Abstract and Introduction
In Western medicine, we are very good at treating the disease, less good at treating the patient, and not very good at treating the person. We devote almost all of our clinical time and practice to implanting the latest devices, imaging and testing each and every symptom, and prescribing mouthfuls (now syringes full) of medicines, yet pay minimal attention to the psychological and physiological milieu in which the heart resides and which affect the heart; namely, the patient’s—and a person’s—mind and body. There is now a growing body of data that the mind and the body can negatively and positively impact cardiovascular health, and the time has come for us as clinicians to take heed of the interconnected, interdependent being of the heart and body with the mind, a relationship that can be termed the “mind-heart-body connection.”
The Interconnectedness of Mind, Heart, and Body
Just as systemic processes in the body, such as hypertension, diabetes mellitus, and obesity, can adversely affect the heart and cardiovascular health, so can dysphoric and negative psychological states and processes of the mind. The most overt, recognizable, and measurable example of a negative interaction between the mind and the heart is the phenomenon of Takotsubo, or “stress-induced” cardiomyopathy, in which intense psychological distress or emotions directly results in a distinct pattern of left ventricular dysfunction, electrocardiographic repolarization abnormalities, and elevation of cardiac biomarkers. Acute stress is also associated with true acute coronary syndrome and with cardiovascular death. For example, on the day of the January 1994 Northridge earthquake, there was a 260% increase in cardiovascular deaths in Los Angeles when compared with other days that month. An overview of anxiety in patients with coronary artery disease found consistent and statistically significant increased relative risk, generally in the range of 2.5 to 4.9, for anxiety as a cardiac risk factor for the development of unstable angina, myocardial infarction, ventricular arrhythmia, and death. That same overview found comparable increased relative risk for nonfatal and fatal myocardial infarction with the presence of depression. In fact, a clear dose-response curve has been found between the degree of depressive symptoms and increased cardiac mortality. It is important to note that depression is associated with decreased medical compliance. In one notable study, one third of patients post acute coronary syndrome who were moderately to severely depressed were noncompliant with their prescribed medications. Even more notable is that the medication studied was not an expensive medication with a complex medical regimen, but rather it was simply aspirin. Even the lack of a sense of worth or purpose has been associated with increased risk of developing cardiovascular disease (relative risk, 1.6) and increased all-cause mortality (risk ratio, 1.9).
An already sizable and growing body of research has shown that maintaining a healthy mind and promoting positive psychological health is associated with, and can potentially improve, cardiovascular health and prognosis. Meta-analysis of studies of psychological life outlook find that in patients with cardiovascular disease, those with a positive psychological outlook (optimism) have lower rates of rehospitalization or mortality. Psychological well-being (eg, contentment, happiness, satisfaction with life) has been repeatedly correlated with lower rates of both cardiovascular and all-cause mortality. Those with high mindfulness (nonjudgmental current self-awareness) scores are more likely to never have smoked (or to have quit), to have desirable body mass indexes, lower fasting glucose levels, and greater physical activity—4 of the American Heart Association’s “Life’s Simple 7.”
Numerous mind-and-body interventions that train the mind and improve psychological health, including meditation, mindfulness-based stress reduction, stress management training, cognitive behavior therapy, yoga, Tai Chi, and Qi Gong, have now been subjected to increasingly more rigorous scientific study. These interventions may decrease detrimental processes, including stress, anxiety, depression, smoking initiation, physical inactivity, poor eating and overeating, weight gain, and medication noncompliance. These interventions may also increase and improve beneficial processes, including equanimity, happiness, optimism, smoking cessation, physical activity, heart-healthy eating, weight loss, and medication compliance. These, in turn, can lead to decreased systemic inflammation, lower low-density lipoprotein cholesterol levels, and lower blood pressure. Biologically plausible mechanisms by which improved psychological well-being may improve cardiovascular health are summarized in the Figure.
Biologically plausible mechanisms by which improved psychological wellbeing may improve cardiovascular health. Figure inspired in part by figures in Kubzansky et al,4 and Rozanski,5 as well as many other sources.
Putting Health Back Into Health Care
As clinicians, academicians, and researchers, we must focus not only on the disease, but on the patient and the person, and strive to promote and prescribe the wellness of the person. Wellness is more than simply the absence of disease. It is an active process directed toward a healthy, happy, and fulfilling life and includes not only physical but also psychological and emotional dimensions.
There are now good data that there are clinically meaningful associations between both negative and positive psychological states and cardiovascular health. Although some mind-body interventions have shown benefit on cardiovascular risk factors and health, others have not been able to demonstrate a clear benefit. Neutral studies often involve relatively small numbers of participants, are underpowered for hard end points, involve a relatively brief duration of intervention, and have modest duration of follow-up. There is thus both an opportunity and need for high quality, well-funded, trials of mind-body interventions.
Psychological health in patients with cardiovascular disease represents a largely untapped opportunity for intervention, an endeavor that has been dubbed behavioral cardiology, which would be synergistic with efforts aimed at weight control, lipid management, increased physical activity, and smoking cessation. We must no longer narrowly focus on coronary, myocardial, valvular, or electrophysiological pathology, but rather on research and interventions that address and improve the mental, emotional, psychological, and overall physical well-being of those we care for. It is time to put the health back into health care.
- Leor J, Poole WK, Kloner RA. Sudden cardiac death triggered by an earthquake. N Engl J Med. 1996;334:413–419. doi: 10.1056/NEJM199602153340701
- Januzzi JL Jr, Stern TA, Pasternak RC, DeSanctis RW. The influence of anxiety and depression on outcomes of patients with coronary artery disease. Arch Intern Med. 2000;160:1913–1921. doi: 10.1001/archinte.160.13.1913
- Rieckmann N, Gerin W, Kronish IM, Burg MM, Chaplin WF, Kong G, Lespérance F, Davidson KW. Course of depressive symptoms and medication adherence after acute coronary syndromes: an electronic medication monitoring study. J Am Coll Cardiol. 2006;48:2218–2222. doi:10.1016/j.jacc.2006.07.063
- Kubzansky LD, Huffman JC, Boehm JK, Hernandez R, Kim ES, Koga HK, Feig EH, Lloyd-Jones DM, Seligman MEP, Labarthe DR. Positive psychological well-being and cardiovascular disease: JACC Health Promotion Series. J Am Coll Cardiol. 2018;72:1382–1396. doi: 10.1016/j.jacc.2018.07.042
- Rozanski A. Behavioral cardiology: current advances and future directions. J Am Coll Cardiol. 2014;64:100–110. doi: 10.1016/j.jacc.2014.03.047