RISK FACTORS IN CARDIOVASCULAR DISEASE Medical research has no exact answer to what causes dangerous build up of atheromatous plaques in the arteries of some people but not in others Risk factors of cardiovascular disease neither explain why some people develop CVD nor make prediction They just show conditions associated with particular disease

Cardiovasculer risk factors include: Inherent Risk Factors Physiological Conditions Behavioral Factors Psychosocial Factors

INHERENT RISK FACTORS: Genetic or physical conditions that cannot be modified through lifestyle changes Do not change But it does not necessarily mean that people with risk factors always develop CVD Identifying people with inherent risk factors is important for controlling the things they can, like smoking or diet. Advancing age: Primary risk factor for CVD As age increases the risk for cardiovascular death also increases

Diabetes People with Type 1 diabetes are more likely to die of heart disease than those with normal sugar metabolism Type 2 diabetes also increase the risk of CVD By healthy life style and adhering to medical reigimen, the risk can be decreased Family History People with a history of CVD in family are more likely to die of heart disease Although family history cannot be altered through lifestyle changes, people with a family history of CVD can lower their risk by engaging healthy behaviors

Gender Men have higher rate of death from CVD than women especially in middle ages  Different life styles of men and women may be responsible for this discrepancy  The discrepancy is greater in some countries In Russia & Chine men are %60 more risky than women, while it is %10 in Iceland.  Estrogen level may have protective function Although men have higher risk for CVD, they are more likely to survive a hearth attack than women.  This difference declines as the age increases  At age 74 women are as likely as men to survive a heart attack.

Ethnic Background African Americans have nearly two fold risk for CVD deaths compared to European Americans  They have same category of risk factors but the level of risk factors are higher for them. The stronges risks for African Americans:  High blood pressure  Low income  Low educational level

PHYSIOLOGICAL CONDITIONS Hypertension Other than advancing age, hypertension is single most important risk factor in CVD Regardless of ethnic background, high blood pressure is an important risk factor  Regardles of people’s age or gender their risk of CVD increases with increases in blood pressure (Dawber, 1980). Hypertension produces no overt symptom so millions of people are not aware of their vulnerability

Serum Cholesterol Level  It is the level of cholesterol circulating through blood system and related mostly on the amount of cholesterol in one’s food Cholesterol: a fat-like substance that is essential for human life as a component of cell membranes.  Normal level of cholesterol in body is 210 to 250  Too much of cholesterol may lead to deaths of CVD  Low cholesterol level (below 165) is also dangerous  CVD death is lower in low cholesterol level, but total mortality level does not decrease.  Liver cancer, colon cancer, suicide and unintentional injuries are high in people with low cholesterol level

Not all cholesterol has equal risk for coronary heart disease Cholesterol circulates in blood in several forms of lipoproteins with different density.  LOW DENSITY LIPOPROTEIN (LDL) : Bad cholesterol Positively related to CVD  HIGH DENSITY LIPOPROTEIN (HDL) : Good protein Offers protection against CVD Higher in women Favorable balance of total cholesterol to HDL is more critical than total cholestoral in avoding CVD There is no significant risk of high cholesterol in older ages.

BEHAVIORAL FACTORS They are life style factors Most important of life style factors are smoking and diet Smoking  Cigarette smoking is strong risk for coronary heart disease.  There is positive relationship between the decline in smoking and decline in coronary heart disease Diet  Depending on the food, it may either increase or decrease one’s risk of developing heart disease  Saturated fat, egg and sodium are the risky food for CVD  Fiber, fruit, vegetable, vitamin E, antioxidants are protecive foods againist the CVD  Obesity, which cause high blood pressure, type 2 diabetes, LDL and total cholesterol, is also risky for CVD.

PSYCHOSOCIAL FACTORS Anxiety, depression, education, income, marital status, social support, cynical hostility and anger are psychosocial factors related to CVD Anxiety & Depression Anxiety is very risky for hypertension in middle aged men. Phobic anxiety increases the sudden death from heart disease in men % 70 depressed people are more likely to develop stroke but it is not same for all ethnic groups (Jonas& Mussolino,2000) Depressed African Americans have higher risk for CVD than depressed European Americans Depressed European American men have higher risk for CVD than depressed European American women.

Educational Level and Income  Low education level is risky for both men and women in developing CVD (Fried et al., 1998)  This risk is higher for African American men  Low level of education is related to being overweight, having high blood pressure and less access to health care system. All these are risky for CVD.  People with lower incomes have higher rate of heart disease than people with higher incomes.  Survive rate is also higher for people with high incomes  People who lack educational or financial resources are less able to seek medical care and have greater risk for varity of disease including heart disease.

Marriage and Social Support  Being single and lacking social support are risk factors of coronary heart disease  People who are living alone and do not have friends have higher rate of CVD  Social support may reduce risk by encouraging people to maintain healthy life styles and seek medical care. Cynical Hostility ann Anger  Cynical hostility is harmful to cardiovascular health  People who mistrust others, think the worst of humanity, and interact with others with cynical hostility are harming their hearts  Cynical hostility is related to alcohol consumption, smoking and body weight.  Expressing anger is harmful to cardiovascular health rather than experiencing it.

 Anger increases cardiovascular reactivity especially in men.  Supressed anger is also toxic for heart  So it is necessary to recognize anger and express it softly and calmly for cardiovascular health

REDUCING CARDIOVASCULAR RISKS Psychology’s contribution to cardiovascular health is mainly in two ways:  Before diagnosis for preventing first heart attacks  After diagnosis for rehabilitating cardiac patients BEFORE DIAGNOSIS: PREVENTING FIRST HEART ATTACKS Stroke and coronary artery disease is closely related with unhealthy behaviors and living habits Modifying the unhealthy habits, like smoking or unwise eating, may help people to avoid this disease

Changing behavior may be very difficult for people Psychologist modify unhealthy behaviors by using some techniques One factor preventing people to change their unhealthy behavior is optimistic bias  People believe that nothing harmful will happen to them because of the unhealthy behavior Accurate feedback about people’s risk status should be given to decrease the optimistic bias Cigarette smoking is the most serious behavioral risk factor in CVD Although hypertension and serum cholesterol are not behaviors, they can be affected indirectly by the changes in behavior

Reducing Hypertension – Hypertension is difficult to control – Number of physiological mechanism (feedback systems) try to keep blood pressure at a setpoint – Antihypertensive drugs can be used for reducing hypertension – But because hypertension does not cause unpleasant symptoms and drugs have side effects, people do not want to use antihypertension drugs. – Obesity and hypertension is positively correlated When obese people lose weight, they reduce their blood pressure – Physical activity and hypertension is negatively correlated – Restricting sodium intake and alcohol consumption reduce blood pressure – Stress management and relaxation training also may reduce blood pressure

Lowering Serum Cholesterol – Intervention for lowering serum cholesterol include drugs,diatery changes or both – For postmenopausal women, estrogen replacement therapy is also a strategy for cholesterol lowering – Physical activity is another important thing – Not the level of total cholesterol but the ratio of total cholesterol to HDL is important – So reducing serum cholesterol may be complex Modifying Psychological Risk Factors – Reducing cynical hostility by 12 step program – Practicing trust and relaxation – Not eliminating but coping with anger – People may buffer the toxic elements of anger by reliving the event in imagination or by speaking softly and slowly about the event (Siegman&Snow, 1997)

– Humor, relaxation techniques, discussing event in a construcing manner are other anger management techniques AFTER DIAGNOSIS: REHABILITATING CARDIAC PATIENTS Cardiac rehabilitation programs help patients deal with their psychological reactions to diagnosis, return their normal life as soon as possible and change unhealthy behaviors Depression and anxiety have negative effect on CVD patients Cardiac rehabilitation programs often include: Stop smoking Eat healthy diet Control weight Moderate alcohol intake Learn to manage stress and hostility Adhere the medication

Rehabilitation programs significantly reduced – Blood pressure – Cholesterol – Body weight – Smoking rates Increasing Physical Activity: There are three main goals of exercise after a diagnosis of heart problem:  Exercise improves functional capacity  It enhances a person’s quality of life  It helps prevent heart attacks Physical activity after a heart attack has some potencial dangers, but its benefits are more than the potential danger.

Changing Eating Habits: – There are researches testing the possibility of reversing heart damage by changing the lifestyle including diet – Even it may not reverse the damage after diagnosis, healthy diets may be sufficient to prevent the development of coronary artery disease – Healthy changes in eating habits combined with exercise and reduction in psychological factors like anxiety, stress, depression can help patients avoid heart attack.

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