By Wasim Kakroo
COVID-19 pandemic has created devastations across globe by claiming millions of lives and infecting millions over the world. The current pandemic has a devastating impact in terms of case numbers and deaths, and thus the pandemic is regarded as the greatest challenge the world has faced since World War II. However, heart disease still remains to be one of the leading causes of morbidity and mortality worldwide as well as in India, particularly in the former state of Jammu & Kashmir. According to a study conducted by the Global Health Research Institute, 29.6 percent of deaths in J&K are attributable to heart-related diseases. According to the survey, 25 percent of deaths occur between the ages of 25 and 69. 32.8 percent of these deaths occur in cities, whereas 22.9 percent occur in rural regions.
Traditional cardiovascular risk factors, such as smoking, high blood pressure, high cholesterol, and diabetes, do not fully account for or explain the population's disproportionate and increasing burden of CVD. Most of the times, medical professionals concentrate their whole efforts on the patient's cardiovascular disease rather than the patient’s psychosocial state as a predisposing factor, triggering factor or even as a maintaining factor in the their bad heart condition. Psychological health and how it affects physical health and disease have received less attention. In cardiovascular medicine, there has been an understandable focus on using pharmaceutical and device-based therapy to address specific heart problems. However, there is now a growing recognition that psychological health can contribute not only in a negative way to cardiovascular disease (CVD), but also in a positive way to improved cardiovascular health and lower cardiovascular risk.
To describe and capture an overall state of health, a variety of phrases have been used from time to time. The term wellbeing is one among them. The term "well-being" refers to how people value various aspects of their lives, such as their physical and mental health, their financial situation, their social supports and sense of community, their opportunities for growth and ability to achieve their goals, and a general sense of purpose and satisfaction with their life course. We must remember that a patient is more than one or more physical disease states; he or she is a human being who does not have only physical aspects but also psychological aspects of being human. Hence, we must work to reduce negative aspects of psychological health while promoting a positive and healthy overall state of being.
The mind, heart, and body are all interconnected and dependent on one another. Factors, situations, and disease states (both physical and psychological) that affect one of these three aspects of a person can have an impact on the other two. Systemic body factors and illnesses, such as diabetes, hypertension, and hyperlipidemia, are widely known to have negative effects on the heart and the broader circulatory system. The development of CVD, such as myocardial infarction (MI), heart failure, stroke, or the requirement for coronary revascularization, can also lead to a decline in psychological wellbeing. Although stress-induced cardiomyopathy, is the most obvious example of how a psychological state can adversely and immediately affect the heart, a growing body of evidence suggests that a broader, long-term relationship exists in which a person's psychological health (mind) can positively or negatively affect cardiovascular health, cardiovascular risk factors, CVD event risk, and prognosis of various cardiovascular diseases. This interconnected pattern of relationship between heart, body, and mind can be called the mind-heart-body connection.
IMPACT OF NEGATIVE PSYCHOLOGICAL WELLBEING ON HEART HEALTH
According to well established research, negative psychological factors, personality traits, and mental health disorders can all have a negative impact on cardiovascular health.
Social Stressors and Chronic Stress
Life events that are stressful, persistent daily stressors, and high levels of perceived stress have all been found to have an impact on heart health. Psychological stress can be caused by a variety of factors, including work-related problems, poor-quality or insufficient relationships, financial hardships, and discrimination. Aside from these forms of stressful events, persons may be subjected to traumatic stress if they experience or witness events with a threat to their sense of safety and security. According to research, both cumulative exposure to regular stressors on daily basis and catastrophic stress can increase the risk of CVD. Work-related stress was found to be associated with a 40% increased risk of incident CVD in a study published in 2011. Social isolation and loneliness, both major sources of stress, have also been related to an increased risk of CVD, with some studies showing a 50% increased risk of incident CVD events. Childhood stressors can have far-reaching consequences on cardiovascular health. Childhood maltreatment, social isolation, and socioeconomic hardship have all been related to increased inflammation and metabolic risk factors later in life. Posttraumatic stress disorder (PTSD) is another mental health condition that develops after experiencing a potentially traumatic life experience and is characterized by significant psychological discomfort. Two studies of relationship between PTSD and CVD have been published, the most recent one in 2018 151 144 individuals. In these studies, PTSD was found to be connected with a 61% increased risk of Coronary Heart Disease.
Hostility and anger
Hostility and anger might elicit an unfavourable fight or flight response as body might feel threatened. One study found that inducing angry rumination in individuals was associated with increases in cardiovascular reactivity as measured by heart rate, diastolic blood pressure, and systolic blood pressure. Anger may also acutely increase the risk of adverse cardiovascular events, including MI/acute coronary syndrome, stroke, and ventricular arrhythmia, in the 2 hours after an outburst of anger. Research has also found that long-term exposure to personality traits of hostility and anger characteristic of Type A personality can result in the development of Coronary Vascular Disease prematurely.
Anxiety is defined by the American Psychological Association as “an emotion marked by feelings of tension, worried thoughts, and physical changes such as elevated blood pressure,” implying the possibility of a relationship between anxiety and CVD risk. Anxiety can occur as a temporary mood or as a general tendency (i.e., trait-like), or it can be a symptom of a clinical disorder such as generalised anxiety disorder (GAD) when experienced frequently or repeatedly at high intensity and in inappropriate contexts. Anxiety may be a risk factor for hypertension, excess adiposity, and smoking, all of which can increase atherosclerosis. Several studies on the relationship between anxiety and CVD have found that anxiety was related with an increased risk of CVD mortality.
Numerous studies have indicated that those who suffer from depression are more likely to develop and die from CVD. Several studies done on association between depression and CVD have been published, including one from 2014 that included 893 850 participants from North America, Western Europe, and Asia. Depression was linked to an elevated risk of Myocardial Infarction and incident CHD in this study. Based on these findings, the American Heart Association released a scientific statement in 2014 proposing that depression be considered a risk factor for recurrent cardiovascular events. The increased CVD risk seen in patients with depression may be driven partially by elevations in traditional cardiovascular risk factors such as obesity because depression can lead to sedentary life style which may increase the possibility of obesity and obesity in turn may lead to increased risk of CVD.
Pessimism is defined by a tendency to expect negative outcomes or to consistently explain events in a negative manner. A pessimistic explanatory style has also been associated with a sense of hopelessness. These factors have been related to an increased risk of cardiovascular disease. In an 11-year long study from Finland, for example, pessimism was a found to be a significant predictor of CHD mortality.
IMPACT OF POSITIVE PSYCHOLOGICAL HEALTH ON HEART HEALTH
Positive psychological health does not have a single universal definition. Positive psychological health, entails the existence of positive psychological elements such as happiness, optimism, gratitude, a feeling of purpose, life satisfaction, eudaimonic (virtuous) well-being, and mindfulness.
Positive psychological health entails more than just the absence of negative psychological elements like despair, anxiety, and pessimism, and the absence of psychological pain does not always imply that people are actively experiencing psychological well-being.
Optimism is defined by a sense of hopefulness and confidence that things will turn out well in the future, as well as anticipating the greatest potential outcomes. Several studies have revealed that optimism is connected with healthier behaviours such as increased physical activity, avoiding smoking, a healthy food choice, improved sleep quality, and higher cardiovascular health status. An optimistic view of life has been linked to healthy ageing and a lower risk of CVD, including stroke and heart failure. According to one study, women with higher optimism levels had slower progression of atherosclerosis in their carotid arteries.
A recent study including 220 391 participants discovered that higher levels of optimism were related with a 35% lower risk of incident CVD events. More optimistic individuals had a 10% longer life expectancy and a higher possibility of surviving to 85 years of age.
Optimism has also been associated to better cardiovascular outcomes in people who already have CVD. Higher optimism was related with a lower incidence of hospital cardiac readmissions in the GRACE research (Gratitude Research in Acute Coronary Events), which measured optimism in 164 patients with Acute Coronary Syndrome (ACS) and then tracked these individuals for 6 months.
Sense of purpose
A sense of purpose can be defined in a variety of ways, but it is commonly thought of as finding meaning in one's daily life and being inspired and guided by one's values and life objectives. Adults with a greater sense of purpose, like optimistic adults, have more favorable lifestyle and cardiovascular risk factors, such as less smoking, more physical exercise, less alcohol and substance misuse, and better glucose control. A stronger sense of purpose in life has been linked to improved cardiovascular health, longevity, and a lower risk of CVD, including a lower risk of MI and stroke. A study involving over 130 000 people discovered that having a greater sense of purpose in life was related with a 17% lower risk of both CVD events.
Positive Affect and Happiness
Happiness is a type of positive affect that is defined by a sense of well-being and contentment. People that are happy tend to sleep better, exercise more, eat better, and do not smoke. Individuals who were evaluated as having a stronger positive affect by trained observers had a 22% decreased incidence of incident CHD in one study. Other research has discovered that positive affect prevents disease progression in the context of diabetes and other cardiometabolic disorders.
Gratitude is the trait of being thankful for and appreciative of persons and situations in one's life. Small clinical trials examining a gratitude intervention (for example, gratitude journaling) found improvements in blood pressure, sleep, inflammatory biomarkers, and heart rate variability, thus resulting in better heart health.
What are the ways to have sound mental health in order to have healthy heart?
We can have the following interventions that might help us to improve both our mental health as well as cardiovascular outcomes.
Several trials have employed psychotherapy to treat depression in people with heart disease. The ENRICHD (Enhancing Recovery in Coronary Heart Disease) experiment, the largest intervention trial for depression in heart disease patients, investigated the effects of cognitive behavioural therapy (CBT) after MI. When compared to the control condition, CBT alleviated depression. Cognitive behavioural treatment was also related with significant improvements in depression and other mental health outcomes in patients with heart failure who had serious depression. When compared to standard care, cognitive behavioural therapy was also related with lower possibilities of hospitalisation after one year.
Some research looked at psychotherapies aimed primarily at lowering anxiety and stress. Three such studies investigated the efficacy of psychotherapy to alleviate stress and increase health in heart disease patients. One such experiment looked at individuals who had been hospitalised in the previous 12 months for MI, percutaneous coronary intervention, or coronary artery bypass graft surgery. They were enrolled for a group-based cognitive behavioural therapy programme for a year, and it was found that CBT intervention had reduced probability of fatal and nonfatal first recurrence of cardiovascular events by 41%. Another trial of a group-based psychosocial intervention programme focusing on relaxation training and coping skills found that the intervention group had lower mortality.
Mindfulness-Based Interventions and Meditation Training
Meditation has been shown in certain studies to reduce various forms of psychological and psychosocial distress such as perceived stress, anxiety, and negative affect; boost smoking cessation rates; and modestly lower systolic and diastolic blood pressures. A recent comprehensive analysis of 16 research studies indicated that mindfulness-based therapies improved negative psychological outcomes (e.g., decreased anxiety, sadness, and stress) and reduced systolic blood pressure. A study of meditation interventions in patients with heart failure discovered significant improvements in depression and symptom management. A 2019 study on effects of meditation trials in CVD patients demonstrated significant benefits in anxiety, perceived stress, depression, and systolic blood pressure with mindfulness-based therapies.
In conclusion, current findings of studies on psychological health and CVD can be summarised as follows:
1. CVD should not be seen as a separate entity, but rather as one component of a larger system in which the mind, heart, and body are all interconnected. Both positive and negative psychological status appears to have a direct impact on cardiovascular health and prognosis.
2. For individuals with or at risk of CVD, psychological health is an important component of wellness/well-being.
3. There is a substantial body of high-quality data showing clear associations between psychological health and CVD and risk.
4. There is growing evidence that psychological health may be causally linked to behaviours that contribute to CVD and risk.
5. The overwhelming body of evidence suggests that psychotherapies to improve psychological health such as cognitive behavioral therapy (CBT) can have a positive influence on cardiovascular health. Simple screening tools for patients with or at risk of CVD should be utilised by health care practitioners to assess psychological health status and if any psychological disorder such as depression or anxiety or any psychosocial issue is found to be the predisposing, precipitating or perpetuating factor for cardiovascular events, such patients should be referred to a mental health professional such as a clinical psychologist to work on psychological issues.
The author is a licensed clinical psychologist (alumni of Govt. Medical College Srinagar) and is currently working as a child and adolescent mental health therapist at Child Guidance and Well-Being Centre at Institute of Mental Health And Neurosciences-Kashmir (IMHANS).
- Author can be reached at [email protected]
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