Minding the heart

When psychologist Robert Allan, PhD, and cardiologist Stephen Scheidt, MD, published the first edition of "Heart and Mind: The Practice of Cardiac Psychology" (APA) in 1996, convincing physicians of the emerging field's value was a hard sell.

That viewpoint has changed since then — in a big way. "I don't think cardiac psychology is controversial at this point," says Allan, a clinical assistant professor of psychology in medicine at Weill Cornell Medical College and professional associate at New York Presbyterian Hospital in New York City.

The American Heart Association, for instance, has issued statements recommending depression screening and treatment for coronary heart disease patients and educational and psychological interventions to reduce anxiety and other problems in patients with implantable cardioverter defibrillators (ICDs). Medicare has begun penalizing hospitals with too many readmissions for heart failure and heart attacks within 30 days of discharge, a development that has prompted some hospitals to hire cardiac psychologists (see this article on cardiac psychologist Kristina J. McGuire, PsyD). "And the empirical database has expanded enormously," says Allan.

While early cardiac psychology research focused on determining psychological risk factors for cardiovascular disease, these days psychologists are moving beyond that kind of epidemiological study. They're beginning to find evidence that psychological interventions may prevent cardiac events and even lengthen lives. They're also exploring new areas, including how psychological risk factors actually affect the heart, how environmental factors such as emergency room crowding affect patients' outcomes and how positive emotions such as optimism and happiness may protect the cardiovascular system.

A life saver?

"The research linking certain psychological traits and heart problems has burgeoned over the last decade," says Allan. A PubMed search on stress and cardiovascular disease, for example, turns up more than 60,000 citations, with more than 35,000 of them related to psychosocial factors, he points out.

Over the last 15 years or so, says Allan, researchers have largely abandoned work on the Type A behavior pattern that dominated the early days of cardiac psychology. Instead, they are now focusing on the role that two key elements of Type A behavior — anger and hostility — play in the development of coronary heart disease. Researchers have already amassed convincing evidence of depression's role, says Allan.

By contrast, there have been very few randomized clinical trials assessing whether treating such psychosocial factors as depression and hostility can save lives.

And some of those few studies have been disappointing. The groundbreaking Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multi-center, National Heart, Lung and Blood Institute-funded trial published in the Journal of the American Medical Association in 2003, for example, found that a six-month intervention focused on treating patients' depression and low social support made patients feel better but had no impact when it came to preventing repeat heart attacks or death.

A 2011 meta-analysis by the Cochrane Collaboration reported that while a small subset of studies found psychological interventions to have a modest positive effect on mortality, there was no strong evidence that such interventions reduced the need for surgical revascularization procedures or the risks of non-fatal heart attacks and total deaths.

For Allan, those findings simply suggest that not enough of the right kind of interventions have been studied yet.

For one thing, he says, it's difficult to study psychological interventions the same way you would pills or other physical interventions. Plus, the psychological interventions that have been studied have been too brief to counter what Allan calls "massive doses of traditional risk factors" — the decades of unhealthy lifestyle choices, depression, anger and other risk factors that most heart patients have amassed before they land in a cardiologist's office or even in the emergency room.

But there have been signs of hope, such as the Stockholm Women's Intervention Trial for Coronary Heart Disease. That 2009 study found an almost three-fold protective effect for an intensive psychological intervention that included 20 sessions over a year.

A 2011 study in Archives of Internal Medicine further supported therapy's heart-helping benefits. In the Secondary Prevention in Uppsala Primary Health Care study, researchers randomized patients discharged after a coronary heart disease event to either traditional care or traditional care plus a cognitive-behavioral therapy intervention focused on individualized stress management. The intervention brought together small groups and leaders for 20 two-hour sessions plus homework. At follow-up, the intervention group had 45 percent fewer recurrent heart attacks and a 41 percent lower rate of both non-fatal and fatal first recurrent cardiovascular events than the group receiving traditional care.

The more sessions participants attended, the stronger their responses, says psychologist Gunilla Burell, PhD, of the department of public health and caring sciences at Uppsala University in Sweden. Previous interventions may not have lasted long enough to produce an effect, says Burell, who was involved in both the Stockholm and Uppsala studies.

"This intervention is sort of an inoculation," she says. "It's not the case that the effect stops when the treatment is over. On the contrary, the effect is more marked as the years go on."

Investigating pathophysiology's pathways

Psychologists aren't only working to reduce mortality — they're taking a deeper look at just how negative psychological states affect the cardiovascular system.

Matthew M. Burg, PhD, one of the ENRICHD principal investigators, is now examining how psychological factors affect endothelin-1, a vasoconstrictor that contributes to coronary plaque rupture and thus heart attacks and other cardiac problems.

In a study published in 2011 in Psychosomatic Medicine, Burg and colleagues found that more depressed participants had higher levels of endothelin-1. In another 2011 study in Molecular Medicine, the researchers found that the stress of recalling anger also increased endothelin-1 levels.

"Our ability to look at these markers has improved," says Burg, an associate professor of medicine at the Center for Behavioral Cardiovascular Health at Columbia University and associate clinical professor of medicine at Yale School of Medicine. "Partly it's our understanding of physiology and partly it's about improvements in technology that make the measurement of these types of markers routinely available."

The ultimate goal? To design clinical trials that target these kinds of pathophysiological mechanisms and possibly improve outcomes, says Burg.

Preventing post-traumatic stress disorder

While researchers have long focused on the role of anger, depression and other psychological factors in worsening outcomes after heart attacks, some researchers are now examining how the trauma of the heart attack itself can affect cardiovascular health.

In a meta-analysis published last year in PLOS ONE, psychologist Donald Edmondson, PhD, MPH, and colleagues found that one in eight people develop significant PTSD symptoms after a heart attack. What's worse, PTSD seems to double the risk of having another heart attack or dying.

"That's a lot of people — one in eight of the 1.5 million people who will have a heart attack in the U.S. this year," says Edmondson, an assistant professor of behavioral medicine at Columbia University's Center for Behavioral Cardiovascular Health.

Not everyone is at equal risk of developing PTSD after a heart attack, however. While there may be patient-level differences, says Edmondson, environmental factors play a major role. In a small study published this year in JAMA Internal Medicine, Edmondson and colleagues found that the more crowded and chaotic an emergency room is, the more likely heart attack patients are to develop PTSD. In fact, says Edmondson, people who were treated in crowded ERs had three times as many PTSD symptoms as those treated in quieter, calmer settings.

That discovery should make intervening easier, he says. "Unlike combat survivors or sexual assault survivors, we know where this traumatic event is going to occur," says Edmondson. "They're going to be coming through our hospitals."

At the institutional level, Edmondson suggests that hospitals do everything they can to ease ER crowding, whether that means altering surgeon schedules or operating on what's called "full-capacity protocols" in which ER patients get sent "upstairs" whether beds are available or not instead of piling up in the ER.

At the clinical level, Edmondson recommends that psychologists and other health-care professionals find ways to lessen patients' stress as they wait for care. "What if we could give them something as simple as a stress reduction program on an iPod?" he asks.

Reducing distress in ICD patients

Other psychologists are already working to make heart patients more comfortable. One emerging area is reducing anxiety and other problems among patients with an ICD, a device implanted in the body that shocks the heart during life-threatening cases of ventricular arrhythmia.

About 245,000 patients now receive ICDs in the United States each year, and that number will soar as the baby boomers age, says Samuel F. Sears Jr., PhD, a professor of psychology and cardiovascular sciences at East Carolina University.

But while the devices can save lives, they may also trigger psychological problems, such as anxiety about having a potentially fatal condition, experiencing the device's high-energy burst of shock or undergoing a product recall. "One move in the right direction in medicine often requires two moves in the right direction for psychologists," says Sears, who offered tips for patients coping with ICD-related stress in a 2013 Circulation article. He also invented ICD Coach, a mobile phone application that gives patients strategies for improving their quality of life.

The American Heart Association has caught on, too: Last year, it issued a scientific statement in Circulation calling for educational and psychological interventions to improve outcomes for both ICD patients and their families. "It's a big deal when medical societies decide that psychological issues are so significant they must address them," says Sears, one of the statement's co-authors.

Focusing on the positive

While most cardiac psychology research focuses on risk factors, an emerging line of research focuses on protective factors. "It's helpful to consider what people are doing right and how that might contribute to cardiovascular health," says psychologist Julia K. Boehm, PhD, a postdoctoral research fellow in the department of social and behavioral sciences at the Harvard School of Public Health.

In a paper in Psychological Bulletin last year, Boehm and Laura Kubzansky, PhD, an associate professor of social and behavioral sciences at the Harvard School of Public Health, analyzed more than 200 studies. They found that psychological well-being — especially optimism — seems to protect both healthy people from cardiovascular disease and heart disease patients from further problems. In most cases, the findings held true even after controlling for traditional risk factors, such as obesity, smoking and high cholesterol. The findings also seem to be independent of psychological risk factors, such as depression, anxiety and hostility.

"There's really something to be gained by not just avoiding depression but having meaning and hope in life," says Boehm, who is now exploring how positive emotions affect biological markers, such as lipids and serum antioxidant levels.

Others, such as Matthew Burg, aren't convinced. "This is an observational finding," he says, explaining that only a clinical trial to test an intervention can determine whether finding meaning in life or making similar changes will reduce risk. "The medical literature is rife with failed clinical trials that ‘should have' worked, given the observational findings," he says, citing hormone replacement therapy as one "no brainer" that turned out to actually increase rather than decrease risk. Plus, he says, "this type of thinking can lead to a blaming of the victim."

Boehm agrees about the need for further research.

"Further down the road, it might be interesting if we could establish that enhancing a person's well-being translates into benefits in terms of cardiovascular health," she says. "There's really no evidence of that to date, but that might be one of the implications of where the research might take us."

Rebecca A. Clay is a writer in Washington, D.C.