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Psychosocial factors in coronary and cerebral vascular disease

Geoffrey H Tofler, MD
Section Editor
Jonathan M Silver, MD
Deputy Editor
David Solomon, MD


Although recent attention has focused on the role of psychosocial factors in the acute precipitation of myocardial infarction and sudden cardiac death, psychosocial factors may also contribute to the early development of atherosclerosis [1]. The link between psychologic stress and atherosclerosis may be both direct, via damage of the endothelium, and indirect, via aggravation of traditional risk factors such as smoking, hypertension, and lipid metabolism.

Unfortunately, human studies of stress and coronary atherosclerosis have been limited in scope, due primarily to the difficulty in quantifying the degree of atherosclerosis in asymptomatic subjects. Thus, although angiographic data suggest that more extensive atherosclerosis is seen in patients with type A personality [2], confounding issues limit the interpretation. Stronger epidemiologic studies have linked psychosocial factors such as bereavement, loss of job, and depression with hard end points such as myocardial infarction and sudden death [3]. One study which followed 1592 men and women for five years reported that the personality trait of submissiveness, a marker for type B behavior, was protective against nonfatal and total myocardial infarction, particularly in women (relative risk 0.59 and 0.69, respectively) [4].

Depression screening — Depression is associated with increased morbidity and mortality in patients with established coronary heart disease. We agree with the 2008 American Heart Association scientific advisory on Depression and Coronary Heart Disease which recommends screening for depressive symptoms in such patients [5]. (See "Screening for depression in adults".)


The best insights into the role of psychological stress in atherosclerosis come from animal studies, in particular a series of experiments using cynomolgus monkeys [6]. When fed a diet sufficiently rich in saturated fat and cholesterol, these monkeys develop atherosclerosis very rapidly with lesions similar to those seen in humans. Also similar to humans, premenopausal female monkeys are relatively protected from atherosclerosis.

These animals display complex patterns of social interaction characterized by hierarchies of dominant (aggressive) and subordinate (submissive) animals. Since the monkeys respond aggressively to new animals attempting to join their social groupings, the placement of strangers within groups forms the basis for a stressful challenge.

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Literature review current through: Nov 2017. | This topic last updated: Aug 15, 2017.
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