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PNI and Heart DiseaseThe number one cause of death in the USA (and in most of Western society), and on its way to becoming number one in the developing countries worldwide, is atherothrombotic, coronary artery disease (CAD), also known as coronary heart disease (CHD), or ischemic heart disease (IHD) () Risk factors that have been identified include diet, age, sex, family history, smoking, hypertension, dyslipidemias, diabetes, HIV, stress, and lifestyles (). Current research provides compelling evidence that in addition to the traditional biological risk factors, psychosocial elements can act independently in the pathogenesis and expression of coronary artery disease (, ). Experts who have reviewed the extensive literature up to 2001 contend that there is convincing evidence for a psychological and social impact on CAD morbidity and mortality (). They analyzed clinical studies on the psychological and psychosocial factors on the development and outcome of coronary heart disease, especially studies employing verifiable outcomes of CAD morbidity or mortality. The researchers identified five key variables as possible psychosocial risk factors: acute and chronic stress, hostility, depression, social support, and socioeconomic status. Loss of control over one’s environment is perhaps a common link (). Indeed, evidence indicates that psychosocial stresses tend to occur as a group (e.g. depression, chronic life-style stress, anxiety), and when they occur as a group, their effect can be as significant for CAD as hypertension and elevation of cholesterol (, , ). PNI Involvement in CADRelationships between CAD and the psychosocial factors are generally considered to be a combination of behavioral and direct influences (). Behavioral influences relate to increased bad health behaviors such as smoking, excessive alcohol consumption, poor diet, and lack of exercise (, ). One hypothesis suggests a feedback between behavior, neuroendocrine changes, immunological responses, and the pathogenesis of CAD (). They propose a prolonged first stage in which there is chronic hostility, prolonged occupational over-exertion, and experiencing other life stressors. This then passes into a shorter second phase of vital exhaustion. They believe that stressors provoke neuroendocrine changes which down regulate immune functions, which leads to reactivation of latent infections and possibly autoimmunity. Release of pro-inflammatory cytokines increases the fatigue associated with vital exhaustion and increases cytokine production in the brain. This in turn stimulates the chronically activated over-compensating neuroendocrine system (especially the limbic-hypothalamic-pituitary-adrenal axis). This lower-than-optimal response results in further fatigue and feeds into the whole cycle again. This ultimately results in atherosclerosis, coronary artery occlusion and myocardial infarction. Stress Management and CADThe effects of stress management training on clinical events and medical expenses were assessed for 5 years in 94 men who had CAD and mental stress induced or ambulatory induced myocardial ischemia (). The exercise group received 16 weeks of aerobic exercise 3 times per week. The stress management group received 16 weeks of stress management (). Compared to the usual care group, the stress management group showed significant reduction in CAD events for the first two years and at the 5-year mark. Relative to usual care and exercise groups, the stress management group showed lower medical costs over the first two years, and relative to the treatment as usual group the medical costs were less at the 5-year mark. Effects of exercise or stress management training on markers of cardiovascular risk were assessed in 134 (92 men and 42 women) patients who had stable ischemic heart disease and exercise-induced myocardial ischemia (). Three intervention groups were usual care, usual care plus 35 minutes of supervised aerobic exercise 3 times weekly for 16 weeks, and usual care plus 90 minutes of stress management training once a week for 16 weeks. Most patients were taking aspirin, most took lipid lowering medications or â-blockers, and about half took calcium channel blockers. The usual care group was not supposed to either exercise or undergo stress reduction therapy. The researchers concluded that exercise and stress management interventions decreased emotional distress and improved cardiovascular risk marker significantly more than the usual care. The clinical significance of these changes in the long term is unknown (, ). It is also unknown what the effects might be of combining stress management and exercise. |
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