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
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
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
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
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