1. Stress and heart disease: a few basics a model and evidence on triggering heart attacks

2. Kop provides a readable account of psychological risk factors for CAD. His model provides a useful way of organising the material on stress and CVD & the material on “vital exhaustion” will be covered later in the lecture on depression. Kop, WJ (1999) Chronic and acute psychological risk factors for clinical manifestations of coronary artery disease. Psychosomatic Medicine, 61, 476-487. Black and Garbutt are not for the feint hearted. They offer a very complex physiological model of stress, inflammation and CVD. Incorporates a lot of important new information but only for those with background in biology. I shall use model illustratively Black, PH., & Garbutt, LD (2002). Stress, inflammation and cardiovascular disease. J. of Psychosomatic Res., 52, 1-23

3. Rozanski paper is very up to date account of stress and heart disease written for cardiologists. I strongly recommend it. Rozanski, A., Blumenthal, JA., Davidson, KW, Saab, PC., Kubzansky, L (2005). The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice. J. American College of Cardiology., 45, 637-651.

4. Process of build up of atherosclerotic plaque, plaque rupture and thrombus formation.

5. What causes a Myocardial Infarction: Plaque rupture and blocked coronary artery No MI, plaque remains Unstable situation Artery blocked, MI results

7. Psychological stress and platelet activation: Differences in platelet reactivity in healthy men during active and passive stressors. Patterson, S. M.; Zakowski, SG.; Hall, Martica H.; Health Psychology, Vol 13, 1994. pp. 34-38.

10. Effects of stress on platelets, and hence clotting & process of atherogenesis. See particularly PF (Platelet Factor) 4

11. The diathesis model: stress plus vulnerability

12. The Triggering of Acute Coronary syndromes: Findings and possible mechanisms

13. The main reference is Strike & Steptoe (2005) Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique. Psychosomatic Medicine, 67, 179-186. This reviews all the studies of triggering. It mentions mechanism in passing but does not cover it in detail. There is not a lot of empirical information on mechanism but many of the acute effects of stress (see earlier lectures & Kop) are likely to be involved.

14. Strike and Steptoe’s review finds evidence for following triggers: Physical exertion Sexual activity Earthquakes Sporting events War Emotional Distress and Anger

15. Population-Based Analysis of the Effect of the Northridge Earthquake on Cardiac Death in Los Angeles County, California Robert A. Kloner MD, et al J American College of Cardiology, 1997, 30, 1174-1180

17. Effects of an earthquake on BP and HR. Parati et al, (2001), Cardiovascular effects of an earthquake: Direct evidence by ambulatory blood pressure monitoring. Hypertension, 38, 1093-1095.

18. Matsuo T et al (1998) Hemostatic activation and cardiac events after the 1995 Hanshin-Awaji earthquake. Iny. J. Hematology, 67, 123-9

19. Mittleman MA et al (1995) Triggering of acute myocardial infarction onset by episodes of anger. Circulation, 92, 1720-1725 1623 patients interviewed average of 4 days (range 0-30) after MI 7 point anger scale (1 calm; 5 Very angry, body tense clenched fists or teeth ; 7 Enraged!. Lost control, throwing objects Case-cross design. 2 hours prior to onset of MI compared with 1)Usual frequency of anger in last year 2) in a 2 hour period 24 hours previously Using anger of 5 or more 36 patients angry in 2 hours after MI compared to 9 in control period. Relative risk of 4 (CI 1.9- 9.4) (NB low frequency of anger means absolute risk low)

20. Period after MI compared to average anger over preceding year. Effect of exertion only seen for first hour

21. Strike & Steptoe identify methodological issues in studies of triggers Retrospective reporting bias Memory decay Premonitory or prodromal symptoms Clinical presentation bias

22. Possible mechanisms involved in triggering Acute Coronary Syndromes