In certain circumstances, intense and sudden emotional changes can have adverse effects on the cardiovascular system. Mortality from cardiovascular causes increases significantly during the first month after the loss of a loved one, and the occurrence of coronary and cardiac events rises notably immediately after natural disasters (floods, earthquakes, fires) or military operations. There are several circumstances that for most people, lead to the increase of their performance anxiety, and consequently, their heart rate, their systolic blood pressure and the demand for more myocardial oxygen. Usually these situations are associated with performing a task under the pressure of many people such as public speaking.
Particularly in patients suffering from coronary heart disease it has been found that 30%-60% of acute myocardial ischemia episodes may be triggered by sudden emotional changes or intense stressful thoughts (mental stress). Interestingly myocardial ischemia associated with stressful stimuli is usually asymptomatic and it has been detected with even a lower heart rate in relation to ischemia caused during physical exercise, which is more commonly manifested by symptomatic and angina pain. Long exposure to traffic in urban centers has been linked to increased risk of acute myocardial infarction for the drivers, although it has not been cleared up completely whether this finding is due to the intense stress of drivers and/or the increased air pollution on roads with heavy traffic.
The stressful stimulus can cause acute myocardial ischemia,through many mechanisms, particularly in patients who already suffer from coronary artery disease. The first mechanism is the sudden increase in myocardial oxygen demand as a result of increase blood pressure and heart rate per minute. The second mechanism is the spasm of the coronary arteries especially in vessels with existing atherosclerotic plaques. The third mechanism is that anxiety activates the sympathetic nervous system and through that, there is a rise on the cortisol hormone and norepinephrine levels, and this in return causes an increase in platelet adhesiveness thereby, predisposing the formation of thrombi in coronary arteries. It has been found that conditions which increase stress such as driving, public speaking, job interviews can cause arrhythmia more frequently in both healthy persons and cardiac patients. It seems that emotional tension and stressful stimuli may be associated with life-threatening arrhythmias and even sudden death, especially in patients suffering from coronary artery disease. Detailed psychiatric examination in patients urgently admitted to hospital dew to severe arrhythmia (ventricular tachycardia or ventricular fibrillation) has indicated that 20%-25% of these patients has a strong emotional stimulus in the previous 24 hours. Furthermore, recent research on the correlation of psychosocial conditions with the occurrence of cardiovascular events concludes that rage and aggressiveness (anger & hostility theory) as individual characteristics of a personality increases significantly the possibility of coronary heart disease. There are studies that show that anger and hostile behavior are associated with strenuous activity of the sympathetic nervous system, decreased activity of the parasympathetic nervous system, and increase platelet adhesiveness. It has been shown that the possibility of acute myocardial infarction rises three to nine times after an anger episode accompanied by highly aggressive behavior.
DEPRESSION & CORONARY DISEASE
Depression occurs very often in patients suffering from coronary artery disease but because the cardiologist and the family doctor do not routinely investigate psychosocial factors, a psychiatric examination of the patient is rarely requested. Symptoms of depression are observed in 40%-65% of patients after acute myocardial infarction and 15%-25% of them suffers from severe depression following the infarction. The rate of depression certainly increases in all coronary patients even the ones with no record of heart attack. Although most patients are men, the incidence of depression in women with coronary heart disease is more than double than that of men. There are many mechanisms that can play a role in the increased correlation between depression and coronary heart disease. Depression can play a role in the development and prognosis of coronary heart disease by affecting the lifestyle and habits of patients. Depressed people care less about themselves, exercise less, smoke more, usually follow a diet in fat and calories, rarely visit the doctor, and do not follow medical advice. Pathophysiological mechanisms connecting the appearance of atherosclerotic disease and depression may be the chronic rise of cortisol’s and catecholamine’s levels, the increased concentration of cholesterol, lipids and free fatty, and the impaired endothelial function which is observed in depressed individuals.
Depression worsens prognosis and increases mortality in patients already suffering from coronary heart disease but also multiplies the possibility of developing coronary heart disease in the future in healthy individuals. It seems that the diagnosis of depression in healthy people without cardiovascular record is associated with 1.5-2 times higher risk of developing coronary heart disease, acute myocardial infarction and sudden death in the next 6-40 years in comparison to non-depressed people; and this finding is independent of the other classical risk factors. Particularly after a myocardial infarction has occurred, it has been proved by relevant studies that diagnosed depression raises significantly the mortality and the possibility of sudden death within the first 6 to 18 months after that acute myocardial infarction; this finding is also independent of the functionality level of the left ventricular myocardium, the patient’s record of heart attacks, and the presence of arrhythmias. Even 5 to 15 years after an infarction, the probability of re-infarction is 1.5 to 6 times larger in depressed patients than in non-depressed ones, and this relationship is independent of other factors such as age, smoking, and cholesterol. It also appears that early diagnosis and treatment of depression –especially through the cardiac rehabilitation programs – improves the quality of life and also, the prognosis in these patients. Today, there are many researchers who claim that antidepressant treatment (not only in the strictly medical sense) will be in the future a cornerstone in the treatment of coronary artery disease.
For any question regarding the treatment of psychosocial factors in cardiac patients, you may contact the Cardiologist and Deputy Head of Noninvasive Diagnostic Techniques, Dr. Athanasios Dritsas (tel. 210 94 93 000) and/or OCSC’s psychologist, Ms. Olga Misirliadou, OCSC Social Care and Psychological Support Office (tel. 210 94 93 000) or the Hellenic Society of Cardiology Working Group of Cardiac Rehabilitation and Preventive Cardiology of the, tel. 210 72 21 633 or www.hcs.gr website (site of Hellenic Society of Cardiology).