David S. Krantz

Assessment of Preferences for self-treatment and information in health care.

It has been assumed that it is beneficial for patients to become active and informed participants in health care. Previous research, however, suggests that individuals differ in their receptiveness to information and self-care in treatment stiuations. This article reports the development and validation of the Krantz Health Opinion Survey, a measure of preferences for different treatment approaches. This measure yields a total score and two relatively independent subscales that measure, respectively, preferences for information and for behavioral involvement (i.e., self-care and active participation) in medical care. Three related studies demonstrated the ability of the subscales or total score to predict with some specificity (a) criterion group membership (clinic users and enrollees in a self-care course), (b) reported use of clinic facilities, and (c) overt behavior (e.g., inquisitiveness, self-diagnosis) in a medical setting. Discriminant validity of the instrument is also established. Theoretical implications of the preference constructs are described in terms of the concept of personal control, and practical implications of the measure are presented.

Mental Stress–Induced Ischemia in the Laboratory and Ambulatory Ischemia During Daily Life Association and Hemodynamic Features

BACKGROUND The purpose of this study was to determine the correspondence of mental stress-induced ischemia in the laboratory with ambulatory ischemia and to assess the relationship between hemodynamic responses to mental stress and the occurrence of ischemia. Although exercise testing is usually used to elicit myocardial ischemia, ischemia during daily life usually occurs at relatively low heart rates and in the absence of strenuous physical exercise. Mental stress has been shown to trigger ischemic events in the laboratory at lower heart rates but at blood pressures comparable to exercise. We therefore compared the extent to which mental stress and exercise testing identify patients who develop ischemia out of hospital. METHODS AND RESULTS One hundred thirty-two patients with documented coronary disease and recent evidence of exercise-induced myocardial ischemia underwent 48-hour ambulatory monitoring and radionuclide ventriculography during exercise and mental stress testing. Patients who displayed mental stress-induced ischemia in the laboratory were more likely to exhibit ischemia during daily life (P < .021). Furthermore, patients who exhibited ischemia during ambulatory monitoring displayed larger diastolic blood pressure (P < .006), heart rate (P < .039), and rate-pressure product responses (P < .018) during mental stress. CONCLUSIONS Among patients with prior positive exercise stress tests, mental stress-induced ischemia, defined by new wall motion abnormalities, predicts daily ischemia independent of exercise-induced ischemia. Exaggerated hemodynamic responses during mental stress testing also identify individuals who are more likely to exhibit myocardial ischemia during daily life and mental stress.

Triggers of myocardial ischemia during daily life in patients with coronary artery disease : Physical and mental activities, anger and smoking

OBJECTIVES This study assessed the potency of physical and mental activities and emotions (anger and anxiety) and smoking and other substance use as proximate triggers of ischemia in patients with coronary artery disease during daily life. BACKGROUND Myocardial ischemia occurs during a wide variety of activities in patients with coronary artery disease, but frequency and relative potency of physical and mental activities, smoking and use of caffeine and alcohol as triggers of ischemia during daily life have not been established. METHODS Patients (n = 63) with coronary artery disease and evidence of out-of-hospital ischemia kept a validated structured diary of physical and mental activities and psychologic states while undergoing ambulatory electrocardiographic monitoring for 24 to 48 h. RESULTS Ischemia occurred most frequently during moderately intense physical and mental activities. Patients spent the largest proportion of time engaged in low intensity physical and mental activities (p < 0.05), but the likelihood of ischemia was greatest during intense physical (p < 0.0001) and stressful mental activities (p < 0.03). The percentage of time in ischemia was elevated and approximately equivalent for high intensity physical and high intensity mental activities (5%) compared with 0.2% when patients were engaged in low intensity activities. Strenuous physical activity (e.g., effortful walking, p < 0.05) and the experience of intense anger were potent ischemic triggers, and heart rates at onset of ischemia increased with the intensity of physical and mental activity and with anger. Among smokers, ischemia was more than five times as likely when patients smoked than when they did not (during 24% vs. 5% of diary entries, p < 0.0001). Coffee and alcohol consumption were also related to ischemia (p < 0.05), but this association disappeared after controlling for concurrent cigarette smoking. CONCLUSIONS Triggers of ischemia in patients with coronary artery disease during daily life include not only strenuous exercise, but also activities involving low levels of exertion, such as anger and smoking. Mental activities appear to be as potent as physical activities in triggering daily life ischemia. Coffee and alcohol consumption are related to ischemia only by virtue of their associations with smoking.

MENTAL STRESS AS A TRIGGER OF MYOCARDIAL ISCHEMIA AND INFARCTION

Recent research on the effects of behavioral activities on myocardial ischemia in coronary artery disease patients has provided a pathophysiologic model for understanding the mechanisms by which mental stress can trigger clinical cardiovascular events. This article reviews epidemiologic research implicating psychosocial stress as an acute trigger of myocardial infarction in patients with pre-existing coronary artery disease, and evidence for the pathophysiologic effects of acute mental stress in individuals with pre-existing coronary artery disease. Via its actions on the central and autonomic nervous systems, stress can produce a cascade of physiologic responses in vulnerable individuals that may lead to myocardial ischemia, ventricular fibrillation, plaque rupture, or coronary thrombosis. Also reviewed are field and laboratory studies that suggest important causal links between mental stress and myocardial ischemia, and evidence suggesting clinical significance for vulnerability to mental stress-induced ischemia.

Depression, the metabolic syndrome and cardiovascular risk.

Background: The relationship between depression and the metabolic syndrome is unclear, and whether metabolic syndrome explains the association between depression and cardiovascular disease (CVD) risk is unknown. Methods: We studied 652 women who received coronary angiography as part of the Womens Ischemia Syndrome Evaluation (WISE) study and completed the Beck Depression Inventory (BDI). Women who had both elevated depressive symptoms (BDI ≥10) and a previous diagnosis of depression were considered at highest risk, whereas those with one of the two conditions represented an intermediate group. The metabolic syndrome was defined according to the ATP-III criteria. The main outcome was incidence of adverse CVD events (hospitalizations for myocardial infarction, stroke, congestive heart failure, and CVD-related mortality) over a median follow-up of 5.9 years. Results: After adjusting for demographic factors, lifestyle and functional status, both depression categories were associated with about 60% increased odds for metabolic syndrome compared with no depression (p = .03). The number of metabolic syndrome risk factors increased gradually across the three depression categories (p = .003). During follow-up, 104 women (15.9%) experienced CVD events. In multivariable analysis, women with both elevated symptoms and a previous diagnosis of depression had 2.6 times higher risk of CVD. When metabolic syndrome was added to the model, the risk associated with depression only decreased by 7%, and both depression and metabolic syndrome remained significant predictors of CVD. Conclusions: In women with suspected coronary artery disease, the metabolic syndrome is independently associated with depression but explains only a small portion of the association between depression and incident CVD. BDI = Beck Depression Inventory; CAD = coronary artery disease; CVD = cardiovascular disease; DASI = Duke Activity Status Inventory; HDL = high-density lipoprotein; LDL = low-density lipoprotein; WISE = Womens Ischemia Syndrome Evaluation; NHLBI = National Heart, Lung, and Blood Institute.

Cardiovascular reactivity and mental stress-induced myocardial ischemia in patients with coronary artery disease.

&NA; This report evaluates the relationships of hemodynamic reactivity and determinants of myocardial oxygen demand to myocardial ischemia during mental stress in coronary artery disease patients. Thirty‐nine patients and 12 controls were studied by radionuclide ventriculography during three mental tasks (arithmetic, Stroop task, and simulated public speaking). Patients were subdivided into three groups based on the severity of ischemic wall motion responses to the mental stressors. Results revealed that systolic blood pressure (SBP) levels during the mental tasks and SBP reactivity (increases) to stress were highest for the severely ischemic group, lowest for controls, with the mild‐moderate ischemic and nonischemic patients in between. Severely ischemic patients started out with lower double product (heart rate x SBP) levels, and reached higher levels during the Stroop and speech tasks. There were no reliable group effects for diastolic blood pressure, heart rate, or left ventricular end‐diastolic volumes. Among severely ischemic patients, the most potent task in eliciting ischemia (the speech) was associated with higher cardiovascular levels and elicited greater heart rate, double product, and ventricular volume responses. The present data indicate a relationship between cardiovascular levels and reactivity and the magnitude of ischemia induced by mental stress.

Frontal electrocortical and cardiovascular reactivity during happiness and anger.

The present study investigated electrocortical and cardiovascular reactivity during positive and negative emotion, and examined the relation of asymmetric frontal lobe activation to cardiovascular responses. Participants were 30 healthy, right-handed university students (mean age, 23.9; 60% female; 76% Caucasian). Electroencephalographic (EEG), blood pressure (BP), and heart rate (HR) responses were assessed while subjects engaged in laboratory tasks (personally-relevant recall tasks and film clips) designed to elicit happiness or anger. Happiness-inducing tasks evoked more prominent left than right frontal EEG activation, and greater left frontal EEG activation than anger-inducing tasks. However, anger-inducing tasks were, on average, associated with comparable left and right frontal EEG activation. Irrespective of emotional valence, cardiovascular activation was more pronounced during personally-relevant recall tasks than during the viewing of film clips. During anger recall, both greater left frontal EEG response (r=-0.46, P<0.02) and greater right frontal EEG response (r=-0.45, P<0.02) were correlated significantly with increased HR reactivity during the task. In addition, a right lateralized frontal EEG response during anger-inducing tasks was associated with greater concomitant systolic BP (P<0.03) and diastolic BP (P<0.008) reactivity. Exploratory analyses also indicated that men who displayed a left lateralized frontal EEG response during happiness-inducing tasks showed the greatest concomitant systolic BP and HR reactivity (Ps<0.03). These findings suggest that asymmetric frontal EEG responses to emotional arousal may elicit different patterns of cardiovascular reactivity in healthy adults.

Effects of Acute Mental Stress and Exercise on T-Wave Alternans in Patients With Implantable Cardioverter Defibrillators and Controls

Background—Malignant cardiac arrhythmias can be triggered by exercise and by mental stress in vulnerable patients. Exercise-induced T-wave alternans (TWA) is an established marker of cardiac electrical instability. However, the effects of acute mental stress on TWA have not been investigated as a vulnerability marker in humans. Methods and Results—TWA responses to mental stress (anger recall and mental arithmetic) and bicycle ergometry were evaluated in patients with implantable cardioverter defibrillators (ICDs) and documented coronary artery disease (n=23, age 62.1±12.3 years) and controls (n=17, age 54.2±12.1 years). TWA was assessed from digitized ECGs by modified moving average analysis. Dual-isotope single photon emission computed tomography was used to assess myocardial ischemia. TWA increased during mental stress and exercise (P values <0.001), and TWA responses were higher in ICD patients than in controls (arithmetic Δ=8.9±1.4 versus 4.3±2.2 μV, P =0.043; exercise Δ=21.4±2.8 versus 13.8±3.2 μV, P =0.038). TWA increases with mental stress occurred at substantially lower heart rates (anger recall Δ=9.7±7.7 bpm, arithmetic Δ=14.3±13.3 bpm) versus exercise (Δ=53.7±22.7 bpm; P values <0.001). After adjustment for heart rate increases, mental stress and exercise provoked increased TWA in ICD patients (P values <0.05), but not in controls (P values >0.2). Ejection fraction and stress-induced myocardial ischemia were not associated with TWA. Conclusions—Mental stress can induce cardiac electrical instability, as assessed via TWA, among patients with arrhythmic vulnerability and occurs at lower heart rates than with exercise. Pathophysiological mechanisms of mental stress–induced arrhythmias may therefore involve central and autonomic nervous system pathways that differ from exercise-induced arrhythmias.

Depressive Symptom Dimensions and Cardiovascular Prognosis Among Women With Suspected Myocardial Ischemia: A Report From the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation

CONTEXT Symptoms of depression and cardiovascular disease (CVD) overlap substantially. Differentiating between dimensions of depressive symptoms may improve our understanding of the relationship between depression and physical health. OBJECTIVE To compare symptom dimensions of depression as predictors of cardiovascular-related death and events among women with suspected myocardial ischemia. DESIGN Cohort study of women with suspected myocardial ischemia who underwent evaluation at baseline for a history of cardiovascular-related problems, depressive symptoms using the Beck Depression Inventory, and coronary artery disease severity via coronary angiography. Principal components analyses (PCAs) of the Beck Depression Inventory items were conducted to examine differential cardiovascular prognosis according to symptom dimensions of depression. SETTING The Womens Ischemia Syndrome Evaluation (WISE), a multicenter study sponsored by the National Heart, Lung, and Blood Institute to assess cardiovascular function using state-of-the-art techniques in women referred for coronary angiography to evaluate chest pain or suspected myocardial ischemia. PARTICIPANTS Five hundred fifty women (mean [SD] age, 58.4 [11.2] years) enrolled in the WISE study and followed up for a median of 5.8 years. MAIN OUTCOME MEASURES Cardiovascular-related mortality and events (stroke, myocardial infarction, and congestive heart failure). RESULTS When a 3-factor structure from PCA was used, somatic/affective (hazards ratio, 1.35; 95% confidence interval, 1.04-1.74) and appetitive (1.42; 1.21-1.68) but not cognitive/affective (0.89; 0.70-1.14) symptoms predicted cardiovascular prognosis in adjusted multivariate Cox regression analysis. When a 2-factor structure from PCA was used, adjusted results indicated that somatic (hazards ratio, 1.63; 95% confidence interval, 1.28-2.08) but not cognitive/affective (0.87; 0.68-1.11) symptoms predicted worse prognosis. CONCLUSIONS In a sample of women with suspected myocardial ischemia, somatic but not cognitive/affective depressive symptoms were associated with an increased risk of cardiovascular-related mortality and events. These results support the need to research dimensions of depression in CVD populations and have implications for understanding the connection between depression and CVD.

Environmental Stress and Health

In this chapter, we critically review the health effects of environmental stressors. To keep the scope of this discussion manageable, we limit our domain in several ways. First, although we will consider the health effects of crowding and air pollution, emphasis will be placed on the noise literature. Second, because possible effects on the cardiovascular system have been among the most widely studied health consequences (particularly with respect to noise), these effects will receive the most attention here. Third, the review will be selective, rather than exhaustive, emphasizing major trends in the literature. Intensive reviews of the particular health effects of individual stressors such as noise, crowding, air pollution, and heat can be found in other sources (Cohen & Weinstein, 1982; Evans, 1982; Evans & Cohen, in press; USEPA, 1980, 1981).