Elsevier

Progress in Cardiovascular Diseases

Volume 46, Issue 4, January–February 2004, Pages 337-347
Progress in Cardiovascular Diseases

Psychosocial factors in the development of coronary artery disease☆

https://doi.org/10.1016/j.pcad.2003.09.001Get rights and content

Abstract

The fact that traditional risk factors only account for approximately two thirds of cases of coronary artery disease (CAD) has stimulated increasing interest in the relationship between CAD and psychosocial factors. Five areas—chronic stress, socioeconomic status (SES), personality, depression, and social support—have been most thoroughly examined. There is evidence to support a causal relationship between chronic stress, SES, depression, and social support and development of CAD. In this article, we discuss the epidemiologic evidence linking psychosocial factors and CAD, and review the effects of psychosocial factors on several pathophysiologic mechanisms that have been proposed as potential mediators of CAD. The hypothalamic-pituitary-adrenal axis, hypertension and cardiovascular reactivity, endothelial function, inflammatory markers, platelets, coagulation factors, fibrinogen, lipids, glucose metabolism, and lifestyle factors have all been implicated in this process. Recently, the first intervention trials have been carried out, although with initially disappointing results. Reducing the cardiovascular risk due to these psychosocial factors will be one of the major health care challenges in the future.

Section snippets

Work stress

It has been estimated that 10% to 40% of the workforce suffer from work stress, and at least one third of these have severe chronic psychosocial stress.2 Work stress tends to be greater in individuals of lower SES, and is also associated with lower social support, conventional cardiovascular risk factors, less education, and certain psychological traits. There are two main models of work stress. The Job Strain model (or demand-control model) centers on the concept that the highest job strain

Socioeconomic status

SES is an important and powerful determinant of CAD incidence and outcomes. The inverse gradient between CAD and SES as defined by occupational position, income, or education has been confirmed in a number of studies internationally,19, 20, 21, 22, 23with little evidence to the contrary. Some have argued that this association may be even stronger in women than men.24 Among men in the United Kingdom, 5000 additional deaths occur each year because of the social disparity in mortality rates.25 The

Depression and anxiety

Depression is a prospective risk factor for the development of CAD and it also influences prognosis after coronary events. Depression is 3 times more common among patients with CAD than controls31; one fifth of patients with CAD have depression32 and 15% to 20% of patients suffer major depression post-MI. This review is limited to the evidence and mechanisms for the involvement of depression in the development of CAD; discussion of the role of depression in patients with established cardiac

Personality, hostility, and anger

Despite early evidence that Type A behavior was an independent risk factor for CAD, subsequent literature has been rather negative and research to date has been inconclusive.4, 31 Attention has more recently been focused on hostility and anger as the potentially harmful aspects of Type A behavior.

Reanalyses of data from large Type A studies provided strong support for hostility being the toxic component.44, 45 However, the confounding effects of gender, ethnicity, social support, increased fat

Social support

In England, 16% of men and 11% of women report a severe lack of social support. Low social support causes greater psychological distress.58 People in unskilled manual jobs are more likely to have low social support than those in professional employment. Individuals with little social contact may have experienced psychologically upsetting events that separated them from friends and loved ones, leading to a diminution of social contact. The adverse effects of stressful life events can be

Mechanisms

Full consideration of the role of psychosocial factors in CAD not only involves scrutiny of the epidemiologic research, but also an understanding of the mechanisms through which social and psychological factors impact on coronary atherogenesis and the initiation of acute cardiac events. Several biological pathways relevant to the development of CAD are sensitive to psychological stress, and this provides a starting point for delineating the mediating mechanisms.

Summary and implications

There are now convincing data to support a link between SES, social support, depression, and work stress and CAD. There is growing evidence to support a link with anger. The wide variation in results relating to hostility prevents any concrete conclusions from being made at this time. It is often difficult to isolate the effects of independent psychosocial variables because they interact and tend to cluster together. For example, lower SES men and women who experience work stress are more

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    ☆

    Supported by the British Heart Foundation.

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