Soft Stuff, Hard Data: AHA Tallies Evidence Linking Psychological Health and CVD

Psychological health can affect CVD risk in both negative and positive ways, raising the potential for clinicians to leverage this when caring for patients, asserts a new scientific statement from the American Heart Association (AHA). He compiles the evidence

“The mind, heart, and body are interconnected, and what affects one affects the other two.” said Glenn N. Levine, MD (Baylor College of Medicine, Dallas, TX). “We need to not only treat a specific disease state but [also] at least try as best we can to consider the patient and the person as a whole.”

Levine, who chaired the document’s writing group, said the AHA statement was inspired by his realization about a year and a half ago that there “were more and more high-quality studies that seem to clearly be linking psychological health, both negative and positive, with cardiac risk and cardiac outcomes.”

This accumulation of knowledge merited a closer look and deserved to be shared with healthcare providers, he told TCTMD. “Fortuitously the timing could not be better, given the current COVID crisis and given that stress, isolation, and depression levels are particularly high after a year of people dealing with this.”

Not Just Negative

Their report, published online earlier this week in Circulation, first tackles the literature that has linked negative psychological health—such as chronic stress, anger/hostility, anxiety, depression, and pessimism—to a wide swath of outcomes: MI, coronary heart disease, stroke, obesity, hypertension, diabetes, CVD mortality, and heart failure, including repeat events.

What the writing group found, said Levine, is striking. For example, one study has suggested that anxiety raises the risk of coronary artery spasm by fivefold, while others have shown depression increases the risk of MI by 30% and stroke by 45%.

“The risk ratios or hazard ratios for certain types of negative psychological health,” he stressed, “are on the order and comparable to the risks that we see with standard risk factors, including high blood pressure, diabetes, and smoking.”

On the flip side, there’s positive psychological health, defined here as the “presence of positive psychological factors such as happiness, optimism, gratitude, sense of purpose, life satisfaction, eudaimonic (virtuous) well-being, and mindfulness.”

Again, the authors lay out the evidence for the individual characteristics. Optimisim, for instance, significantly reduces CVD risk by 35%, hospital readmission post-ACS by 8%, and all-cause mortality by 14%, according to two studies. Mindfullness, “a present, moment-by-moment, nonjudgmental awareness of one’s thoughts, emotions, and actions,” is not merely associated with better CV health, lower body mass index, and lower fasting glucose level, it’s also been linked to better habits like more physical activity and less smoking.

There are limitations to the existing research, they note. These “include the quality of ascertainment tools used to assess the psychological factors, lack of standardized consensus agreement about the best tools to use in such studies, the potential for misclassification bias, and assessments of positive psychological attributes often measured at baseline, with few studies evaluating change in psychological states over time.

“That said,” they continue, “many studies use a variety of methods to address concerns about residual confounding or reverse causation by poorer health status, and the overall body of current data are largely consistent and strongly suggestive that these positive psychological factors should be considered independent factors that play at least some causal role in better cardiovascular health.”

Several underlying mechanisms can explain this connection, ranging from direct biological effects to impact on behaviors that influence health and access to resources for protecting health or buffering against stress.

What Clinicians Can Do

To put this knowledge into practice, “clinical cardiology visits can provide an excellent opportunity to assess psychological factors that may affect cardiac health maintenance,” Levine et al say.

Front-line staff pressed for time can employ brief screening tools or ask questions to test the waters:  “How do you think things will go with your health moving forward? . . . How often do you experience pleasure or happiness in your life? . . . Do you ever feel grateful about your health? Do you ever feel grateful about other things in your life?”

The authors acknowlege that “many clinical cardiologists may feel ill-equipped to have substantial discussions about mental health.”

To this end, they also offer suggestions for what to say when a patient shows signs of negative psychological health, such as depression: “It seems like feeling down or even a little hopeless might be affecting the way you are taking care of yourself. Let’s think about how we can tackle this problem together.”

And ways to encourage positivity, such as optimism: “I have taken care of many patients with this kind of heart problem before, and many of them have done very well. I think you can, too.”

Resources are also available for patients who need help, the document notes. Among them are more-traditional options such as antidepressants and psychotherapy, as well as a team-based approach involving a nonphysician care manager to keep track of symptoms and treatment as well as physician input on medication. It’s also possible, the document notes, to promote positive psychological health through interventions like stress management programs and meditation training.

Levine pointed out that, beyond the paper itself, there is a 50-page supplement that details the studies that have been conducted. “My sense is that cardiologists like hard data, and in this scientific statement I believe we present a good amount of hard data that clearly show associations . . . and, at least to some extent, suggest that interventions have the potential to decrease cardiac risk and improve cardiac outcomes,” he said, adding that he hopes this work inspires researchers to pursue further studies in this area.