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Chapter 13

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PSYC 314
Frances Chen

Chapter 13: What is Coronary heart disease? -number 2 killer in Canada, a major chronic disease -accounts for 20 percent of deaths in men and over 22 percent in women (most occur before age 75) -CHD caused by atherosclerosis, narrowing of the arteries blocking flow of blood to the heart -temporary shortages of blood flow cause pain like angina pectoris which radiates across the chest and arms which may result in a heart attack (myocardial infarction) Causes: pro-inflammatory cytokine stimulates the process of atherosclerotic plaque buildup - low grade inflammation appears to underlie most cases of CHD - presence of C-reactive protein predicts heart disease (is produced by acute/chronic inflammation showing damage to the arterial walls) - waist circumference, low levels of physical activity (can also be associated with C-levels as well) - CHD considered systemic disease rather than coronary artery disease because is responsive the the inflammatory process - other risk factors include high blood pressure, diabetes, smoking, obesity, high cholesterol, air pollution metabolic syndrome (obesity centered around waist, high B.P., low levels of HDL good cholesterol, difficulty metabolizing sugar, high levels of triglycerides - family history: genetically based related to low SES. Exposure to stress and family relationship problems may also explain why the factors are related to CHD Role of Stress: -cardiovascular reactivity contributes to CHD by damaging of the endothelial cells which facilitates the deposit of lipids, increase in inflammation, ultimately contributes to atherosclerotic lesions -reactivity to stress via hostility may interact with other risk factors to enhance overall risk -CHD more common in low SES people, especially males and symptoms develop earlier (these patterns reflect high rates of physical inactivity, smoking, elevated cholesterol, being overweight -one study found that higher work stress was related to low physical activity and poor diet which increase risk for angina, and people whose lives have high levels of demands coupled with low levels of control outside the workplace experience a higher risk for atherosclerosis -industrialized countries have have higher incidence of CHD then underdeveloped -migrants have higher incidence of CHD then geographically stable individuals, and becoming adapted to westernized foods risks chance of high blood pressure Women and CHD: -CHD lead killer in women in Canada, 2003 accounted for 37 percent of deaths, know less about heart disease then men -less likely to recover from an CH event then men, few women referred to seeing a specialist after heart attack (getting medication, counseling etc.), and 17 percent more die for heart problems compared to men, more likely to be misdiagnosed -34 percent can’t work compared to 18 percent of men -more protected at a younger age then men because of their higher levels of HDL (higher levels of estrogen) estrogen may help B.P. neuroendocrine and metabolic responses as well -however, they experience a higher risk after menopause because of typical weight gains and increases in BP and cholesterol, tryglicerides -experience more anxiety after a heart attack then men do -more likely referred to long term care facilities rather then sent home, also experience poorer quality of life - In one study women with chest pain were viewed as less important vs male patients in getting medical intervention (although was found that women do report more pain/ emotional symptoms/ loss of appetite as opposed to men) - similar facts between genders: social support related to less advanced disease, hostility linked to poor cardiovascular recovery, as is pessimism -progression of CHD predicted by anger and metabolic syndrome -job related factors can predict CHD Cardiovascular Reactivity, Hostility, and CHD -cynical hostility: suspiciousness, resentment, frequent anger, antagonism, distrust of others. -appear to be negative to others and further increase risk of CHD -people both hostile and defensive show greatest association between cardiovascular response under stressful situations -more men are hostile, one study found that hostility was significantly associated with a variety of CHD risk factors including cholesterol levels in white men but unrelated to CHD risk factors in women -higher hostility found in non whites with lower SES -particular child-rearing practices may foster hostility (lack of acceptance, abuse etc), as well as genetic and environmental factors as well as hyperactivity -another study found that among hostile individuals, those who suppress hostility interpersonally had higher cardiovascular reactivity than those who expressed hostility -this relationship may not be as reliable for women as in men -hostile individuals have less social support, or may see social support as stressful rather then supportive: In a study of 60 couples of agree/disagreeing with each other, husbands who were high in hostility showed greater BP reactivity in response to martial interaction in response to threat, however, the same relationship was not found in wives -hostile people show a weak response to sympathetic activity in response to stress saying their initial reaction to stress is greater and will last longer, and show more psychological reactions to interpersonal stressors, they also have different patterns of immune activation in response to sympathetic immune activation which may contribute to accelerated development of heart disease -when paired with anger and depression, hostility predicts high levels of c- reactive protein and reactivity-hostility relationship thought of as a biopsychosocial process -stress causes vasorestriction causing wear and tear of the arteries which produces atherosclerotic lesions, BP variability may produce plaque formation -more factors to coronary heart disease: catecholamines exert a direct chemical effect on blood vessels, sympathetic activation causes lipids to be shunted from the blood stream, low levels of tonic vagal cardiac control, stress can contribute to migration and recruitment of immune cells to sites of infection and inflammation Depression and CHD -depression is a major independent factor in it’s own right, environmentally with CHD -depression linked to metabolic syndrome, likelihood of a heart attack, heart failure in the elderly, hopelessness -depression strongly related to elevated C-reactive protein, a marker for low-grade systematic inflammation (depression promotes inflammation), and also associated with indicators of the metabolic syndrome -treated by seritonin re-uptake inhibitors which prevent seritonin from attaching to receptors which prevents formation of blood clots Other Psychological Factors and CHD -anxiety, helplessness, pessimism, tendency to ruminate over problems -social dominance is related to mortality due to heart disease -vital exhaustion, extreme fatigue may predict likelihood of heat attack Modification of CHD Risk-Related Behaviours: -interventions regarding risk-related behaviours at an individual level -programs for diet restrictions for people with high cholesterol, programs for smoking and heart disease, exercise for reducing CHD effects, psychological well-being, and morbidity, weight management Management of Heart Disease: Role of Delay: 6 percent of canadians report having heart problems, one of the problems for high rates of mortality and disability is because people don’t get help with treatment soon enough (ex. unable to face the fact they had a heart attack, depressed etc.) Initial Treatment: one study followed 266 patients waiting to have CABg in montreal from the time they were on the waiting list until the time they had surgery. Symptoms and quality of life were measured initially and after 6 months of surgery. Scores of the physical/social functioning scales of SF-36 were significantly lower for those who had to wait more than 3 months for the CAGB and longer wait times were associated with an increased number of adverse cardiac events and increased risk for unemployment post surgery. Cardiac Rehabilitation: once acute phase has passed, patients are encouraged to become active by means of education with health risks, diet, emotional stress and work as well as take part in exercise. (women receive less information then men) - involvement in treatment can improve self efficiency and better health - cardiac rehabilitation: the active process by which individuals with heart disease attain their optimal physical, medical, SES status. goals are to reduced symptoms and severity of disease - depends on the ability of the patient to act to his/her full potential to getting better - more specific programs (ex. specified to women’s health have an 85 percent complete rate as opposed to a typical rehabilitation of 50 percent Treatment by Medication: clot dissolving drugs and medical procedures such as angioplasty and coronary artery bypass surgery, once acute phase is over, preparing for a rehabilitation begins such as beta blocking agents (resist the effects of the sympathetic nervous system stimulation) or aspirin (prevent blood clots) and statins (target LDL cholesterol and lower lipids) Diet and Activity Level: getting back into regular jobs is suggested, however, if some patients have a high stress job they are recommended to cut back, when patients have families that have low income, they may need a form of counseling to adjust to the low SES loss Stress Management: stress can trigger fatal cardiac events (those who are young, female and have high conflict/negative events are most at risk) so it is important in rehabilitation Targeting Depression: CHD patients with high depression/ anxiety have decreased heart rate variability as compared with norms so they have sustained alterations in their autonomic nervous system modulation over time Evaluation of Cardiac Rehabilitation: most studies find that interventions involving weight control, BP reduction, smoking and increasing quality of life are successful in reducing patients standing risk factors for disease. People who are optimistic with high levels of social support do better Problems of Social Support: In one study, patients without a spouse were twice as likely to die rather then someone who was married/with a partner -rehabilitation situations may be difficult (feelings of hopelessness, low self- esteem) therefore some social support may be interpreted as criticism or controlling behaviour causing more stress -some spouses may become stressed over their partner as a patient and become stressed and overprotective of them in survival (good to get counseling for this) -cardiac invalidism: patients and their spouses both see the patients abilities as lower then they are, in a study it was seen better that the wives who took part in their husbands rehabilitation performance (as to getting better/ improving progress) increased their perception of his cardiac efficiency as opposed to wives that were told of their husbands efficiency and just kept seeing them as impaired -approx. 80 percent of potential sudden deaths from heart attacks occur in the home rather then the workplace so it is suggested that family members learn CPR What is Hypertension? -High blood pressure, occurs when the supply of blood through the vessels is excessive -cardiac input is too high (pressure to arterial walls, as blood flow increases) -resistance to blood flow through the small arteries of the body -Hypertension is considered an important risk factor for cardiac, cerebrovascular disease and accounts for 7.5 million deaths per year. -19 percent of canadians have blood pressure, 20 percent (pre- hypertension range) How is it measured? -assessed by levels of systolic and diastolic blood pressure as measure by a sphygmomanometer (systolic- contraction, diastolic-relaxed) -systolic greater value in diagnosing hypertension -mild hypertension =systolic pressure of 140-159 -moderate “ =160-179 -severe “= above 180.............keeping it below 120 is best! -people at risk show a less rapid recovery following sympathetic arousal (stays higher longer) therefore it may be characterized as greater reactivity to stress and slower recovery -patients can show dampened emotional response and reduced pain sensitivity What are the Causes? -5 % of Hyp. is caused by failure of the kidneys to regulate blood pressure, however almost 90% is of unknown origin -genetic factors (if one parent has it, 45% chance giving it to child, if both parents do, 95 % chance!) -genetic factor may be reactivity, a hereditary pre-disposition toward elevated sympathetic nervous system activity especially in response to stress -for those with a family history, but don’t have the disease themselves have an anticipation of stress and greater cardiovascular activity -prior to age 50, males are at a greater risk than females, above 55, both men and women face a 90 percent chance of developing in Canada -cardiovascular disease risk factors higher for min
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