Does thinking about Monday give you the blues? Well, you’re not alone. The peak time for many heart attacks is Monday morning, a clear indication of the relationship between stress and heart failure.

But stress alone does not trigger heart failure. Increasingly, research shows that that certain personality traits make a person more susceptible to heart failure – especially when combined with fatty diets, smoking, drinking too much alcohol and being overweight.

Studies in the USA and Europe over the last decade show that anger, depression, anxiety and feelings of social isolation are lethal in those already genetically predisposed to heart failure.

In addition, angry, depressed and anxious people who are not initially predisposed to heart failure may expose themselves to risk as they are more likely to smoke and drink too much alcohol than people who are more laid back.

“It is not the event, but the way in which a person perceives the event, that is important [in determining stress levels],” says Dr Craig Hassed, from Monash University in Melbourne, Australia.

“When doctors don’t take into account people’s natures, they don’t find the psycho-social connections [to heart disease],” says Hassed who was in South Africa last week to attend the World Congress of Family Doctors.

In the past, medical students were taught that “A-type personalities” – those competitive, super-achievers – were the most susceptible to heart failure. But more recent research shows that people who feel disempowered in their jobs are more vulnerable to heart problems than their “A-type” bosses, who have the power to change their situations.

A 1997 study of British civil servants (conducted by Dr Michael Marmot from University College London) found that men and women in “low control” jobs had a 50% higher incidence of coronary heart disease than those in “high control” jobs.

Those in jobs that offered intermediate control had a 20% higher incidence of heart disease than their high control colleagues.  

Those who felt disempowered tended to smoke and drink more, and to be overweight – all risk factors in heart disease.  

Heart disease is one of the main causes of death in the world, and it kills more South Africans than TB, cancer or car accidents.  

Treating cardiac patients is costly, yet if treatment includes both psycho-social and physical therapy, their recovery rate is improved substantially.

Hassed says that there is a “large body of evidence from well constructed clinical trials which clearly show that psycho-social factors play a significant and primary role in heart disease aetiology (causes) and progression”.

The SA Heart Foundation’s director of nutrition and education, Shan Biesman-Simons, says many cardiac rehabilitation programmes offer psychological counselling and alternative therapies such as yoga to teach heart patients how to relax.

“Psychological factors [in heart disease] are now widely acknowledged as an important part of rehabilitation,” says Biesman-Simons.  

The Sports Science Institute in Cape Town runs a rehabilitation programme for cardiac patients that includes relaxation, yoga and tai chi.  

“We have a psychologist on the programme and new patients are encouraged to have a counselling session with him when they start,” says programme co-ordinator Nadine Spencer. “But many patients don’t want to as they say they are fine.”

The programme, which is headed by Professor Tim Noakes along with a team of doctors, nurses and bio-kineticists, costs R65 per session for the first 36 sessions, then R42 a session after that.

Anger management has been isolated as a crucial element in the fight against heart disease – although this approach is more prevalent in the US than here.

A US study conducted by Dr Janice Williams of 12 986 people found that those most prone to anger were 2,7 times more likely to have a heart attack than those who had low anger scores.

In addition, those who scored high for anger and hostility (according to the Speilberger Trait Anger Scale) were more likely to be smokers and drinkers.  

Participants were controlled for physical risk factors such as cholesterol. Hassed points to another US study which showed that teenagers who scored high in hostility tests were 10 times more likely than non-hostile peers to develop coronary calcification (hardening of the arteries).

“The relative risk of heart attack among angry patients looks as strong as it is for hypertension or smoking,” commented Professor Ichiro Kawachi of Harvard’s School of Public Health on Williams’ study.

 “Clinicians should screen their patients for a history of anger, and consider referring them to counselling or anger management therapy.”

The apparent reason for this connection between anger and heart disease is a hormone called homocysteine, a risk factor in heart disease, which is found in higher concentration in the blood plasma of angry, hostile people than in those who are more laid back.

Hassed adds that teenagers who have lost a parent in childhood or have poor family relations are at risk of developing high blood pressure and have a lower stress tolerance (measured by neuro-hormonal response). In addition, these teenagers experienced more anxiety and depression and were more likely to smoke.

Cardiac patients who are depressed or anxious have a lower chance of recovery than those who were not, according to a number of studies. Those patients who felt a lack of social and emotional support had three times the mortality rate of those who said they had people that they could turn to.

This prompted the American College of Cardiology to observe at a recent congress that, as “clinically significant depression is common after a coronary artery disease event (approximately 30% of patients), family physicians should see patients soon after an event and ask directly about stress, depression, fears and anxieties.  

“Referral to a psychologist or psychiatrist may be necessary for patients who are not adapting or who are significantly anxious or depressed.”  

We need to teach people to be more in control of themselves,” says Hassed. “They need to be able to create new behaviours through self-observation and experience. This includes learning how to relax.”

Significant proof of how a change in lifestyle and attitude can affect a cardiac patient’s prognosis comes from a programme developed by Dr Dean Ornish of the Preventive Medicine Research Institute in San Francisco.  

In a five-year study, 28 patients made radical lifestyle changes. They adopted a low fat (10% fat) vegetarian diet, quit smoking, took up aerobic exercise and were taught stress management, including relaxation techniques.  

These patients also joined psycho-social support groups, and were given back-up support by a range of medical staff.  

A further 20 patients made moderate changes to their lives by cutting the fat content of their diets to 25% and doing regular exercise.  

The first group reduced their angina frequency by 91% after a year, and reduced the narrowing of their arteries (stenosis) by 4.5%.

But in the second group that only made moderate lifestyle changes, angina increased by 186% in a year and stenosis worsened by 5.4%.  

“Intensive lifestyle changes can stop and even reverse the effects of atherosclerosis in the coronary arteries,” said Ornish. “The problem is getting people to change. We found that fear of dying was a short-term motivator but the key was to help people discover why they smoked, drank or ate too much.”

Terminology  

Coronary arteries: the two main vessels and their associated branches that supply the heart with oxygen and nutrients it needs to function) Coronary artery disease (CAD): When fatty deposits accumulate in the cells lining the walls of the coronary artery and obstruct the flow of blood to the heart. If untreated, the fatty deposits build up gradually and cause a heart attack.

Ischemia: Inadequate supply of blood to the heart as a result of the build-up of fatty deposits. This damages the muscle of the heart (called the myocardium).

Angina: Temporary chest pains when the heart muscle isn’t getting enough oxygen.

Cardiovascular Disease: A group of disorders of the heart and blood vessels, including heart attacks, strokes and high blood pressure.  

Atherosclerosis: Fat deposits in the coronary artery