Bethesda, MD - Although psychology was once considered a "soft" science, the hard evidence linking psychosocial factors to increased cardiovascular risk makes it unethical for conscientious cardiologists to overlook behavioral and psychological symptoms in their patients, experts say.

Dr Charles F Emery (Source: Ohio State University)

A new "state-of-the-art" review paper appearing in the March 1, 2005 issue of the Journal of the American College of Cardiology summarizes the evidence and provides concrete advice to cardiologists wanting to tackle psychological risk factors in their patients.[1] Researchers who have been working in this field for more than a decade applaud the paper and say it's high time cardiologists sat up and took notice.

"I was glad to see this review because I think there is now enough of a body of literature that you could go to a skeptical cardiologist and say, look, here are the data," Dr Charles F Emery (Ohio State University, Columbus) told heartwire. "And in fact, you're doing your patients a disservice by not, at the very least, performing an assessment of depression and social support."

You're doing your patients a disservice by not, at the very least, performing an assessment of depression and social support.

The review paper, by Dr Alan Rozanski (Columbia University, New York, NY) and colleagues, notes that while cardiologists are well-versed in assessing behavioral factors such as diet, exercise, and smoking, they are less likely to assess psychosocial risk factors such as depression and chronic stress.

"A potential dilemma is that, on the one hand, it is not the function of cardiologists to serve as mental-health professionals; on the other hand, the strong and robust relationship between psychosocial risk factors and CAD suggest that cardiologists need to be practiced in addressing this important aspect of patient care," Rozanski et al write.

He and his colleagues point out that psychosocial factors that promote atherosclerosis generally fall into two different categories—emotional factors and chronic stressors—with frequent clustering of factors between categories.

Evidence supporting a role for these behavioral risk factors comes not only from quality-of-life studies, but pathophysiological research. Indeed, it is this "harder" science that is the most persuasive to some physicians, Rozanski notes.

"We know that when you're depressed, not only do you turn on the sympathetic nervous system and the hypothalamic pituitary-adrenal cortical axis so that you have high cortisone levels and high heart rate, but depressed patients also have endothelial dysfunction and sticky platelets, with lots of different forms of platelet abnormality," he explained to heartwire. "Depressed patients have high C-reactive protein levels, they have increased abdominal girth, even if they lose weight, meaning more metabolic syndrome, more diabetes. And that's compelling to an internist and cardiologist."

Rozanski and his coauthors point out that one of the largest studies to bolster the field was the recent INTERHEART study of more than 12 000 post-MI patients presented at the 2004 European Society of Cardiology meeting, as reported by heartwire. INTERHEART found psychosocial index to be one of the strongest predictors of acute MI, in the same league as diabetes, smoking, and hypertension.

The INTERHEART data, says Rozanski, a burgeoning body of literature, and even the fact that the Journal has labeled his paper a "state-of-the-art" review signal an upsurge in interest and acceptance of psychosocial risk factors for CVD.

"I think that we're moving from a debate about whether psychological factors are important in cardiac disease to a debate over what we should do about it," he says. A major barrier, he admits, is the sheer amount of information coming in.

We're moving from a debate about whether psychological factors are important in cardiac disease to a debate over what we should do about it.

"We live in an age where medical research moves so fast that there's often an information boondoggle and it's hard for physicians to keep up with what's new," Rozanski said. "This is uniquely more difficult in this area, because the literature in which this information is disseminated is far wider than the articles that deal with, say, valvular heart disease. It's hard for a physician to keep track of all of these things."

Rozanski's advice to cardiologists is twofold: first, they should make themselves aware of the evidence linking psychosocial risk factors to cardiovascular disease, and that was the principal aim of the Journal paper.

Second, cardiologists should initiate a dialogue with their patients that at least opens the door to a better awareness of emotional and stress issues.

"You start to ask a few additional questions—do you get down in the dumps? Do you have trouble unwinding after work? How are things at home?" Rozanski advises. "And when you do, you can often pick up small things and big things. The incidence of depression symptoms and major depression is much higher in cardiac practice than in the general population, so the cardiologist has a tremendous opportunity to diagnose a lot of this."

He continues, "Small steps can often make a big difference. We're not proposing that cardiologists do a formal intake on depression the way a psychiatrist does, but by asking a few questions, you signal to the patient that you care about these sorts of symptoms and you give them the opportunity to volunteer some information, because they don't necessarily know that you think these things are important. And then, if you're a good physician, if you really care, you can recognize when they have severe symptoms and you can refer them to someone appropriate."

Emery, who was not a coauthor on the review, agrees that interest in behavioral cardiology is increasing but acknowledges that the gap between knowledge and practice remains.

"I think that lip service is paid to behavioral interventions in cardiology and more so in cardiac rehabilitation than anywhere else," he says. For years, cardiologists have been instrumental in urging people to quit smoking, eat better, and exercise more; now they need to extend their role into areas like depression, anxiety, and social support, he argues.

"We now have good solid data that indicate that people who have cardiac disease who are depressed are at greater risk of further events. But this is an area where, yes, the data are out there and the problem is acknowledged, but the degree to which we actually do a good job of getting in there and assessing depression and then appropriately treating it is still up in the air."

Part of the problem is time, Emery says. "It does take more time to make an assessment of someone's psychological state." As well, cardiologists may want to stick to the basics like drug compliance—a classic definition of a "good patient"—and not delve into murkier waters. "Some people may not want to acknowledge that a patient is maybe having more distress than they can see on the surface."

Finally, there is the issue of resources and training, Emery says. "A cardiologist isn't trained in and probably shouldn't be evaluating psychological functioning in their patients, but they do need to be in a place where they have some more resources they can draw on to conduct that evaluation and address any problems."

Rozanski thinks the process is instinctual for most cardiologists. Engaging the patient in a few questions about his or her work or home life in time makes it easier to recognize which patients may need referrals to other specialists and which ones can be helped through simple suggestions. Physicians also become more tapped in to resources outside the medical field.

"Physicians underestimate the impact they can have on patients," Rozanski insists. "I'm old enough to remember in the old days that when you went to your doctor, he had more time, he used to be more there, as a person. And patients love it when their cardiologist takes just a few minutes out to ask them a few questions outside the regular scope. And as you start to do this, you become cognizant that in any community, you have Overeaters Anonymous, you can recommend an exercise group that meets on Saturdays, you have the Road Runners Club that does this or that, and you start to be able to refer patients to these different sorts of things. It doesn't take a lot of time to do a small amount, but a small amount now can have big effect later."