Disclosures: Levine reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
January 25, 2021
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AHA: Cardiac clinicians should consider mental health in CVD management

Disclosures: Levine reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Positive and negative psychological factors could significantly affect outcomes in cardiac health, according to a scientific statement from the American Heart Association published in Circulation.

Cardiac clinicians may be able to apply screening techniques to identify patients with poor mental wellness, and with the assistance of team-based care, improve prevention and targeted treatment strategies, according to the authors.

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Glenn N. Levine

“A person’s mind, heart and body are all interconnected and interdependent in what can be termed ‘the mind-heart-body connection,’” Glenn N. Levine, MD, FAHA, master clinician and professor of medicine at Baylor College of Medicine, chief of the cardiology section at the Michael E. DeBakey VA Medical Center and chair of the writing committee for the scientific statement, said in a press release. “Research has clearly demonstrated that negative psychological factors, personality traits and mental health disorders can negatively impact cardiovascular health. On the other hand, studies have found positive psychological attributes are associated with lower risk of cardiovascular disease and mortality.”

For this scientific statement, researchers included clinical studies and meta-analyses that evaluated the associations between CV health and psychological variables such as depression, anxiety, stress, trauma, anger, hostility, pessimism, optimism, gratitude, happiness, resilience, mindfulness, life satisfaction and hope.

“In cardiovascular medicine, there has been an understandable focus on the treatment of specific cardiac disorders with pharmacological and device-based therapies,” the committee wrote. “However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to CVD, but also in a positive way to better cardiovascular health and reduced cardiovascular risk.”

Negative psychological health and CVD

According to the scientific statement, various studies and meta-analyses have correlated specific negative psychological factors with risk for CVD:

  • depression was associated with MI, CHD, stroke, obesity, hypertension and diabetes;
  • anxiety was associated with CVD mortality, coronary artery spasm, stroke and HF;
  • work-related stress was associated with CVD events;
  • any stress was associated with CHD and CHD mortality;
  • PTSD was associated with CHD;
  • social isolation and loneliness were associated with CVD events;
  • pessimism was associated with CHD mortality; and
  • chronic anger and hostility were associated with recurrent and incident CHD.

“Given the nature of this work, most human studies in this area are observational, with many involving large administrative databases or self-reporting of exposures. The potential thus exists for bias from misclassification and confounding, presenting challenges to establishing causal associations,” the committee wrote. “However, many studies have used methodology including carefully adjudicated events and objective measures of CVD and adjustment for a broad range of potential confounders, and overall, there appear to be good data to support associations between negative psychological health and cardiovascular risk.”

Positive psychological health and CVD

According to the scientific statement, many positive psychological factors have been associated with lower CVD risk, including:

  • optimism and incident CVD, readmission for ACS and all-cause mortality;
  • sense of purpose and CVD risk and all-cause mortality;
  • happiness and incident CHD;
  • mindfulness and better CV health, nonsmoking, lower BMI and fasting glucose and increased physical activity;
  • higher emotional vitality and incident CHD; and
  • psychological well-being and CV mortality.

“There is no single universal definition of positive psychological health. For the purposes of this scientific statement, positive psychological health includes the presence of positive psychological factors such as happiness, optimism, gratitude, sense of purpose, life satisfaction, eudaimonic (virtuous) well-being and mindfulness,” the committee wrote. “Although prior work has noted some conceptual similarities across various facets of positive psychological well-being, a substantial body of work also suggests that each facet is distinctive in important ways and, as a result, may have different effects on health-related outcomes.”

Assessment of psychologic factors in clinic

According to the scientific statement, clinical cardiology visits may represent a good opportunity to evaluate a patient’s psychological health, and contemporary reviews exist that outline approaches to screening during these encounters (Kubzansky LD, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.07.042; Rozanski A. J Am Coll Cardiol. 2014;doi:10.1016/j.jacc.2014.03.047).

“As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person,” the committee wrote. “The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease.”

The committee added that cardiac clinicians can also prescribe exercise, meditation and other self-care actions in addition to providing appropriate referral to mental health providers.

Among patients with substantial distress, team-based care that includes psychiatrists, psychologists and other clinicians with experience in behavioral cardiology may utilize patient information gathered during clinical cardiology visits. This information may help members of the care team to help the patient reduce stress, address psychiatric conditions and promote aspects of psychological well-being associated with improved CV outcomes.

“Wellness is more than simply the absence of disease,” Levine said in the release. “It is an active process directed toward a healthier, happier and more fulfilling life, and we must strive to reduce negative aspects of psychological health and promote an overall positive and healthy state of being. In patients with or at risk for heart disease, health care professionals need to address the mental wellness of the patient in tandem with the physical conditions affecting the body, such as blood pressure, cholesterol levels, chest pain, etc.”