Heart disease is the number one killer of both adult men and women in the United States and the leading cause of permanent disability from the work force.

Certain aspects of behavior -- including diet, smoking, and a sedentary lifestyle -- increase the chances that heart disease will develop or get worse.

Various psychological factors -- such as hostility, anger, stress, and depression -- also increase risk. A number of cognitive and behavioral strategies have been used successfully to keep people on their diet and exercise regimes and to teach them ways to counter the effects of stress and a coronary-prone personality.

When these strategies are employed in a comprehensive program that targets multiple risk factors, people stand the best chance of avoiding a heart attack or preventing another cardiac event.

The Facts:

Heart disease afflicts more than 12.2 million people in the United States and is the single largest cause of death among both men and women and the leading cause of premature, permanent disability.[1]

Heart disease costs the U.S. economy $214.7 billion a year, including $105.9 billion in direct treatment costs and $108.8 billion in lost productivity due to illness or death.[1]

A number of psychological factors significantly increase the risk of developing heart disease or help speed its progression, including stress, Type A behavior, hostility, depression, and social isolation. Stress management skills, relaxation techniques, and other behavioral treatments can reduce the risk of death from heart disease among those at risk of developing heart disease as well as those with established illness.[14]

Although women frequently express greater fear of breast cancer than heart disease, more than eight times as many women die each year from heart disease, making it the number one cause of death among women.[19]

Women who have had heart attacks are significantly less likely than men to undergo invasive diagnostic procedures, such as cardiac catheterization, or to receive clot-busting thrombolytic drugs, angioplasty, or bypass surgery to improve blood flow to their hearts.[13]

Women take significantly longer to seek care for heart attack symptoms than do men -- 6.2 hours for women vs. 5.4 hours for men, in one recent study.[9]

Differences in the symptoms that women experience compared with men may explain the added delay. Women are significantly more likely than men to describe their chest pain as "pressure," "heaviness," or "tightness," but are significantly less likely than men to report the more "classic" pain in the center or left side of their chest.[17]

Women are also more likely to report other symptoms not related to chest pain, including back pain, nausea, vomiting, indigestion, and shortness of breath.

A small group of patients with heart disease who completed an intensive lifestyle modification program were able to reduce significantly the narrowing in their coronary arteries without taking cholesterol-lowering medications. The program included an extremely low-fat vegetarian diet, exercise, stress management, smoking cessation, and group support.[20]

Collaboration between physicians and other health care providers can help heart patients reduce their risk factors for another heart attack. Patients who had frequent follow-up contacts with nurse case-managers who helped guide their care were significantly more successful in reducing their cholesterol levels, quitting smoking, and exercising than were patients who received usual care.[7]

Interview #1:

'Targeting Multiple Risks'

Robert F. DeBusk, MD, is a cardiologist and professor of medicine at the Stanford University School of Medicine, Stanford, California. Dr. DeBusk has conducted research on the management of heart disease and other chronic illnesses for more than two decades, and he has pioneered the use of nurse case-managers to assist physicians in helping patients adhere to exercise, medication, and other medical advice.

Q: How serious a problem is heart disease?

A: It affects tens of millions of Americans in one way or another. There are 10 to 12 million people with angina, chest pain that occurs when the heart muscle does not receive enough blood. There are a 1.5 million heart attacks each year and in excess of 750,000 coronary revascularization procedures, such as bypass surgery and angioplasty.

As the population ages, heart disease stands to become an even larger problem. African Americans and Native Americans are more likely than other groups to suffer from hypertension and diabetes -- two conditions that increase the risk for heart disease. Contrary to popular belief, women have about the same rate of death from coronary artery disease as men do. Women acquire the disease somewhat later in life, but they also tend to live longer than men do.

Q: Is heart disease preventable?

A: Studies show that there is a 25 to 33 percent reduction in mortality from coronary events among patients treated with medications to lower blood cholesterol. Other studies show a similar reduction among people who stop smoking or get their blood pressure under control.

Unfortunately, many patients never begin therapy, and most never achieve the same sustained benefit achieved in clinical trials. That’s because in clinical trials, there is a delivery system that ensures that patients take their medicines, exercise, or keep on their diets.

But once patients’ active participation in the research study is over, there's no system to make sure patients follow treatment recommendations. This gap is at the very root of the problem in prevention of heart disease and other chronic health problems today.

Q: How would you reduce that gap, for example, in getting people to quit smoking?

A: Smoking cessation is the single most powerful intervention in terms of its impact on coronary mortality, but logistically it is very difficult to encourage within the framework of a standard medical practice.

Physicians have about a 5 percent success rate in helping their patients who smoke quit over any given year. But specialized programs in hospitals and other settings have quit rates that can range from 40 to 75 percent. Most physicians simply are not in the position to follow up with the kind of behaviorally oriented treatment protocol that could help their patients stop smoking.

Q: So consistent and frequent follow-up is key to behavior change?

A: Exactly. And it doesn't need to be face to face. In a number of clinical trials, we’ve employed nurse case-managers to follow up with heart patients by phone to see how they were doing with their medicines, exercise, diet, or smoking.[16]

There's a standard repertoire of issues that are quite easy to lay out for the patient and find out where any problems may lie. With smoking cessation, for example, the nurses work with patients to anticipate situations where they are likely to smoke again and come up with strategies on how they can avoid smoking in those situations.

Q: You've also studied ways to promote exercise. What have you found?

A: We started out looking at patients who were recovering from a heart attack. Many were concerned that they would be unable to resume their usual activities. We started them on an exercise program as early as two weeks after their attack. Once we demonstrated that they could resume activity safely, it wasn’t difficult to motivate them to continue exercising. They were delighted to be able to do as much as they were doing, and they felt they were contributing to their long-term health.

In a later series of studies, we worked with sedentary middle-aged individuals without heart disease.[12] We demonstrated that it really is quite easy for them to undertake a home-based exercise program. In fact, patients who exercised at home spent more time on their exercise bicycles than patients who were randomized to the gym program spent in their cars, driving to and from the gym. Many people do not have access to gyms or do not like group exercise programs. For them, exercise training at home is a very attractive alternative.

Q: Many people have more than one risk factor for heart disease. How do you work with them?

A: One of our most important clinical trials, called MULTIFIT(SM) for Multiple Risk Factor Intervention Trial, focused simultaneously on exercise training, smoking cessation, and diet and drug management for high cholesterol among patients who had their first heart attack.[8]

The approach used in that study was innovative because it had three simultaneous objectives. The teaching to that point had been that each goal would need to be introduced over time in a gradual fashion, but we found that was not the case. Patients had no difficulty beginning changes in various areas of their lives if the changes made sense to them, if they had regular contact with the nurse case-manager coordinating their care, and if they could see their progress.

Q: So if people are willing to make one change for their health, they frequently are willing to make others at the same time?

A: Absolutely. One needs to strike while the iron is hot, which often is after a coronary event or instability in the patient's life that focuses his or her attention on the problem. But it needn’t wait for something drastic to happen. We try to get patients at risk to begin to focus their efforts and show them with timely feedback that their efforts are having an immediate effect on their blood pressure or cholesterol, instead of focusing on a distant goal, such as preventing a heart attack. That way they are more likely to stick with their medicines, exercise, and diet over the longer term. We think that such feedback will become more mainstream over time with use of e-mail, the Internet, and the like.

Q: How does the nurse case-manager approach work in the real world?

A: I've had the good fortune to work with Kaiser Permanente over the last 15 years, and they have implemented a number of programs based on the MULTIFIT(SM) model. Experience has shown that when the nurse case-managers are given access to information about the patient and their illness -- when they are given a clear-cut series of objectives, they can become extremely adept at managing patients with chronic conditions such as hypertension and diabetes, and in particular, with heart failure.[27]

Many physicians get uneasy about this incursion on their turf, but I think if they are honest, they will acknowledge that there are limits to what they can accomplish alone. We find that there can be a very close integration between what the nurses do in these areas and how the physician manages the overall care of the patient.

But it requires a collaborative and cooperative effort -- one that is still comparatively new. I think the next large step in chronic disease management in America will be an explicit development and acknowledgement that these kinds of cooperative efforts are highly effective in addressing chronic illnesses.

Interview #2:

'Stress Takes a Deadly Toll'

James A. Blumenthal, PhD, is a professor of medical psychology in the Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC. Much of his research over the past two decades has focused on the effects of mental stress on the cardiovascular system.

Q: Much of your recent work deals with the effects of mental stress on the heart, particularly a phenomenon called myocardial ischemia. What is myocardial ischemia?

A: Myocardial ischemia is a condition in which there is an inadequate supply of blood to the heart. Ischemia usually occurs in the context of some degree of coronary atherosclerosis -- that is, some narrowing of the blood vessels. Most episodes of ischemia are "silent" and without symptoms. Exercise is the most well-studied trigger of ischemic episodes.

People with exercise-induced ischemia are more likely to show increasing symptoms of heart disease and are at increased risk to have a heart attack, to require cardiac surgery, or to suffer from sudden cardiac death.

Q: What have you learned from your studies of ischemia induced by mental stress?

A: The first thing we found is that mental stress in the laboratory was associated with increased risk of having ischemia during daily life.[3] The second thing we found is that people who have mental stress-induced ischemia in the laboratory also show the largest blood pressure changes in response to mental stress.

In our field studies, we learned that mental stress during daily life can also be a potent trigger of ischemia.[10]

When we monitored people and had them complete diaries about their emotional state throughout the day, people were more likely to report feeling angry, frustrated, or sad in the hour preceding ischemic episodes than at other times. Finally, we know that people who have ischemia in response to mental stress have a worse prognosis over and above what we see with exercise stress testing.[11]

Q: Do we know how mental stress causes myocardial ischemia?

A: In exercise-induced ischemia, heart rate increases significantly -- it may increase two- to three-fold, reflecting increased demand for oxygen. Ischemia occurs when this increased demand for blood exceeds the supply. In ischemia induced by mental stress, the problem is not just increased demand -- and heart rate elevations are usually lower than what is typically seen with exercise -- but reduced blood supply.

Reduced supply is likely to result from abnormal constriction of the blood vessels. We think it may be related to the motion of coronary and other blood vessels. We know that in individuals with coronary artery disease, the endothelium -- the lining of the blood vessels -- does not respond to stress and other stimuli in the same way as normal healthy blood vessels do.[25]

Rather than dilating or opening up, the vessels may stay the same or even constrict.

Q: You've also studied interventions for people with mental stress-induced myocardial ischemia. What did you find?

A: We randomly assigned a group of patients to receive stress management training, exercise training, or their usual care.[5] We saw a 74 percent reduction in the risk of cardiac events among patients in the stress management group compared with the usual care group and a 34 percent reduction among those who received the exercise training.

Interestingly, those in the stress management group were more likely to see reductions in ischemia induced by mental stress while those in the exercise group had less ischemia induced by exercise. So there is some specificity to the treatments.

Q: And the stress management program, what does it include?

A: There are three components: education, group support, and skills training. First, we teach patients about heart disease risk factors and the role of stress and its effects on the body. The second component is social support. All of our stress management training is done in groups where people can share their frustrations and their successes and see they are not alone in facing these challenges.

The third component includes a variety of different skills to cope with stress, ranging from relaxation training to teaching people different cognitive behavioral strategies to help them respond differently to situations that previously were regarded as very stressful.

Q: What do you mean by cognitive behavioral strategies?

A: Cognitive behavioral strategies refer to techniques for modifying the ways in which individuals perceive and interpret various situations. We teach people to monitor their thought patterns, to recognize when their thinking is not realistic, and to challenge their unrealistic thought patterns and substitute them with more appropriate, realistic, and adaptive cognitions.

Q: So we know mental stress is a significant risk factor for heart attack. What other psychological states are important?

A: The most widely studied psychological risk factor for heart disease is Type A personality. People who have Type A personalities tend to be impatient and irritable. They also feel a real sense of time urgency, and they get easily angered. Many studies suggest this last component -- the propensity toward anger or hostility -- might be particularly important as a risk factor for heart disease.

Q: What possible mechanism would account for this link between Type A and hostility and heart disease?

A: Numerous studies have shown that people with Type A behavior and high levels of hostility show greater heart rate and blood pressure changes and a greater release of certain stress hormones in response to stress.

Q: How about the role of depression in heart disease?

A: Well, we know that in individuals who have had a heart attack, perhaps 30 to 40 percent have symptoms of major or minor depression. Studies have shown that people who are depressed after a heart attack have three to four times increased risk of having additional heart problems, including death. We are currently participating in a multi-center study sponsored by the National Heart, Lung, and Blood Institute to see if heart patients who are depressed or socially isolated can benefit from cognitive behavioral therapy.[4]

Q: Do depressed patients simply take poorer care of themselves or is there some other factor related to depression that increases their risk of additional cardiac events?

A: There are several potential mechanisms including behavioral factors. For example, studies have shown that depressed patients may indeed be less compliant with medications and may be more sedentary than non-depressed patients. There are also a number of physiologic mechanisms that could contribute to the increased risk of cardiac events in depressed individuals.

There have been several studies in patients without heart disease showing there are differences in certain clotting factors among depressed patients compared with those who are not depressed. Some researchers suggest that depression may be associated with a greater propensity to develop blood clots and this may be responsible for additional heart attacks and other cardiovascular complications.

Depressed people also exhibit an imbalance between the sympathetic and parasympathetic nervous system that may be a marker that their hearts are impaired in the ability to respond to a host of stimuli.

Q: You mentioned targeting people who are socially isolated. What is the role of social support in heart disease?

A: A number of studies have demonstrated that people who perceive themselves as having good social support systems are at lower risk of heart problems and those who see themselves as socially isolated are at increased risk. One of the challenges in our current study is to increase people’s perceptions of social support.

Q: So it isn’t just a matter of the number of relatives, friends, and others that people see on a regular basis? They have to believe that there are other people who can offer them support?

A: Yes. We work with many people who have low perceived social support, and yet when you speak with them, you find out they’ve received many get-well cards and have family members who care about them. I think it's probably related to depression, because if you are depressed, even though you may have family members who care about you, you may not feel that they care or you feel you are not worth caring about. That’s where the cognitive therapy can make a difference, to counter some of these misperceptions of reality.

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