1. Stress and Health

2. Psychological Factors Affecting a Medical Condition A general medical condition Psychological factors adversely affect the general medical condition in one of the following ways: –associated with exacerbation/improvement –interfere with treatment of the medical condition –constitute additional health risk –stress-related physiological responses precipitate or exacerbate symptoms of the medical condition

3. What is CVD? Cardiovascular disease (CVD) consists of a number of disorders affecting the heart and circulatory system. *Coronary Heart Disease (CHD) *Angina *Myocardial infarction (MI) *Congestive Heart Failure *Hypertension (HTN) *Cerebrovascular disease

4. Coronary Heart Disease CHD is the leading cause of death in the U.S. One person in the U.S. dies from CHD every 33 seconds Nearly 58 million people in the U.S., or approximately ¼ of the population, live with some form of CHD The NHLBI (1993) suggests that: “although great advances have been made in treating CHD [coronary heart disease], changing one’s habits remains the single most effective way to stop the disease from progressing.”

5. Imaging the Coronary Anatomy: RCA Stenosis

6. Established Risk Factors for CVD Behavioral factors: –HTN –Dietary factors –Obesity –Non-insulin-dependent diabetes –Insulin resistance –Smoking –Alcohol use –Physical activity Psychosocial factors: –Adherence –Stress –Negative affect –Social isolation/support –Occupational load –Type A Behavior Genetic Vulnerabilities

7. CVD Modifiable Behavioral Risk Factors Dietary Factors Hypertension Obesity Diabetes Smoking Alcohol use Physical activity

8. Obesity

9. How is Obesity defined clinically? Body Mass Index (BMI) is W/H 2 Lowest morbidity and mortality occurs in persons with BMI’s in the 20 - 22 range Mortality increases with BMI of 27 (lower for women) Individuals with a BMI of 30+ are at much greater risk for mortality BMI  30 = Obesity

10. Obesity Trends* Among U.S. Adults BRFSS, 1985 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

11. Obesity Trends* Among U.S. Adults BRFSS, 1986 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

12. Obesity Trends* Among U.S. Adults BRFSS, 1987 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

13. Obesity Trends* Among U.S. Adults BRFSS, 1988 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

14. Obesity Trends* Among U.S. Adults BRFSS, 1989 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

15. Obesity Trends* Among U.S. Adults BRFSS, 1990 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

16. Obesity Trends* Among U.S. Adults BRFSS, 1991 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

17. Obesity Trends* Among U.S. Adults BRFSS, 1992 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

18. Obesity Trends* Among U.S. Adults BRFSS, 1993 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

19. Obesity Trends* Among U.S. Adults BRFSS, 1994 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

20. Obesity Trends* Among U.S. Adults BRFSS, 1995 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

21. Obesity Trends* Among U.S. Adults BRFSS, 1996 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

22. Obesity Trends* Among U.S. Adults BRFSS, 1997 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

23. Obesity Trends* Among U.S. Adults BRFSS, 1998 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

24. Obesity Trends* Among U.S. Adults BRFSS, 1999 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

25. Obesity Trends* Among U.S. Adults BRFSS, 2000 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

26. Obesity Trends* Among U.S. Adults BRFSS, 2001 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

27. Obesity B “ B ased on prevalence studies from 1960 to 1991, we calculate that by the year 2230, 100% of the adults in the USA will be overweight, as defined by a Body Mass Index (BMI) of more than 27.8 for men and 27.3 for women.” Foreyt and Goodrick The Lancet 1995

28. Cigarette Smoking

29. Health Consequences of Smoking Tobacco is the leading cause of preventable deaths in the US, causing more than 440,000 deaths each year. More than 60,000 studies link smoking to CVD, cancer, and lung disease Direct medical costs in the US attributable to smoking is more than $50 billion Each year, smoking kills more than AIDS, alcohol, drug abuse, car crashes, murders, suicides, and fires – combined. More than 5 million children living today will die prematurely because of their decisions to smoke Source: Centers for Disease Control and Prevention

30. Nicotine Dependence is a Tenacious Addiction 70% of smokers want to stop 1 35% quit for at least 1 day each year 2 Most relapse within days Less than 10% achieve abstinence each year 3 Most quitters require multiple attempts before succeeding 4 1. MMWR Morb Mortal Wkly Rpt 1994;43(50):925-930. 2. Hatz, Andrew et.al. J Cancer Inst 1990;821(17):1403-1406. 3. Fiore et.al. JAMA 1990;263(20):2760-2765. 4. Amsten. Prim Psychiatry 1996; 3:27-30.

31. Deaths Attributable to Smoking

32. How Smoking Kills

33. Psychological Factors Contributing to CHD Type A Behavior Pattern Anger and hostility Psychosocial stress Job strain Vital exhaustion Social isolation/Social support Depression Anxiety Cardiac denial

34. Type A Behavior Friedman & Rosenman - an intense and competitive drive for achievement and advancement, an exaggerated sense of the urgency of passing time and the need to hurry, considerable hostility toward others. Of the Type A Characteristics - Hostility has emerged as the major predictor of CHD. Another important factor appears to be cynicism

35. Social Support and Stress Structured Social Support –Well-established predictor of mortality –Low levels increase chances of death after MI Functional Social Support –High levels related to lower rates of atherosclerosis –High levels related to good adjustment to rheumatoid arthritis in women

36. Effects of Social Support on BP Stress SBP Change (mmHg) DBP Change (mmHg)

37. Depression and CHD Several lines of evidence suggest that clinical depression may be a risk factor for coronary artery disease (CAD). Ford et al. Arc Intern Med; 1998; 158: 1422- 1426.

38. Post-operative Depression Depression following CABG surgery is common, however it is often not looked for. –Depression may be more severe in patients who have also suffered a recent loss and those with preoperative psychological disorders. Depression scores increase significantly after surgery (despite increases in functional status and quality of life), and onset of depression is prevalent. Social Isolation and Depression related to poor long-term prognosis and high mortality rates post CABG.