Stress and the Heart! Anthony James Bashall, MD, FACC Suzanne Kunkle, PhD, HSPP

Stress and the Heart! Anthony James Bashall, MD, FACC Suzanne Kunkle, PhD, HSPP

We have no relevant financial relationships to disclose

Goals & Objectives Identify the association between stress and cardiovascular disease Examine strategies to decrease stress

Stress and the heart What do we mean when we say stress? Does stress really affect the heart? Why and how does it affect the heart? How do you know when you are stressed? What can we do to intervene?

When we say Stress what do we mean? Chronic FUN Acute and intense Necessary

When we say say stress what do we mean? Self reported I feel stressed and overwhelmed. Stress assessment scores I don t know how to define it but I know what it is when I see or feel it Judge Potter. 1964

Stress in day to day language? Inability to cope due to an excess of, or too little, stimulus Feeling overwhelmed, depressed, stressed OR

Does stress cause heart disease?

Stress cardiomyopathy 1990 Japan

Stress cardiomyopathy 1990 s Women - 80% Average age 66 Smokers Recent stressful event in 70-80% - physical or emotional or both Death of a loved one Recent illness Infarction CVA

Does stress cause heart disease? 4.1 % mortality in the International Registry

So it can kill in acute events what about chronic? 1958 Friedman and Rosenman - accountants stress increased cholesterol and clotting times 1982 increase BP under stress with type A personality 1999 Circulation, Rosanski, et.al. psychosocial factors affect CAD 2000 JACC, Roest. Et al., - anxiety affect cad 2017 Lancet, Tawakol et al. - stress, inflammation and CAD

How does it affect the heart? Increases catecholamines and cortisol Increases Blood Pressure Increases Heart Rate Prepares the body for an attack Activates the bone marrow The Lancet 1/2017

How does stress affect the heart? The amygdala!!

The evil amygdala.why is it evil if chronically overstimulated? It stimulates the brain and body It prepares you for an attack It remembers The stimulation causes blood vessel inflammation The first step of heart disease! The Lancet Increased Amygdala Activity Leads to Heart Disease

Stress, the amygdala and the heart The Lancet 2017

Stress what does it do? The Lancet 2017

How serious is stress compared to other risks? Hypertension Smoking High cholesterol Obesity Diabetes Sleep apnea Kidney disease Inactivity

So what causes stress? Health problems Money Sleeping disorders Work related amount vs. intensity vs. both No job Personal traits Relationships

When were you asked by your doctor? Are you feeling stressed, anxious? Are you depressed? Are you feeling sad? Do you have difficulty sleeping? Has your appetite changed? Do you ever trapped or suicidal?

What do you do when you are stressed? Over or under eat Abuse substances Become irritable Shop Procrastinate Gamble Sleep: less or more Withdraw Push yourself harder More perfectionistic Ignore Hyper/hypo sexual

Stress what can we do???

How can you calm yourself? Stop, pause and check yourself for stress symptoms Iimplement a stress reduction strategy Remind yourself that your health is important tool

Locus of Control Thoughts: supportive vs unsupportive Feelings: healthy self-soothing skills and processing Physiology: regulating SNS, PNS, C-P Behaviors: self-monitoring and intervening Environment: boundaries, beautify, take breaks

Hands Arms Face Neck Shoulders Chest Throat Abdomen Sighing Legs Feet Physiological Stress Manifestations Striated Sympathetic Parasympathetic Cog-Perceptual Legs Feet Tension headaches Mouth, Eyes: Too dry Too wet Mucous dry Sweating Chilling Blushing Heart: Increased Heart rate Blood pressure Nausea Vomiting Diarrhea Excessive salivation Mucous wet Heart: Decreased Heart rate Blood pressure Ulcer Reflux Diarrhea Constipation Frequent urination Vomiting Butterflies IBS Thoughts Processes: Incoherent, Chaotic, Drifting, Delayed, Empty headed, Accelerated, Confusion, Losing track of thoughts, Poor memory Thought Content: Disturbed orientation: to time, place, persons Perception: Visual acuity: Hazy view, Blurring, Tunnel, Loss of vision Auditory Perception: Tinnitus, Hallucinations Dissociation, Detached, Unreal, Numbness, No contact with arms, legs, etc., Fainting, Freezing, Loss of identity, memories, personality

Body Scan: check in

Stress: What can we do? Change the person Mindfulness, meditation, relaxation Exercise, yoga, tai chi, qi gong, art, spiritual renewal Dietary improvements Get a medical check-up, eliminate curbside medicine Improve sleep hygiene, have a sleep study Counseling Medication

Mindfulness

Mindfulness Being aware of what is happening right now without wishing it was different; Enjoying the pleasant without holding on when it changes (it will); Being with the unpleasant without fearing it will always be this way (which it won t). James Baraz

Mindfulness In the moment Paying attention to yourself, your body and mind Self assess Non critical Return to the present moment Repeat frequently daily: rememeber to remember to check in

Work stress: Control what you can Mindfulness Pause Smart phone apps and alerts to check in Plan and take mini breaks and vacations, staycations Healthy boundaries Monitor thoughts and feelings: unhealthy guilt Accurate attribution of causation Production line Shift work

Can you change the environment? Change the stressful environment: New job or shift focus New relationship or improve existing New home or simplify current New bank

Next steps in controlling stress What is your next step for regulation? How committed and motivated are you to keep it? Who will be your accountability partner? How will you check your progress weekly with your partner?

Summary Stress can be healthy or unhealthy. Stress can contribute to heart attacks and strokes. Stress can be observed and managed. Causes of stress can be changed. Your response to stress can be adapted.

Thank you

References Reeder, G, & Prasad, A. Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy. UpToDate.com, topic last updated January 30, 2018 Arnold, S, Smoldersen, I, Buchanan, D, Li, Y, & Spertus, J. 2013. Perceived Stress in Myocardial Infarction: Long-term Mortality and Health Status Outcomes. J Am Coll Cardiology, 60(18); 1756-1763 1958 Friedman and Rosenman - accountants stress increased cholesterol and clotting times 1982 Increase BP under stress with type A personality; ncbi.nlm.nih.gov/pubmed 1999 Circulation, Rosanski, et.al. psychosocial factors affect CAD 2000 JACC, Roest. Et al., - anxiety affect cad 2017 Lancet, Tawakol et al. - stress, inflammation and CAD 2017 Baldwin, D., Stein, M., Hermann, R. UpToDate.com; Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clincial manifestations, course, assessment, and diagnosis.