Behavioral Cardiology - Where the Heart and Head Meet

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Psychosocial Factors and CAD Risk Reduction

The first step in reducing the psychosocial risk of a person with CAD is to identify those at increased risk. The accurate identification of negative and positive psychosocial factors in people with CAD may initially appear to be straightforward and feasible. Unfortunately, this is often not the case even for healthcare providers who have significant medical training and experience. One study found that less than 25% of persons with CAD and probable depression could be identified correctly by healthcare workers. Standardized tools are available to help identify individuals with psychosocial distress, but these are sometimes lengthy and difficult to administer in the clinical setting of a cardiology practice. A recently published landmark article has recommended the use of a handful of basic, open-ended questions to help CV clinicians identify patients in need of further psychosocial risk assessment and treatment (see Table 2).

As difficult as it may be to identify persons with increased psychological risk factors for CAD, it is even more difficult to identify the method of treating psychosocial risk that is most likely to improve psychosocial health and reduce overall CAD risk at the same time. Behavioral and pharmacologic treatments are available that can effectively help to treat most negative psychological factors. Unfortunately, treatments aimed at improving psychosocial health may not necessarily reduce CAD-related risk. Results of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, for instance, showed that individuals with CAD and depression who underwent an intense behavioral and pharmacologic intervention showed improvements in their depression but not in overall CAD events when compared with individuals who were randomized to a lower intensity 'usual careÔÇÖ control group. An unexpectedly low rate of CAD events in the usual care group appears to explain at least some of the negative outcome of the study. The Sertraline Anti-Depressant Heart Attack Randomized Trial (SADHART) study, another similar randomized, controlled clinical trial, likewise found that treatment of depression did not translate into an improvement in CAD events in people with a previous history of MI and depression. It should be noted that the SADHART investigators designed the study as a safety study and did not plan it to have sufficient power for assessing the impact on CAD events.

Results from ENRICHD, SADHART, and other studies highlight the aforementioned dilemma in current behavioral cardiologyÔÇösome psychosocial factors associated with an increased risk of CAD are treatable, yet their treatment may not reduce CAD risk. Results of an observational sub-study from the ENRICHD study have increased the hope of finding a solution to this dilemma.