COMMENTARY

Treating the Person: The Mind-Body-Heart Connection

Neil Skolnik, MD

Disclosures

October 19, 2022

This transcript has been edited for clarity.

I'm Dr Neil Skolnik, and today we are going to talk about the American Heart Association's Scientific Statement on the mind-heart-body connection. This scientific statement provides an in-depth discussion of the evidence connecting how we think and feel with our cardiovascular (CV) outcomes. This wonderful paper goes over the modern evidence that supports what the ancient Greeks called "a healthy mind in a healthy body," and what Hippocrates claimed, that "the natural healing force within each one of us is the greatest force in getting well."

The article says, essentially, that "the mind, heart, and body are interconnected and interdependent." Most of us in primary care know that, but it is nice to see the evidence. Let's go over some of the evidence and touch on some of the mechanisms by which these connections occur.

First, chronic stress. Two different meta-analyses of prospective studies covering more than 100,000 people showed that stress was associated with 27%-40% increased risk for coronary disease and CV disease. Social isolation and loneliness — both far too common — are linked to a linked to a 50% increased risk for incident CV events. The mechanism may be that chronic stress can lead to increased sympathetic tone and decreased vagal tone, increased arterial stiffness and inflammation, and endothelial dysfunction.

Let's now talk about anxiety and depression. A meta-analysis of more than 2 million adults from 46 studies showed that those with anxiety had a 40% increase in risk for CV mortality. In a meta-analysis of almost 900,000 people from 30 studies, depression was associated with a 30% increased risk for myocardial infarction (MI). Another large meta-analysis showed a 45% increase in the risk for stroke. The strength of relation here is so strong that the American Heart Association considers depression a risk factor for recurrent CV events in people who have had an acute coronary syndrome (ACS).

Even chronic anger and hostility appear to increase adverse CV events by 19% in healthy people, and they increase recurrent events by 24% in people who have CV disease. Studies have even shown that there is an increase in the rate of CV events, including MI/ACS, stroke, and ventricular arrhythmias, in the 2 hours after an outburst of anger. So be careful. The mechanism here is that anger is associated with increased platelet aggregation and an elevation in catecholamine levels that can induce myocardial ischemia.

There are some fascinating data on pessimism. An 11-year cohort study showed that pessimistic people may have double the risk for coronary heart disease mortality when comparing those in the highest vs lowest quartiles on a pessimism rating scale.

How about the positive side of things? A recent meta-analysis included 15 observational studies of more than 220,000 individuals and found that higher levels of optimism were associated with a 35% decreased risk for CVD and a 14% decreased risk for all-cause mortality. It may be that the mechanism at work here is the fact that optimism is associated with healthier behaviors: more physical activity; not smoking; better diets, relationships, and sleep quality. Optimistic people have 50%-70% greater odds of living to 85 years of age and beyond.

On another trait — a sense of purpose — 10 prospective studies of more than 300,000 participants showed that those with a greater sense of purpose have a 17% decrease in the risk for CV events and all-cause mortality. You get the picture: Attitude, emotion, and connection with others matter. Other traits associated with good outcomes include happiness, mindfulness, and gratitude.

While the correlations and mechanisms at this point are pretty solid, we still do not have convincing evidence about interventions. Interventions such as selective serotonin reuptake inhibitors and cognitive-behavioral therapy for depression, or stress management training for stress, have some positive studies, but there are also studies that do not show an effect on CV outcomes, although many studies were underpowered to detect an effect.

It is about 45 years since George Engel published his seminal paper in the journal Science, coining the term biopsychosocial as a new model of medicine. This is one of the tenets of family medicine — to pay attention to the context (social and psychological) in which illness occurs. This scientific statement by the AHA gives us a detailed understanding of this context for the development of heart disease. It is now up to us to figure out how to best use this information with our patients.

I'm Neil Skolnik, and this is Medscape.

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