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Lifestyle Modification for Cardiovascular Disease

Therapeutic Inertia in Cardiovascularu00a0Disease Prevention; Relationship of <br>Negative & Positive Psychological Health With Cardiovascular Disease and Health; <br>( ) Psychological Factors in CVD After Adjustment for Traditional Cardiac Risk Factors & (-) Psychological Health;<br>Biological Mechanisms of Psychological Stress, Cardiovascular Disease & Health<br><br>

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Lifestyle Modification for Cardiovascular Disease

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  1. Integrative Medicine Rounds Lifestyle Modification for Cardiovascular Disease: Role of Mind-Body Medicine

  2. Volume 74, Issue 13, October 2019 Therapeutic Inertia in Cardiovascular Disease Prevention Time to Move the Bar Dave L. Dixon, Garima Sharma, Pratik B. Sandesara, Eugene Yang, Lynne T. Braun, George A. Mensah, Laurence S. Sperling, Prakash C. Deedwania and Salim S. Virani

  3. Relationship of Negative & Positive Psychological Health With Cardiovascular Disease and Health

  4. Association Between High Perceived Stress Over Time and Incident Hypertension in Black Adults Association Between High Perceived Stress Over Time and Incident Hypertension in Black Adults: Findings From the Jackson Heart Study. Tanya M. Spruill, Mark J. Butler, S. Justin Thomas, et al. Originally published16 Oct JAHA.119.012139 Journal of the American Heart Association. 2019;8:e012139

  5. Positive Psychological Health Factors and Mortality ** Chida 2008 Chida and Steptoe Psychosom Med. 2008 Sep;70(7):741-56

  6. (+) Psychological Factors in CVD After Adjustment for Traditional Risk Factors & (-) Psychological Health ** Dubois 2015 Dubois CM Int J Cardiol. 2015 Sep 15;195:265-80

  7. Optimism and All-Cause Mortality From Giltay et al., Arch Gen Psych, 2004 Reviewed in Kubzansky, JACC 2018

  8. Explaining the Fall in CHD Deaths in USA (1980-2000) • Risk Factors worse +17% • Obesity (increase) +7% • Diabetes (increase) +10% • Risk Factors better -61% • Population BP fall -20% • Smoking -12% • Cholesterol (diet) -24% • Physical activity -5% • Treatments -47% • AMI treatments -10% • Secondary prevention -11% • Heart failure -9% • Angina: CABG & PTCA -5% • Hypertension therapies -7% • Statins (primary prevention) -5% • Unexplained -9% CHD deaths 341,745 fewer deaths in 2000 1980 2000 N Engl J Med 2007; 356:2388-2398

  9. Biological Mechanisms of Psychological Stress, Cardiovascular Disease & Health

  10. Behavioral and Physical Adaptation During Acute Stress Charmandari E, Tsigos C, Chrousos G. Endocrinology of the stress response. Annu Rev Physiol. 2005;67:259-84.

  11. The Flight or Fright Stress Yesterday and Today

  12. (1) (2) (3) (4) 4 Types of Allostatic Load Top panel: normal allostatic response, in which a response is initiated by a stressor, sustained for an appropriate interval, and then turned off; remaining panels illustrate 4 conditions that lead to allostatic load:(1)repeat ‘hits’ from multiple stressors;(2) lack of adaptation; (3) prolongedresponse due to delayed shutdown; (4) inadequate response that leads to compensatory hyperactivity of other mediators (e.g., inadequate secretion of glucocorticoids, resulting in increased concentrations of cytokines that are normally counterregulated by glucocorticoids). McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998 Jan 15;338(3):171-179.

  13. Myocytolysis: Catecholamine-induced Contraction Band Necrosis Normal myocytes H & E stain (10x magnification) Contraction band necrosis of myocytes H & E stain (25x magnification) Contraction bands: thick intensely eosinophilic staining bands (4-5 μm wide) that span the short axis of the myocyte and occur in the wake of myocytolysis. Contraction band necrosis: a type of uncontrolled cell death (necrosis) unique to myocytes, arising during reperfusion or 20 to catecholamines hypercontraction, resulting in sarcolemmal rupture. Turek, J. W. et al. Interact CardioVasc Thorac Surg. 2006;5:202-206.

  14. Catecholamine-induced  Frequency of Ventricular Arrhythmias Degrading From Bigeminy  Polymorphic VT  VF

  15. Depression & Cardiovascular Diseases Share a Variety of Biological Mechanisms & Behavioral Mediators Vicious cycle of declining health outcomes that may occur with depression in patients with CVD due to worsening of lifestyle & socioeconomic factors Khandaker, GM et al. Shared mechanisms between coronary heart disease and depression: findings from a large UK general population-based cohort. Molecular Psychiatry; 19 March 2019; DOI: 10.1038/s41380-019-0395-3

  16. Stress Stress The Stress System in Chronic Stress & Depression Stress Stress Raison C.L., Capuron L., Miller A.H. Cytokines sing the blues: Inflammation and the pathogenesis of depression Trends in Immunology; 2006; 27 (1), pp. 24-31. Viral Immunol. 18 (2005), pp. 41–78

  17. Depression & CVD Pathophysiological Mechanisms  Inflammation (TNFα; IL-1; IL-6; CRP)  Blood clotting (fibrinogen)  Platelet activation & aggregation  ROS (oxidative stress)  Subclinical hypothyroidism  Sympatho-adreno-medullary activity Hypothalamic-pituitary-adrenal activity Endothelial progenitor cells  Arterial repair processes  HR variability  Genetic factors • Depression associated with  risk of CVD & acute CV sequelae; i.e., MI, CHF, systolic HTN • M & M in CVD patients with depression at  than in those not depressed Heartache and heartbreak—the link between depression and cardiovascular disease Charles B. Nemeroff & Pascal J. Goldschmidt-Clermont; Nature Reviews Cardiology volume 9, pages526–539 (2012)

  18. Effects of Psychological Stress on Atherosclerosis

  19. Biological & Behavioral Mechanisms: Interaction Biological Mechanisms ↓ Inflammation ↑ Endothelial function ↑ Autonomic function Positive Psychological Well-Being Medical Outcomes Behavioral Mechanisms ↑ Diet ↑ Physical activity ↑ Medication adherence ↓ Smoking Kubzansky 2018; Grant 2009; Serlachius 2015

  20. Convergence of Mental & Physical Healthin Positive Cardiovascular Health Positive Cardiovascular Health; A Timely Convergence. Darwin R. Labarthe, Laura D. Kubzansky, Julia K. Boehm, Donald M. Lloyd-Jones, Jarett D. Berry and Martin E.P. Seligman

  21. Convergence of Mental & Physical Healthin Positive Cardiovascular Health Positive Cardiovascular Health: A Timely Convergence. Darwin R. Labarthe, Laura D. Kubzansky, Julia K. Boehm, Donald M. Lloyd-Jones, Jarett D. Berry and Martin E.P. Seligman

  22. Mind-Body Interventions

  23. Meditation & Cardiovascular Risk Reduction

  24. Common Types of Meditation

  25. AMERICAN HEART ASSOCIATIONScientific Statement on Meditation and CV Risk Reduction • Studies of meditation suggest a possible benefit on cardiovascular risk… • Meditation may be considered as a cost effective adjunct to... cardiovascular risk reduction Levine et al, Journal of the American Heart Association, 28;6(10), 2017

  26. Meta-analysis of Meditations in Anxiety Reduction Meta-analysis of 30 studies Effect Size: Standardized Mean Difference (Cohen’s data) • The effect sizes d were converted from the reported effect sizes r to make them comparable to other studies. • Interpretation of effect sizes: .2 = small effect, .4 = medium effect, .8 or more = large effect Psychological Bulletin 138 (2012): 1139–1171.

  27. Baseline Anxiety Levels Predict Response to Meditation Orme-Johnson, D. W., and V. A. Barnes. 2013. Effects of the Transcendental Meditation technique on Trait Anxiety: A Meta-Analysis of Randomized Controlled Trials. Journal of Alternative and Complementary Medicine 19, 1-12.

  28. Comparison of TM and Mindfulness on Anxiety Reduction: Meta-Analyses 1. Orme-Johnson DW, Barnes VA. Effects of the Transcendental Meditation technique on Trait Anxiety: A Meta-Analysis of Randomized Controlled Trials. J Altern Complement Med 2013;19:1-12. 2. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol 2010;78(2):169-183.

  29. Burnout, Depression and Perceived Stress Randomized Controlled Trial of TM in Teachers Mean Change The Permanente Journal 18(1), 9-23 (2014)

  30. Post Traumatic Stress Disorder (PTSD): Meditation, CBT, and Health Education Transcendental Meditation Prolonged Exposure Health Education 1.20 Between-Group Comparisons Adjusted by ANCOVA: TM vs. HE (p values < .001) PE vs. HE (p values < .05) TM vs. PE (p values <.001, non-inferiority comparisons) 1.00 .80 Within-Group Unadjusted Effect Sizes .60 .40 .20 Effect Sizes Small = .20 Medium = .50 Large = .80 0 Clinician-Administered PTSD Scale PTSD Checklist – Military Version Patient Health Questionnaire ( CAPS) Interview (PCL-M) Self-Report (PHQ)-9 Depression Nidich, S., Mills., P., Rainforth, M., Heppner, P., Schneider, R., Salerno, J., Gaylord-King, C., Rutledge, T. Non-trauma-focused meditation compared to exposure therapy in veterans with post-traumatic stress disorder: a randomized controlled trial. The Lancet Psychiatry, online Nov. 15, 2018.

  31. Behavioral – Meditation techniques, stress reduction, biofeedback, yoga Procedures – Device-guided breathing, acupuncture Exercise – Aerobic, resistance, isometric Objectives Critical analysis of the efficacy of AA for BP-lowering Practical summary and guidance for health care providers Recommendations for future research

  32. Systematic Review and Meta-analysis Transcendental Meditation & Blood Pressurein Hypertensive Patients Change in Blood Pressure (mm Hg) p = .04 11 randomized controlled trials with 899 participants Bai et al, Journal of Human Hypertension, 2015

  33. Randomized Trial of Meditation on Mortality, MI and Stroke 100 90 80 Cumulative Proportion Event-free 70 TM 60 HE 50 0.52 (95% Cl, 0.29-0.92) (p = .025) 50 0 4 6 8 9 10 1 2 3 5 7 0 Years Schneider RH et al. Circulation: Cardiovascular Quality and Outcomes. 5(6):750-8, 2012

  34. Reduced Rates of Death, Heart Attack, and Stroke 48% lower risk p = .025 Risk of Events (Expected Number of Events per Year per 1000 Event-free Persons) Health Education Transcendental Meditation Schneider RH, Grim CE, Rainforth MA, Kotchen TA, et al. Stress reduction in the secondary prevention of cardiovascular disease: Randomized controlled trial of Transcendental Meditation and health education in Blacks. Circulation: Cardiovascular Quality and Outcomes. 5(6):750-8, 2012.

  35. Effects of Meditation on Mortality Pooled Results of 2 Randomized Controlled Trials 100% 90 80 70 TM 60 Surviving Cumulative Proportion 50 40 Combined controls 30 RR = .77; p = .04 long term 20 10 0% 0 2 4 6 8 10 Years Schneider RH, et al Long Term Effects of Stress Reduction on Mortality in Persons >55 Years of Age with Systemic Hypertension. American Journal of Cardiology 2005, 95: 1060-1064

  36. Physiology of Restful AlertnessDuring Transcendental Meditation Alpha (8-10 Hz) Plasma Lactate TM Rest Respiration Rate Basal GSR .2 .4 .6 .8 1 0 Explore (NY). 2018 Jan - Feb;14(1):19-35

  37. Life Course of Cardiovascular Health & CVD: 4 Opportunities for Positive Psychology Intervention

  38. Acute and Chronic Stressors and Depression Change in financial state Death of spouse Foreclosure of mortgage or loan Life Crisis Units as measured by the Holme-Rahe Scale Jail term Business readjustment Raison C.L., Capuron L., Miller A.H. Cytokines sing the blues: Inflammation and the pathogenesis of depression Trends in Immunology; 2006; 27 (1), pp. 24-31.

  39. Psychopathology of Brain's Stress System in Depression • (-) emotions may indirectly affect CHD via association with traditional risk factors i.e., smoking,  ETOH consumption,  BMI, &  physical activity. • (-) lifestyle choices = cause of or caused by (-) emotional states (chronic stress, depression) • Emotions may also influence CHD through their effects on  social support &  social isolation CHD Depression as a Risk Factor for Coronary Heart Disease: Implications for Advanced Practice Nurses; Diane Valentine, BSN, RN, et al. Topics in Advanced Practice Nursing eJournal. 2001;1(3)

  40. Depressive Symptoms Are Associated With Mental Stress-Induced Myocardial Ischemia After Acute MI Mean unadjusted perfusion ischemic defect severity with mental stress according to 5 groups of progressively higher depressive symptoms using quintiles of BDI-II total score. Error bars = standard errors; p-value is from a linear regression model where quintiles of BDI-II score modeled as ordinal variable; statistically significant progressive  in mental stress-induced ischemia with increasing depressive symptom severity. doi: https://doi.org/10.1371/journal.pone.0102986.g001

  41. The Effect of Depression on Arterial Repair Heartache and heartbreak—the link between depression and cardiovascular disease Charles B. Nemeroff & Pascal J. Goldschmidt-Clermont; Nature Reviews Cardiology volume 9, pages526–539 (2012)

  42. NLRP3 Inflammasome Inducers Related to Depression/Cardiovascular Disease; Inhibitory Strategies Alcocer-Gómez, E. & Cordero, M. D. (2017) NLRP3 inflammasome: common nexus between depression and cardiovascular diseases. Nat. Rev. Cardiol. doi:10.1038/nrcardio.2016.214

  43. Occasional Acute Stress: a Healthy Lifestyle Strategy Interactions & interdependency between CNS-ANS, endocrine, & immune system in response to the social environment Avoid fatty foods Get daily exercise Practice relaxation techniques Eat your veggies

  44. ‘Fight or Flight’

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