthy individuals w/ no history of high blood pressure have an history of high blood pressure have an elevated blood pressure at their work. elevated blood pressure at their work.

Anger’s Role Anger’s Role • ““Anger in Young Men and subsequent Anger in Young Men and subsequent premature cardiovascular disease: the premature cardiovascular disease: the

precursors study”precursors study” by Chang et al. Arch. of Int. Medicine April by Chang et al. Arch. of Int. Medicine April

20022002

•The experimental group with the highest levels of The experimental group with the highest levels of anger in response to stress were more than three anger in response to stress were more than three times as likely to develop premature heart times as likely to develop premature heart disease….and six times more likely to have a heart disease….and six times more likely to have a heart attack.attack.

Emotional Aspects of CAD

Case presentations

Case 1

• Patient is a 50yo female with a long standing history of hypertension, who is currently on an ACE-I, beta-blocker, and aspirin. Patient is obese, smokes 1 PPD , and a strong family history of CAD. Patient is married and has two children, ages 17 and 20. Patient works as a teacher. Her husband is currently unemployed.

Case 1 (cont)

• What questions would you be asking this patient in order to illicit a social, emotional, and psychological profile in order to more adequately deal with her physical and emotional health?

Case 1(cont)

• Questions to be asked– Do you feel stressed?– Do you feel anxious?– Do you have difficulty sleeping?– How are you getting along with your husband?– What is your relationship with your husband?– How are you getting along with your children?– What is your relationship with your children?

Case 1 (cont)

• Questions (cont)– Do you enjoy your work?– Do you find work pressured?– Are you having any financial problems?– What is your relationship with your colleagues at

work?– What is your relationship with your mother and father

and siblings?

Case 1 (cont)

• More Questions– Are you concerned about your finances?– Have you tried to stop smoking?– Have you thought about exercising?– Have you tried to loose weight?– Does your husband smoke?– Does your husband exercise?– Are your parents overweight?

Case 1 (cont)

• Questions cont– Are your children overweight?– Do your children exercise?– Do your children smoke?– Do you have any significant problems with your

children?– Has your husband being unemployed created any

problems?

Case 1 (cont)

• Solutions– What can be done to improve the emotional quality of

your life, your relationship with your husband and children, and relatives?

Case 2

• Patient is a 30 year old female with a history of mitral valve prolapse that was diagnosed ten years ago when patient was complaining of palpitations, light headedness, and dizziness. Patient was treated with a beta-blocker and her symptoms did improve. Patient is currently separated from her husband whom she was married to for 6 years. Patient has a 4 year old daughter and a two year old son.

Case 2 (cont)

• Patient works as a secretary 30 hours a week, and her children are at daycare while she works, patients husband does not help in child support. Patient recently became more symptomatic and is now having more difficulty in functioning. Patient was re-evaluated and no further causes for symptoms could be found. Patient smokes 1 PPD, is mildly overweight, and complains of being anxious and nervous all of the time.

Case 2 (cont)

• Questions– What do you think is precipitating all of the symptoms

that patient is complaining of? (is it the underlying mitral prolapse or is there a large emotional component to all of her symptoms??)

– What would you ask her to help you to differentiate between physical and emotional causes of her symptoms?

Case 2 (cont)

• Questions (cont)– Have you always felt anxious, or is it just recently?– Do you have problem sleeping at night?– What kind of support system do you have?– Is your husband supportive in any way?– Are your parents assisting you in any way?– How does your future look to you, and what would

you do to improve it??

Case 2 (cont)

• Questions– Do you have any relationships that are helpful and

supportive to you?– How do you feel about your work?– How do you feel about your children being in

daycare?– Have you tried to stop smoking?