Psychosocial Stress and Cardiovascular Disease Part 2: Effectiveness of the Transcendental Meditation Program in Treatment and Prevention

Abstract

Psychosocial stress is a nontraditional risk factor for cardiovascular morbidity and mortality that may respond to behavioral or psychosocial interventions. To date, studies applying such interventions have reported a wide range of success rates in treatment or prevention of cardiovascular disease (CVD). The authors focus on a natural medicine approach that research indicates reduces both psychosocial and traditional risk factors for cardiovascular disease—the Transcendental Meditation (TM) program. Randomized controlled trials, meta-analyses, and other controlled studies indicate this meditation technique reduces risk factors and can slow or reverse the progression of pathophysiological changes underlying cardiovascular disease. Studies with this technique have revealed reductions in blood pressure, carotid artery intimamedia thickness, myocardial ischemia, left ventricular hypertrophy, mortality, and other relevant outcomes. The magnitudes of these effects compare favorably with those of conventional interventions for secondary prevention.     

The role of vagal function in the risk for cardiovascular disease and mortality

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. The understanding of the risk factors for CVD may yield important insights into the prevention, etiology, course, and treatment of this major public health concern. We review the evidence for the role of vagal function in the risk for cardiovascular disease and mortality. Using a broad range of indicators of vagal function including resting heart rate, heart rate recovery, heart rate variability, and baroreflex sensitivity we show that decreased vagal function is associated with an increased risk for morbidity and mortality. These effects are independent of traditional risk factors. Moreover, we show that decreased vagal function is associated with both traditional and emerging risk factors as well as modifiable and non-modifiable risk factors. Most importantly, we provide evidence to support the notion that decreased vagal function precedes the development of a number of risk factors and that modification of risk profiles in the direction of lower risk is associated with increased vagal function. We close with a brief overview of the neural concomitants of vagal function and suggest that a model of neurovisceral integration may provide a unifying framework within which to investigate the impact of risk factors, including psychosocial factors, on cardiovascular disease.     

Psychosocial stress and cardiovascular disease: pathophysiological links

The remarkable decline in cardiovascular disease (CVD) experienced in developed countries over the last 40 years appears to have abated. Currently, many CVD patients continue to show cardiac events despite optimal treatment of traditional risk factors. This evidence suggests that additional interventions, particularly those aimed at nontraditional factors, might be useful for continuing the decline. Psychosocial stress is a newly recognized (nontraditional) risk factor that appears to contribute to all recognized mechanisms underlying cardiac events, specifically, (a) clustering of traditional cardiovascular risk factors, (b) endothelial dysfunction, (c) myocardial ischemia, (d) plaque rupture, (e) thrombosis, and (f) malignant arrhythmias. A better understanding of the behavioral and physiologic associations between psychosocial stress and CVD will assist researchers in identifying effective approaches for reducing or reversing the damaging effects of stress and may lead to further reductions of CVD morbidity and mortality.     

Mental health and HIV risk in men who have sex with men

Evidence-based HIV prevention interventions with men who have sex with men (MSM) in the United States have moderate effect sizes in reducing HIV sexual risk behavior. Mental health and psychosocial problems, which both disproportionately affect MSM populations and are implicated in HIV transmission risk behaviors, also likely interfere with the uptake of HIV behavioral interventions. Moreover, given that mental health and psychosocial problems such as depression, substance use, and violence frequently co-occur for many MSM (eg, as syndemic conditions), what is probably needed are combination prevention efforts, or prevention "cocktails," similar to treatment "cocktails," that address the psychological and behavioral mechanisms that interact to produce elevated risk for HIV. Such interventions should incorporate a holistic framework to address the sexual health and overall well being of MSM. Addressing co-occurring psychosocial risk factors is apt to improve effect sizes of current HIV prevention interventions and allow for more effective uptake by MSM.     

Primary care organisational interventions for secondary prevention of ischaemic heart disease: a systematic review and meta-analysis

BackgroundIschaemic heart disease (IHD) is the most common cause of death worldwide.AimTo determine the long-term impact of organisational interventions for secondary prevention of IHD.MethodSearches were conducted for randomised controlled trials of patients with established IHD, with long-term follow-up, of cardiac secondary prevention programmes targeting organisational change in primary care or community settings. A random-effects model was used and risk ratios were calculated.ResultsFive studies were included with 4005 participants. Meta-analysis of four studies with mortality data at 4.7–6 years showed that organisational interventions were associated with approximately 20% reduced mortality, with a risk ratio (RR) for all-cause mortality of 0.79 (95% confidence interval [CI] = 0.66 to 0.93), and a RR for cardiac-related mortality of 0.74 (95% CI = 0.58 to 0.94). Two studies reported mortality data at 10 years. Analysis of these data showed no significant differences between groups. There were insufficient data to conduct a meta-analysis on the effect of interventions on hospital admissions. Additional analyses showed no significant association between organisational interventions and risk factor management or appropriate prescribing at 4.7–6 years.ConclusionCardiac secondary prevention programmes targeting organisational change are associated with a reduced risk of death for at least 4–6 years. There is insufficient evidence to conclude whether this beneficial effect is maintained indefinitely.     

Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality

OBJECTIVES: Social isolation has been linked to poor survival in patients with coronary artery disease (CAD). Few studies have closely examined the psychosocial characteristics of CAD patients who lack social contact. METHODS: Social isolation was examined as a predictor of mortality in 430 patients with significant CAD. More isolated patients were compared with their less isolated counterparts on factors that might help explain the association between isolation and survival. RESULTS: The mortality rate was higher among isolated individuals. Those with three or fewer people in their social support network had a relative risk of 2.43 (p = .001) for cardiac mortality and 2.11 (p = .001) for all-cause mortality, controlling for age and disease severity. Adjustments for income, hostility, and smoking status did not alter the risk due to social isolation. With the exception of lower income, higher hostility ratings, and higher smoking rates, isolated patients did not differ from nonisolated patients on demographic indicators, disease severity, physical functioning, or psychological distress. Isolated patients reported less social support and were less pleased with the way they got along with network members, but they did not report less satisfaction with the amount of social contact received. CONCLUSIONS: Patients with small social networks had an elevated risk of mortality, but this greater risk was not attributable to confounding with disease severity, demographics, or psychological distress. These findings have implications for mechanisms linking social isolation to mortality and for the application of psychosocial interventions.     

Psychosocial Stress and Cardiovascular Disease: Pathophysiological Links

Abstract

The remarkable decline in cardiovascular disease (CVD) experienced in developed countries over the last 40 years appears to have abated. Currently, many CVD patients continue to show cardiac events despite optimal treatment of traditional risk factors. This evidence suggests that additional interventions, particularly those aimed at nontraditional factors, might be useful for continuing the decline. Psychosocial stress is a newly recognized (nontraditional) risk factor that appears to contribute to all recognized mechanisms underlying cardiac events, specifically, (a) clustering of traditional cardiovascular risk factors, (b) endothelial dysfunction, (c) myocardial ischemia, (d) plaque rupture, (e) thrombosis, and (f) malignant arrhythmias. A better understanding of the behavioral and physiologic associations between psychosocial stress and CVD will assist researchers in identifying effective approaches for reducing or reversing the damaging effects of stress and may lead to further reductions of CVD morbidity and mortality.     

Psychosocial treatments in pain management of sickle cell disease

The principal symptom of sickle cell disease (SCD) is pain. Many studies have been conducted on pain management strategies for this illness. There is recognition that psychosocial factors influence clinical disease outcomes; therefore, more attention is being provided to behavioral interventions that address psychosocial problems. This review examines the psychosocial interventions that have been researched for children and adults with SCD, the limitations of these studies, and barriers to implementing the treatments. The intervention receiving the most empirical support was cognitive-behavioral therapy. Additional research is needed to define the efficacy and effectiveness of the other psychosocial treatments. Suggestions for future investigations include conducting research that has better methodology, and providing more education for health care providers about psychosocial treatments and the importance of considering cultural factors in health care delivery. In addition, individuals with SCD need to have more information about their illness and better access to psychosocial interventions.     

A psychosocial risk assessment model (PRAM) for use with pregnant and postpartum women in primary care settings

Recognition of high rates of mental health morbidity and mortality that affect women during the perinatal period has prompted the development of psychosocial risk assessment programs. Designed to identify women, at risk, during routine health checks and delivered by primary care health service providers, these fit within a primary prevention and early intervention strategic approach to the reduction of perinatal mental illness and reflect an integrated approach to perinatal health services delivery. This paper describes the development and use of the psychosocial risk assessment model (PRAM) at the Royal Hospital for Women in Sydney, Australia. Data is presented on 2,142 women who attended the Antenatal Midwives Clinic between 2002 and 2005. The PRAM guides primary care staff to quickly identify women experiencing emotional distress and/or psychosocial problems during pregnancy or postnatal checks. Measures used in pregnancy are the symptom-based Edinburgh Depression Scale and the psychosocial risk-based Antenatal Risk Questionnaire. In postnatal setting the Postnatal Risk Questionnaire is used. Scores can be used to compute a Psychosocial Risk Index (PRI) to guide individualized care planning, define needs for referral and classify groups for clinical and research purposes. Based on the PRI, among 2,142 women assessed in pregnancy 70.6% were classified as low/no risk (no interventions indicated currently), 24.1% as medium risk (in need of monitoring), and 5.3% as high risk (complex). The PRAM offers a conceptual framework, methods and measures for brief psychosocial assessment with clinical and research applications. Postpartum follow up studies of women assessed during pregnancy have commenced. Randomized controlled trials and cross-cultural studies are now indicated to strengthen the evidence base for the model.     

n-3 PUFAs-From dietary supplements to medicines.

Although there has been a great progress in the prevention of cardiovascular diseases, the mortality of patients with acute myocardial infarction (AMI) still remains high. One of the most important underlying causes explaining this phenomenon is the sudden cardiac death. Nearly half of all cardiovascular deaths in the USA each year is attributed to this unpredictable and unexpected complication of AMI. Hence, there is an urgent medical need for a targeted therapy to reduce the incidence of sudden cardiac death. Since 1980 there have been several epidemiological and other studies concerning the benefits of n-3 polyunsaturated fatty acids (n-3 PUFAs) in cardiovascular health and prevention. Results from one of the largest studies, GISSI Prevenzione Trial show that adding the n-3 PUFAs to standard therapy of patients who survived AMI reduces sudden cardiac death (44% risk reduction, p=0.0006). In addition, significant decline in all-cause cardiovascular mortality (21% risk reduction, p=0.0064) further emphasizes the role of n-3 PUFA in cardiovascular prevention. To date, beneficial effects of n-3 PUFA are attributed to their antiarrhythmic, lipid lowering, antithrombotic and anti-inflammatory properties. To conclude, EPA and DHA improve the prognosis of cardiovascular patients in the secondary prevention of sudden cardiac death without any documented side effects.     

Cardiovascular Reactivity During Positive and Negative Marital Interactions

Marriage reduces risk of cardiovascular disease (CVD) but marital stress increases risk, perhaps through cardiovascular reactivity (CVR). However, previous studies have lacked controls necessary to conclude definitively that negative marital interactions evoke heightened CVR. To test the specific effects of marital stress on CVR, 114 couples engaged in positive, neutral, or negative interactions in which speaking and task involvement were controlled. Compared to positive and neutral conditions, negative discussions evoked larger increases in systolic blood pressure, heart rate, and cardiac output, and larger decreases in peripheral resistance and pre-ejection period--similarly for men and women. Hence, CVR could contribute to the effects of marital difficulties on CVD. Previous evidence of sex differences in this effect might reflect factors other than simple reactivity to negative interactions.     

Does calcium intake affect cardiovascular risk factors and/or events?

Dietary intervention is an important approach in the prevention of cardiovascular disease. Over the last decade, some studies have suggested that a calcium-rich diet could help to control body weight, with anti-obesity effects. The potential mechanism underlying the impact of calcium on body fat has been investigated, but it is not fully understood. Recent evidence has also suggested that a calcium-rich diet could have beneficial effects on other cardiovascular risk factors, such as insulin resistance, dyslipidemia, hypertension and inflammatory states. In a series of studies, it was observed that a high intake of milk and/or dairy products (the main sources of dietary calcium) is associated with a reduction in the relative risk of cardiovascular disease. However, a few studies suggest that supplemental calcium (mainly calcium carbonate or citrate) may be associated with an increased risk of cardiovascular events. This review will discuss the available evidence regarding the relationship between calcium intake (dietary and supplemental) and different cardiovascular risk factors and/or events.     

Individualised multifactorial lifestyle intervention trial for high-risk cardiovascular patients in primary care.

BACKGROUND: The multiprofessional teams in Finnish health centres are well placed to carry out interventions aimed at the prevention of cardiovascular diseases. AIM: To evaluate the effectiveness of an individually tailored multifactorial lifestyle intervention in primary care for individuals at high risk for cardiovascular disease. DESIGN OF STUDY: A randomised controlled trial was conducted over 24 months with interim assessments at six and 12 months. SETTING: A health centre in Finland with a patient population of 11,000. METHOD: One hundred and fifty adults aged 18 to 65 years old with existing cardiovascular disease or multiple risk factors were randomised to active multiprofessional risk factor intervention or to standard care. The main outcome measure was a change in cardiovascular risk-factor score. Secondary outcomes were changes in blood pressure, weight, body-mass index, serum cholesterol, blood glucose, smoking cessation, and exercise habits. RESULTS: The cardiovascular risk score decreased by 28% in the intervention group (23% in the control group), body weight decreased by 3.7% (2%) and total cholesterol decreased by 10.8% (6.5%), while time engaged in exercise increased by 39% (43%). Differences were not significant. CONCLUSIONS: Cardiovascular risk levels of high-risk individuals decreased in both intervention and control groups. Primary care prevention should be targeted to high-risk persons. Long-term follow-up studies are needed.     

The Role of Carotid Ultrasound for Cardiovascular Risk Stratification beyond Traditional Risk Factors

Primary prevention and early detection of cardiovascular disease is important, as it is the leading cause of death throughout world. Risk stratification algorithms, such as Framingham Risk Score and European Systematic Coronary Risk Evaluation, that utilize a combination of various traditional risk factors have been developed to improve primary prevention. However, the accuracy of these algorithms for screening high risk patients is moderate at best. Accordingly, the use of biomarkers or imaging studies may improve risk stratification. Carotid ultrasound, which measures both carotid intima-media thichkness (cIMT) and carotid plaque, is useful in detecting the degree of subclinical carotid atherosclerosis, and has the advantage of being noninvasive and safe. Several large epidemiologic studies have indicated that cIMT and carotid plaque are closely related with other cardiovascular risk factors and may be useful for risk reclassification in subjects deemed to be at intermediate risk by traditional risk scores. Moreover, recent clinical guidelines for management of hypertension or dyslipidemia highlight the usefulness of cIMT in high risk patients. In this article, we review evidence for the usefulness of measurement of cIMT and carotid plaque for cardiovascular risk stratification.     

C-reactive protein: a nontraditional serum marker of cardiovascular risk.

Cardiovascular disease (CVD) is multifactorial in etiology. Traditional cardiovascular risk factors, such as increased cholesterol concentrations and blood pressure, are used to assess CVD risk. Recently, better understanding of the role of inflammation in atherosclerosis has prompted many to propose the measurement of various inflammatory markers to better identify those who are at increased risk. C-reactive protein (CRP) is found in endothelial atherosclerotic lesions, and evidence suggests that it may play a role in atherogenesis. Of candidate serum markers that might add information to clinical risk assessment, high-sensitivity C-reactive protein (hsCRP) measurement has the most potential for clinical use for multiple reasons: (a) high hsCRP is associated with a twofold to a threefold increase in the prevalence of myocardial infarction, stroke, and peripheral vascular disease, and it predicts incident cardiovascular events in those with and without preexisting CVD; (b) the increased risk associated with high hsCRP is independent of other established risk factors; (c) hsCRP augments the predictive capacity of the Framingham Risk Score; (d) hsCRP assays are standardized, and this analyte is biologically stable over time; (e) various risk-reducing interventions also reduce hsCRP, and research is underway to assess whether specifically targeting hsCRP reduces CVD risk. National guidelines regarding the clinical utility of hsCRP in primary and secondary prevention settings have been recently issued.     

Web-Based Interventions Targeting Cardiovascular Risk Factors in Middle-Aged and Older People: A Systematic Review and Meta-Analysis

BackgroundWeb-based interventions can improve single cardiovascular risk factors in adult populations. In view of global aging and the associated increasing burden of cardiovascular disease, older people form an important target population as well.ObjectiveIn this systematic review and meta-analysis, we evaluated whether Web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people.MethodsEmbase, Medline, Cochrane and CINAHL were systematically searched from January 1995 to November 2014. Search terms included cardiovascular risk factors and diseases (specified), Web-based interventions (and synonyms) and randomized controlled trial. Two authors independently performed study selection, data-extraction and risk of bias assessment. In a meta-analysis, outcomes regarding treatment effects on cardiovascular risk factors (blood pressure, glycated hemoglobin A1c (HbA1C), low-density lipoprotein (LDL) cholesterol, smoking status, weight and physical inactivity) and incident cardiovascular disease were pooled with random effects models.ResultsA total of 57 studies (N=19,862) fulfilled eligibility criteria and 47 studies contributed to the meta-analysis. A significant reduction in systolic blood pressure (mean difference –2.66 mmHg, 95% CI –3.81 to –1.52), diastolic blood pressure (mean difference –1.26 mmHg, 95% CI –1.92 to –0.60), HbA1c level (mean difference –0.13%, 95% CI –0.22 to –0.05), LDL cholesterol level (mean difference –2.18 mg/dL, 95% CI –3.96 to –0.41), weight (mean difference –1.34 kg, 95% CI –1.91 to –0.77), and an increase of physical activity (standardized mean difference 0.25, 95% CI 0.10-0.39) in the Web-based intervention group was found. The observed effects were more pronounced in studies with short (<12 months) follow-up and studies that combined the Internet application with human support (blended care). No difference in incident cardiovascular disease was found between groups (6 studies).ConclusionsWeb-based interventions have the potential to improve the cardiovascular risk profile of older people, but the effects are modest and decline with time. Currently, there is insufficient evidence for an effect on incident cardiovascular disease. A focus on long-term effects, clinical endpoints, and strategies to increase sustainability of treatment effects is recommended for future studies.     

Adequate nutrient intake can reduce cardiovascular disease risk in African Americans

Cardiovascular disease kills nearly as many Americans each year as the next seven leading causes of death combined. The prevalence of cardiovascular disease and most of its associated risk factors is markedly higher and increasing more rapidly among African Americans than in any other racial or ethnic group. Improving these statistics may be simply a matter of improving diet quality. In recent years, a substantial and growing body of evidence has revealed that dietary patterns complete in all food groups, including nutrient-rich dairy products, are essential for preventing and reducing cardiovascular disease and the conditions that contribute to it. Several cardiovascular risk factors, including hypertension, insulin resistance syndrome, and obesity, have been shown to be positively influenced by dietary patterns that include adequate intake of dairy products. The benefits of nutrient-rich dietary patterns have been specifically tested in randomized, controlled trials emphasizing African American populations. These studies demonstrated proportionally greater benefits for African Americans without evidence of adverse effects such as symptoms of lactose intolerance. As currently promoted for the prevention of certain cancers and osteoporosis, regular consumption of diets that meet recommended nutrient intake levels might also be the most effective approach for reducing cardiovascular disease risk in African Americans.     

Older men's knowledge about osteoporosis and educational interventions to increase osteoporosis knowledge in older men: a systematic review

Objective

The prevalence of osteoporosis and low bone density in men over the age of 65 is approximately 45%. The public health response to a disease affecting almost half of a given population includes assessment of knowledge and design of educational interventions in order to improve screening and prevention. The aim of this systematic review is two fold. We aim to describe older men's knowledge about the osteoporosis disease process, risk factors, and prevention. Second, we examine educational interventions designed to increase older men's knowledge about osteoporosis.

Methods

Computerized literature searches were performed with multiple databases including Academic Search Premier, CINAHL, MEDLINE, SocINDEX, and Psychology and Behavioral Sciences Collection. Studies were considered if they included men aged 50 years or older, included a measure of osteoporosis knowledge and/or had an intervention designed to change osteoporosis knowledge and/or lifestyle risk factors for osteoporosis.

Results

Thirteen studies were included in the review. Nine of the studies were cross-sectional studies on men's knowledge of osteoporosis. All of the studies found that men have minimal knowledge of the osteoporosis disease process, risk factors, and prevention. Four studies focused on education about osteoporosis. Educational interventions were found to increase initiation of calcium supplementation and knowledge about osteoporosis prevention.

Conclusion

Older men know remarkably little about the osteoporosis disease process, risk factors for the disease, or prevention. Education has the potential to improve this situation. Unfortunately, so few clinical trials have occurred that the best method for improving men's knowledge cannot be stated. Future studies examining knowledge and education of osteoporosis for men need to use validated instruments with a focus on risk factors pertinent to men.     

Behavioral mediation of the relationship between psychosocial factors and HIV disease progression

The psychological and physical demands of coping with medication side effects and comorbid illnesses can be overwhelming and may influence behaviors, such as medication adherence, substance use, sexual risk behavior, and exercise that, in turn, affect health outcomes. Cross-sectional and prospective studies among diverse populations of persons living with HIV suggest that these behavioral mechanisms may be associated with HIV disease progression. The motivation to change behavior is often highest in the immediate aftermath of a stressor. However, over time the motivation to continue a particular behavior change is often challenged by habits, environmental influences, and psychosocial factors. Furthermore, a number of studies suggest that behavioral mechanisms may mediate the relationship between psychosocial variables (e.g., stress, depression, coping, and social support) and disease progression in HIV. Thus, developing clinical interventions that address these psychosocial factors and enhance protective health behaviors and reduce behaviors that convey risk to health are likely to lessen overall morbidity and mortality among patients living with HIV/AIDS.