Mind-Body-Heart Connection: Anger and Stress Linked to Cardiovascular Events

 

With your massive stress from your incompetent doctor not having 100% recovery protocols, and the fact your doctor doesn't know about this, you are on your own to prevent cardiovascular events! Good luck.

Mind-Body-Heart Connection: Anger and Stress Linked to Cardiovascular Events

Preventive strategies for cardiovascular disease (CVD) have often involved looking into risk factors such as stress, anxiety, hostility, and anger. Stress-related disorders are known to increase risk for atherosclerosis,stroke, and myocardial infarction (MI).¹nbsp;An acute experience of anger, as well, has been associated with greater likelihood of CVD onset, though the pathways that underlie the development and progression of CV events are not yet fully known. In addition, lifestyle behaviors, psychosocial variables, personality types, and mental health illnesses may affect the etiology of CVD. However, there is limited information in clinical guidelines for the evaluation and management of this subset of patients.¹ We received perspectives from experts in the field regarding the association between anger, stress, and CV events, the potential risk factors and stressors involved, and how providers can address it with their patients. Viola Vaccarino, MD, PhD, is the Wilton Looney Distinguished Professor of Cardiovascular Research in the department of epidemiology at the Rollins School of Public Health, Atlanta, Georgia, and professor in the department of medicine at Emory University School of Medicine, Atlanta, GA. Elizabeth Vella, PhD, is the chair and professor of psychology at the University of Southern Maine.

Research Reveals a Link Between Anger, Stress, and CV Events

“There is a longstanding history of medical science research investigating intersections between anger/stress and CV events,” Dr Vella noted, which goes as far back as 1975 when Rosenman et al coined the term “type A behavior pattern” as a toxic component of trait hostility that predicts CV mortality and morbidity.Recent evidence also revealed the role of a “brain-heart axis” in prognosing CVD and the need for understanding the psychologic impact on CVD, especially among certain population subsets, such as younger women, patients with early-onset MI, and those from racial and ethnic minority groups (owing to disparities in the field).⁴  Following this research, Dr Vaccarino discussed the impact of acute stressors — environmental disasters or acute emotional states, such as anger, fear, and bereavement — on CV events. She noted the importance of physiologic responses to stress in predicting risk for CVD. “Adverse physiologic responses to acute stress (vascular, ischemic, autonomic, and inflammatory perturbations) can be reproduced in the lab, using a mental stress test/anger recall test, and are associated with adverse CV events in patients with CVD.” To understand the pathways involved, researchers have highlighted the effect of anger on the elevated activity of the sympathetic nervous system, such as blood pressure, heart rate, and reductions in cardiac vagal tone. The association between trait anger/hostility and daily cortisol production is significant in understanding the inflammatory states through elevated proinflammatory cytokines.⁶ In addition, findings of a recently published research paper by Shimbo and colleagues showed that a brief provocation of anger negatively affected endothelial cell health by way of impairing endothelium-dependent vasodilation.² There is a longstanding history of medical science research investigating intersections between anger/stress and CV events. Elizabeth Vella, PhD

Influence of Risk Factors and Stressors in CVD Demographic and socioeconomic factors may predict CVD, with these factors interacting with psychosocial factors, such as anger disposition. Dr Vella added that a combination of these factors result in unique patient-specific disease trajectories, including direct effects (eg, stress-induced inflammation that hastens atherosclerotic progression) and indirect effects (eg, stress-induced changes in lifestyle behavior that lead to unhealthy patterns of disrupted sleep, poor diet, excessive alcohol consumption, and smoking).⁷ Previous studies have indicated clinically significant sex differences in the prevalence, presentation, management, and outcomes of CVD, as well as socioeconomic status being an “unrecognized” risk factor in the primary prevention of CVD.^8,9 Dr Vaccarino noted an increased burden of psychosocial stressors, especially in midlife, as well as higher rates of depression and anxiety, in women compared with men. However, “Existing evidence suggests that anger is more strongly associated with CVD in men than in women,” though there are only a few studies that have evaluated sex differences. Referencing a study published in 2022, Dr Vella indicated, “Although the female sex appears to confer benefit as a buffer from CVD, these advantages may disappear in thecontext of underlying traditional risk factors, such as type 2 diabetes, hypertension, central adiposity, and dyslipidemia.” Racial and ethnic minority groups, especially Black American and Hispanic individuals, have a higher burden of psychosocial stressors, such as more adverse life events and discrimination, lower economic resources and access to care, and more chronic stressors.¹⁰Both Dr Vaccarino and Dr Vella pointed to socioeconomic factors such as low education levels, lack of financial resources, lack of insurance, and living in poor neighborhoods that are barriers to accessing mental and psychologic care, and thereby, increasing levels of stress among individuals.Exacerbation of already elevated stress levels increases reliance on maladaptive coping responses.^8,9,10

Anger Management in Patients: Strategies for Providers

The American Heart Association (AHA) released a statement in 2021 to highlight the association between psychologic health and CV health and disease and to determine steps for clinicians to better screen for and manage this population. The authors noted that CVD should not be treated as a disease but as a system in which the mind, heart, and body are interconnected. They added that the wellness and well-being of patients should not only involve physical factors but also psychologic factors.¹² “Because stress and mental health issues are common in the general population and especially in patients with CVD, it is important to consider mental health aspects during routine cardiovascular care,” Dr Vaccarino added. Regular aerobic and resistance exercise have shown to result in better adaptiveness to stress and potentially reduce rates of stress and depression. However, researchers of the HL-PIVOT Network have recommended formal cardiac rehabilitation programs for the reduction of stress-related mortality.^>1 “Stress-management training is beneficial to both mental health and CV health. Many cardiologists and primary care providers may feel unprepared to engage in in-depth discussions about stress and mental health with their patients. However, brief targeted conversations can be very useful and are often highly appreciated by patients,” Dr Vaccarino noted. Dr Vella also discussed the efficacy of interventions to lower stress levels among those with anger, such as web-based cognitive behavioral therapy (CBT), which has resulted in significant reductions in anger and hostility, along with states of calm, in patients with coronary artery disease.¹¹ “Physicians may consider referring patients to CBT-based interventions and therapy aimed at enhancing stress management skills and physical activity.” To identify patients who need a referral for anger/stress management or mental health care, the AHA has suggested the use of brief composite screening tools, such as patient questionnaires provided at in-office visits. In addition, cardiology providers and mental health professionals must work together to develop a treatment plan.¹²

In Summary

Overall, because of increasing evidence to support the relationship between negative emotions, such as anger and stress, and CV events, clinicians must consider psychologic health in the evaluation and management of patients with or at risk for CVD, using a multipronged and multidisciplinary approach. This article originally appeared on The Cardiology Advisor