chapter 13 (251-262

Vigilant coping—that is, chronically searching the environment for potential threats—has also been associated with risk factors for heart disease

Anxiety predicts a worsened course of illness

Vital exhaus- tion may be a bodily expression of depression

In combination with other risk factors, vital exhaustion predicts the likelihood of a heart attack

Hostile people exhibit a weak antagonistic response to sympathetic activity in response to stress, suggesting that their physiological reactivity not only is greater ini- tially but also may last longer

In response to provocation, hostile people have larger and longer-lasting blood pressure responses to anger-arousing situations. When coupled with anger and depression, hostility predicts high levels of C-reactive protein, an indicator of inflammation

Coronary heart disease (CHD)

is a general term that refers to illnesses caused by atherosclerosis, the narrow- ing of the coronary arteries, the vessels that supply the heart with blood

More recently, research has suggested that an imbalance between control and demands in daily life more generally (not only at work) is a risk for atherosclerosis.

that is, people whose lives are characterized by high levels of demands coupled with low levels of control both in and outside the workplace are at higher risk for atherosclerosis

Risk factors for heart disease are more common in individuals low in SES, especially men, and the symptoms of cardiovascular disease develop earlier

A harsh (cold, non-nurturant, neglectful, and/or conflictual) family environment in childhood increases risk in its own right, and the stress and difficulty developing social support that can result from these early harsh circumstances also increases cardiovascular risk. Low SES also predicts a worsened course of illness and poor prospects for recover

Negative emotions, including anger and hostility, increase risk for metabolic syndrome and for CHD

Anger not only increases the risk of heart disease but also predicts poor likelihood of survival and acts as a potential trigger for heart attacks

Some people have coronary artery bypass graft (CABG) surgery to treat blockage of major arteries.

Following myocardial infarction (MI), the patient is typically hospitalized in a coronary care unit in which cardiac functioning is continually monitored.

Perhaps the most important way depression is linked to coronary heart disease progression and prog- nosis is through inflammation

Inflammation is typically measured as C-reactive protein, which provides an indication of buildup of plaque on artery walls. Depression may be more closely linked to C-reactive protein in people who are hostile and in African Americans

Coronary heart disease (CHD) is the number-one killer in the United States

It was not a major cause of death until the 20th century because, prior to that time, most people did not live long enough to develop heart disease; most people died of infectious diseases.

Identifying people with metabolic syndrome also helps predict heart attacks.

Metabolic syndrome is diagnosed when a person has three or more of the following problems: obesity centered around the waist; high blood pressure; low levels of HDL, the so- called good cholesterol; difficulty metabolizing blood sugar, an indicator of risk for diabetes; and high levels of triglycerides, which are related to bad cholesterol.

Much of what has been learned about women's heart disease has come from long-term clinical studies, such as the Nurses' Health Study.

Over the past 25 years, the expected inci- dence of heart disease in this sample has not appeared— in large part because more older women have stopped smoking and have changed their diets in healthy direc- tions

Cardiac invalidism can be one consequence of MI:

Patients and their spouses see the patient's abilities as lower than they actually are (

One reason for high rates of mortality and disability following heart attacks is that patients often delay several hours or even days before seeking treatment.

People who believe their symptoms are caused by stress delay longer

A particular type of hostility is especially implicated, namely, cynical hostility, characterized by suspiciousness, resentment, frequent anger, antagonism, and distrust of others.

People who have negative beliefs about others, such as the perception that other people are being antagonistic or threatening, are often verbally aggressive and exhibit subtly antagonistic behavior. People who are high in cynical hostility may have difficulty extracting social support from others, and they may fail to make effective use of available social support they also have more conflict with others, more negative affect, and more resulting sleep disturbance, which may further contribute to their heightened risk. Hostility combined with defensiveness may be particularly problematic

Underlying the philosophy of cardiac rehabilitation is the belief that such efforts can stem advancing disease, reduce the likelihood of a repeat MI, and reduce the risk of sudden death.

Successful cardiac rehabilitation depends critically on the patient's active participation and commitment. An underlying goal of such programs is to restore a sense of mastery or self-efficacy; in its absence, adherence to rehabilitation and course of illness is poor

An important component of cardiac rehabilitation involves medication.

Such a regiment often includes self-administration of beta-adrenergic blocking agents. These are drugs that resist the effects of sympathetic nervous system stimulation. Unfortunately, these drugs can have negative side effects including fatigue and impotence, and so targeting adherence is important. Aspirin helps prevent blood clots by blocking one of the enzymes that cause platelets to aggregate.

when these vessels become narrowed or closed, the flow of oxygen and nourishment to the heart is partially or completely obstructed.

Temporary shortages of oxygen and nourishment frequently cause pain, called angina pectoris, that radiates across the chest and arm. When severe deprivation occurs, a heart attack (myocardial infarction) can result.

Communion, a focus on other people in relation- ships, reflects a positive caring orientation to others, and it is typically higher in women than in men. It has few relations to mental and physical health outcomes.

Unmitigated communion, however, exemplified in a self-sacrificing individual who fails to focus on her own needs, is tied to poor mental and physical health outcomes

Treatment of depression may improve the prospects of long-term recovery from heart attack. Depression is typically treated with serotonin reuptake inhibitors, such as Prozac, which help prevent serotonin from attaching to receptors

When the receptors in the bloodstream are blocked, it may reduce the formation of clots by preventing the aggregation of platelets in the arteries. Essentially, antide- pressants may act as blood thinners

Reactivity is reflected not only in initial reactions to stress but can also be reflected in a prolonged recovery period; some people recover from sympathetic activity due to parasympathetic counterregulation quite quickly, whereas others do not.

following cardiovascular activation due to stress, there is parasympathetic modulation of sympathetic reactivity. is rebound is an important part of the stress process, and diminished vagal rebound during recovery is strongly tied to risk factors for cardiovascular disease

Risk factors for CHD include

high cholesterol, high blood pressure, elevated levels of inflammation, and diabetes, as well as behavioral factors of cigarette smoking, obesity, and little exercise

Cardiac rehabilitation

is the active and progressive process by which people with heart disease attain their optimal physical, medical, psychological, social, emotional, vocational, and economic status.