Appels, A. Depression and Coronary Heart Disease: Observations and Questions. Journal of Psychosomatic Research 1997, 43(5), 443-452.
Abstract
The evidence that depressive symptomatology precedes the onset of the acute coronary syndromes and influences the course of disease after their manifestation is accumulating. However, we still are far short of proof that depression has a casual role in the etiology and pathogenesis of coronary heart disease (CHD). Some unresolved questions concern the causes and the nature of the depression preceding a first or recurrent cardiac event, the biological mechanisms relating depression and CHD, the time window of the exposure-disease association, and the power of therapy programs for depression to reduce the risk of a first or recurrent cardiac event.

Barnes, Vernon A./ Orme-Johnson, David W. Clinical and Pre-clinical Applications of the Transcendental Meditation Program® in the Prevention and Treatment of Essential Hypertension and Cardiovascular Disease in Youth and Adults. Current Hypertension Reviews, 2006, 2, 207-218.
Abstract: Acute and chronic environmental and psychosocial stress contributes to the pathogenesis and progression of cardiovascular diseases (CVD). Stress reduction via Transcendental Meditation (TM)® has been shown to lower blood
pressure (BP) levels and reduce CVD risk in adults and adolescents. This article reviews recent findings indicating a beneficial BP-lowering impact of TM in hypertensive adults at rest and in pre-hypertensive adolescents at rest, during acute laboratory stress and during normal daily activity. These findings have important implications for inclusion of TM in efforts to prevent and treat cardiovascular diseases and its clinical consequences.

Benson, Herbert/ Dusek, Jeffery A./ Sherwood, Jane B./ Lam, Peter/ Bethea, Charles F./ Carpenter, William/ Levitsky, Sidney/ Hill, Peter C./ Clem, Jr, Donald W./ Jain, Manoj K./ Drumel, David/ Kopecky, Stephen L./ Mueller, Paul S./ Marek, Dean/ Rollins, Sue/ Hibberd, Patricia L. Study of the Therapeutic Effects of Intercessory Prayer (STEP) in Cardiac Bypass Patients: A Multicenter Randomized Trial of Uncertainty and Certainty of Receiving Intercessory Prayer. Am Heart J 2006, 151, 934-42.
Background Intercessory prayer is widely believed to influence recovery from illness, but claims of benefits are not supported by well-controlled clinical trials. Prior studies have not addressed whether prayer itself or knowledge/certainty that prayer is being provided may influence outcome. We evaluated whether (1) receiving intercessory prayer or (2) being certain of receiving intercessory prayer was associated with uncomplicated recovery after coronary artery bypass graft (CABG) surgery.
Methods Patients at 6 US hospitals were randomly assigned to 1 of 3 groups: 604 received intercessory prayer after being informed that they may or may not receive prayer; 597 did not receive intercessory prayer also after being informed
that they may or may not receive prayer; and 601 received intercessory prayer after being informed they would receive prayer. Intercessory prayer was provided for 14 days, starting the night before CABG. The primary outcome was presence of any complication within 30 days of CABG. Secondary outcomes were any major event and mortality.
Results In the 2 groups uncertain about receiving intercessory prayer, complications occurred in 52% (315/604) of patients who received intercessory prayer versus 51% (304/597) of those who did not (relative risk 1.02, 95%
CI 0.92-1.15). Complications occurred in 59% (352/601) of patients certain of receiving intercessory prayer compared with the 52% (315/604) of those uncertain of receiving intercessory prayer (relative risk 1.14, 95% CI 1.02-1.28). Major events and 30-day mortality were similar across the 3 groups.
Conclusions Intercessory prayer itself had no effect on complication-free recovery from CABG, but certainty of receiving intercessory prayer was associated with a higher incidence of complications.

Eaker, Elaine D./ Sullivan, Lisa M./ Kelly-Hayes, Margaret/ D’Agostino, Ralph B./ Benjamin, Emelia J. Anger and Hostility Predict the Development of Atrial Fibrillation in Men in the Framingham Offspring Study. Circulation 2004, 109, 1267-1271.
Background—Conflicting findings in the literature with regard to the ability of type A behavior, expressions of anger, or hostility to predict incident coronary heart disease (CHD) have created controversy. In addition, there are no prospective studies relating these characteristics to the development of atrial fibrillation (AF).
Methods and Results—From 1984 to 1987, 3873 men and women, 18 to 77 years of age, participating in the Framingham Offspring Study, were examined and monitored for 10 years for the incidence of CHD, AF, and total mortality. Measures of type A behavior, anger, hostility, and risk factors for CHD and AF were collected at the baseline examination. After controlling for age, diabetes, hypertension, history of myocardial infarction, history of congestive heart failure, and valvular heart disease in Cox proportional hazards models, trait-anger (RR=1.1; 95% CI, 1.0 to 1.4; P=0.04), symptoms of anger (RR=1.2; 95% CI, 1.0 to 1.4; P=0.008), and hostility (RR=1.3; 95% CI, 1.1 to 1.5; P=0.003) were predictive of 10-year incidence of AF in men. After controlling for risk factors for CHD, none of the measures of anger, type A behavior, or hostility were related to incident CHD; however, trait-anger (RR=1.2; 95% CI, 1.1 to 1.4; P=0.01) was related to total mortality in men. None of the psychosocial variables were related to the 3 outcomes in women.
Conclusions—This is the first study to examine and demonstrate a predictive relation between measures of anger and hostility to the development of AF in men. As opposed to type A behavior, measures of anger and hostility may be more productive avenues for research in studying the risk of arrhythmias and total mortality in men.

Ellard, D.R./ Barlow, J.H./ Mian, R./ Patel, R. Perceived Stress, Psychological Well - Being and the Activity of Neutrophils in Patients Undergoing Cardiopulmonary Bypass Surgery. Stress and Health 2006, 22, 143–152.
Summary
This study explored relationships, before and after surgery, between perceived stress and the activity of white-blood cells (neutrophils) in 82 patients undergoing heart surgery involving cardiopulmonary bypass surgery (CPB).
On the evening before surgery and at follow-up, 6-weeks after discharge, patients completed self-administered standard psychological measures. Small peripheral blood samples were taken, from which neutrophil activity was quantified using nitro-blue tetrazolium (NBT) and luminoldependant chemiluminescence (phagocytic capacity).
There were consistent, statistically significant associations between stress and percentageNBT cells at baseline and at follow-up. Regression analysis showed that perceived stress was a predictor of neutrophil activity at follow-up suggesting that higher levels of stress are associated with higher levels of activity. Results from the phagocytic capacity data support and strengthen the NBT findings; in response to stimuli the phagocytic capacity of the neutrophils is reduced at baseline (high stress) and increased at follow-up (lower stress). Significant decreases were found on perceived stress, anxiety, depression, negative affect and health-related stress at follow-up. Patients’ self-efficacy was high at baseline and remained high throughout the study.
Results highlighted a consistent, significant relationship between perceived stress and the ‘activity’ of neutrophils. The implications of this finding are worthy of exploration given that stressactivated neutrophils may adversely influence health outcomes.

Falgaard Eplov, Lene/ Jorgensen, Torben/ Birket-Smith, Morten/ Petersen, Janne/ Johansen, Christoffer/ Lykke Mortensen, Erik. Mental Vulnerability—a Risk Factor for Ischemic Heart Disease. Journal of Psychosomatic Research 2006, 60, 169– 176.
Abstract
Objective: The purpose of this study is to examine whether mental vulnerability is a risk factor for the development of ischemic heart disease (IHD) after adjustment for well-established risk factors.
Methods: In three prospective cohort studies in Copenhagen County, Denmark, we recorded the level of mental vulnerability and possible risk factors to IHD at baseline. For follow-up, the sample was linked to relevant registries to identify all cases of fatal and nonfatal IHD. The relationship between mental vulnerability and IHD was examined using both Kaplan–Meir and Cox proportional hazard models adjusting for possible confounding factors.
Results: Mental vulnerability was significantly associated with the risk for IHD (medium mental vulnerability: hazard ratio 1.41, 95% confidence interval 1.04–1.91; and high mental vulnerability: hazard ratio 2.05; 95% confidence interval 1.46–2.88), after adjusting for confounders.
Conclusion: Our results imply that mental vulnerability is an independent risk
factor for IHD.

Feinstein, Robert E./ Blumenfield, Michael/ Orlowski, Barbara/ Frishman,  William H./ Ovanessian, Simon. A National Survey of Cardiovascular Physicians’ Beliefs and Clinical Care Practices When Diagnosing and Treating Depression in Patients With Cardiovascular Disease. Cardiology in Review 2006, 14, 164–169.
Abstract: A national survey was administered to determine 1) cardiovascular physicians’ beliefs about the association between depression and cardiovascular disease (CVD), 2) the methods used to diagnose depression, 3) referral patterns for treatment of depression, and 4) frequency of use and preferred choice of antidepressant. A national survey of 50% of randomly selected U.S.  cardiovascular physicians belonging to the American College of Cardiology was conducted; 796 of 8854 physicians who received the questionnaires responded. Cardiovascular physicians were aware of indirect associations between
depression and coronary artery disease (CAD). However, 49.9% were unaware of depression as an independent cardiac risk factor; 71.2% asked less than half their patients with CAD about depression; 79% used no standard screening method to diagnose depression. Among cardiovascular physicians, 84.8% reported that between 1% and 50% of their patients have depression, and 49.2% indicated that they treat the symptoms of depression in their patients with CAD. Cardiovascular physicians often refer depressed patients with CAD to mental health professionals and recommend exercise, relaxation training, stress management, psychotherapy, and diaries for their patients. Among cardiovascular physicians, 55.5% treat depression/CAD with antidepressant medication: sertraline (28%), paroxetine (16.1%), fluoxetine (10.8%), escitalopram (8.7%), citalopram (7.9%), bupropion (4.4%), tricyclic antidepressants (3.8%), and venlafaxine 2.9%.

Theorell, Tores/ Floderus-Myrhed, Birgitta. ‘Workload’ and Risk of Myocardial Infarction – A Prospective Psychosocial Analysis. Int J Epidermiol 1977, 6(1), 17-21.
The study group consisted of 5187 building construction workers aged 41-61 in Greater Stockholm who had all responded to a psychosocial questionnaire and had been in full-time work without long-lasting illness episodes in the year before the study. A factor analysis of about 60 psychosocial variables was performed, and on this basis three indices were formed. The study group was followed for two years in official registers yielding information on morbidity and mortality. The ‘workload’ index was demonstrated to be significantly associated with subsequent risk of myocardial infarction.

Frasure-Smith, Nancy/ Lespérance, François/ Talajic, Mario. Depression and 18-Month Prognosis After Myocardial Infarction. Circulation 1995, 91, 999-1005.
Abstract
Background We previously reported that major depression in patients in the hospital after a myocardial infarction (MI) substantially increases the risk of mortality during the first 6 months. We examined the impact of depression over 18 months and present additional evidence concerning potential mechanisms linking depression and mortality.
Methods and Results Two-hundred twenty-two patients responded to a modified version of the National Institute of Mental Health Diagnostic Interview Schedule (DIS) for a major depressive episode at approximately 7 days after MI. The Beck Depression Inventory (BDI), which measures depressive symptomatology, was also completed by 218 of the patients. All patients and/or families were contacted at 18 months to determine survival status. Thirty-five patients met the modified DIS criteria for major in-hospital depression after the MI. Sixty-eight had BDI scores 10, indicative of mild to moderate symptoms of depression. There were 21 deaths during the follow-up period, including 19 from cardiac causes. Seven of these deaths occurred among patients who met DIS criteria for depression, and 12 occurred among patients with elevated BDI scores. Multiple logistic regression analyses showed that both the DIS (odds ratio, 3.64; 95% confidence interval [CI], 1.32 to 10.05; P=.012) and elevated BDI scores (odds ratio, 7.82; 95% CI, 2.42 to 25.26; P=.0002) were significantly related to 18-month cardiac mortality. After we controlled for the other significant multivariate predictors of mortality in the data set (previous MI, Killip class, premature ventricular contractions [PVCs] of >10 per hour), the impact of the BDI score remained significant (adjusted odds ratio, 6.64; 95% CI, 1.76 to 25.09; P=.0026). In addition, the interaction of PVCs and BDI score marginally improved the model (P=.094). The interaction showed that deaths were concentrated among depressed patients with PVCs of >10 per hour (odds ratio, 29.1; 95%
CI, 6.97 to 122.07; P<.00001).
Conclusions Depression while in the hospital after an MI is a significant predictor of 18-month post-MI cardiac mortality. Depression also significantly improves a riskstratification model based on traditional post-MI risks, including previous MI, Killip class, and PVCs. Furthermore, the risk associated with depression is greatest among patients with >10 PVCs per hour. This result is compatible with the literature suggesting an arrhythmic mechanism as the link between psychological factors and sudden cardiac death and underscores the importance of developing screening and treatment programs for post-MI depression.

Iribarren, Carlos/ Sidney, Stephen/ Bild, Diane E./ Liu, Kiang/ Markovitz, Jerome H./ Roseman, Jeffrey M./ Matthews, Karen. Association of Hostility with Coronary Artery Calcification in Young Adults. JAMA May 2000, 283(19) 2546 – 2551.
Context: Psychosocial factors, including personality and character traits, may play a role in the development of expression of coronary artery disease.
Objective: To evaluate whether hostility, a previously reported predictor of clinical coronary artery disease, is associated with coronary calcification, which is a marker of subclinical atherosclerosis.
Design: Prospective cohort study.
Setting and Participants: Volunteer subsample from Chicago, Ill, and Oakland, Calif, consisting of 374 white and black men and women, aged 18 to 30 years at baseline, who participated in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Cook-Medley hostility assessment data were collected at baseline from 1985 to 1986 and at year 5 examinations from 1990 to 1992. After the 10-year examinations in the 1995-1996 year, electron-beam computed tomographic scans were performed.
Main Outcome Measures: Presence of any detectable coronary artery calcification (coronary calcium score >0), and coronary artery calcium scores of 20 or higher.
Results: In logistic regression analysis adjusting for age, sex, race, and field center comparing those with hostility scores above and below the median of the distribution of the present sample, the odds ratio of having any coronary calcification was 2.57 (95% confidence interval, 1.31 – 5.22), and the odds ratio of having a score of 20 or higher was 9.56 (95% confidence interval, 2.29-65.9) for calcium scores of 20 or higher. The associations with any coronary artery calcification persisted after adjusting for demographic, lifestyle, and physiological variables. Results using a cynical distrust subscale were somewhat weaker than for those using the global hostility score. Power was inadequate to perform sex- or race-specific analyses.
Conclusion: These results suggest that a high hostility level may predispose young adults to coronary artery calcification.

Jaffe, Allan S./ Krumholz, Harlan M./ Catellier, Diane J./ Freedland, Kenneth E./ Bittner, Vera/ Blumenthal, James A./ Calvin, James E./ Norman, James/ Sequeira, Rafael/ O’Connor, Christopher/ Rich, Michael W./ Sheps, David/ Wu, Colin. Prediction of Medical Morbidity and Mortality after Acute Myocardial Infarction in Patients at Increased Psychosocial Risk in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Study. Am Heart J 2006, 152, 126-35.
Background Patients with myocardial infarction (MI) are at further increased risk for untoward events when patients also exhibit low social support and/or depression. The ENRICHD study was the largest controlled trial in post-MI patients attempting to treat these psychological comorbidities and provides an opportunity to examine the medical and psychological characteristics that may affect risk in this population.
Methods We analyzed the baseline characteristics and their relationship to the primary end point of long-term mortality and recurrent infarction and to the secondary end points of overall mortality and cardiovascular mortality in 2481 post-MI patients. Cox proportional hazards models were used to predict the risk of these outcomes over a mean of 2.5 years of follow-up.
Results Death or nonfatal MI occurred in 24.1%, all-cause mortality in 13.7%, and cardiovascular mortality in 8.4% of the sample (62% of the total). Age, heart failure, pulmonary disease, Killip class, ejection fraction, an elevated creatinine, the use of non–angiotensin-coverting enzyme asodilators, prior MI, diabetes, depression, and bypass surgery after acute MI were all significant multivariable predictors.
Conclusions The medical predictors of adverse events in post-MI patients with low social support and/or depression were similar to those of patients with MI in other clinical trials.

Kop, Willem J. The Integration of Cardiovascular Behavioral Medicine and  Psychoneuroimmunology: New Developments Based on Converging Research Fields. Brain, Behavior, and Immunity 2003, 17, 233–237.
Abstract
The immune system plays a role in the progression of coronary artery disease and its clinical manifestations as acute coronary syndromes. It is well established that psychological factors can act as risk factors for acute coronary syndromes.
This review describes psychoneuroimmunological pathways involved in coronary disease progression and documents that the stage of coronary disease is a major determinant of pathophysiological mechanisms accounting for the association between psychological risk factors, immune system parameters, and acute coronary syndromes. Chronic psychological risk factors (e.g., hostility and low socioeconomic status) are important at early disease stages, episodic factors (e.g., depression and exhaustion) are involved in the transition from stable to unstable atherosclerotic plaques, and acute psychological triggers (e.g., mental stress and anger) can promote myocardial ischemia and plaque rupture.
The psychoneuroimmunological pathways are described for each of these three types of psychological risk factors for acute coronary syndromes.

Lesperance, Francois/ Frasure-Smith, Nancy/ Talajic, Mario. Major Depression Before and After Myocardial Infarction: Its Nature and Consequences. American Psychosomatic Society March/April 1996, 58(2), 99-110.
Abstract
The prevalence and prognostic impact of previous depression, depression in the hospital, and depression after discharge were studied in 222 patients admitted for acute myocardial infarction (MI).Patients were interviewed 1 week, 6 months, and 12 months after the index MI using a modified version of the Diagnostic Interview Schedule (DIS); patients also completed the Beck Depression Inventory (BDI). Patients or family members were recontacted at 18 months to determine survival. Some 27.5% of patients had at least one episode of major depression before their MI, but only 7.7% were depressed at some point during the year preceding the infarct. Overall, 31.5% of patients experienced depression in the hospital or during the year postdischarge. Some 35 patients were depressed in the hospital, 30 became depressed between discharge and 6 months, and five more between 6 and 12 months after the MI. History of depression increased the risk of depression in the hospital and after discharge. Depression in the hospital was associated with an increased risk of mortality over 18 months. Patients who experienced a recurrent depression in the hospital were at particularly high risk. Although patients who became depressed after discharge differed from those who remained depression-free in terms of age, history of depression, BDI scores, and the number of depression symptoms on the DIS in the hospital, a model including these variables identified only 14.7% of the patients who became depressed after returning home. Post-MI depression is common and largely unrelated to medical and psychosocial factors.

Lewis, Jordana/ Adler, Jerry. Forgive and Let Live. Newsweek  9/27/2004, 00289604, 144(13).
Revenge is sweet, but letting go of anger at those who wronged you is a smart route to good health.

Linden, Wolfgang/ Gerin, William/ Davidson, Karina. Cardiovascular Reactivity: Status Quo and a Research Agenda for the New Millennium. Psychosomatic Medicine 2003, 65, 5–8.
This article introduces a series of articles that assess the present status of the cardiovascular reactivity construct as well as the progress that has been made since a critical review of the reactivity literature by Pickering and Gerin was published in 1990.

Lovallo, Willliam R./ Gerin, William. Psychophysiological Reactivity: Mechanisms and Pathways to Cardiovascular Disease. Psychosomatic Medicine 2003, 65, 36–45.
Objective: This article examines possible sources of heightened psychophysiological reactivity in relation to risk for hypertension and coronary artery disease. The idea that exaggerated reactions to psychological stress may predict greater risk for future disease has some support in the psychosomatic and behavioral medicine literature. However, the pathways by which exaggerated reactivity could arise in a given person and the implications of different sources of reactivity for potential disease relationships have received little attention.
Methods: This topic is approached through a selective literature review and by means of a neurophysiologically based model of individual differences in physiological reactivity. Temperament characteristics, cognitive processes, neurophysiology, and peripheral physiology are used to indicate three levels that could contribute to exaggerated physiological reactivity.
Results: At the top level in the model, activity of the frontal cortex and limbic system establish cognitive-emotional sources of activation that may underlie exaggerated physiological reactivity. In the absence of these influences, large responses may be more likely when exaggerated subcortical response tendencies are present via the hypothalamus or brain stem. Finally, peripheral alterations may account for larger reactions in persons who have otherwise normal emotional and hypothalamic and brainstem response tendencies. Cognitive-emotional and hypothalamic-brainstem sources of altered reactivity may cause or aggravate disease. In contrast, altered peripheral reactivity suggests that a pathophysiologic process may be present, serving as a marker for disease.
Conclusions: These three levels of analysis allow for organization of existing data in the area of cardiovascular reactivity and for planning future studies in a hypothesis-building framework.

Lucini, Daniela/ Di Fede, Gaetana/ Parati, Gianfranco/  Pagani, Massimo. Impact of Chronic Psychosocial Stress on Autonomic Cardiovascular Regulation in Otherwise Healthy Subjects. Hypertension 2005, 46, 1201-1206.
Abstract—Elevated psychosocial stress might favor the occurrence of cardiovascular disease; however, mechanisms are incompletely understood. We hypothesized that patients (n=126; 44+1 years of age) referred to an internal medicine clinic because of symptoms related to chronic psychosocial stress would demonstrate signs of autonomic dysregulation compared with controls (n=132; 42+1 years of age). We used autoregressive spectral analysis of RR interval variability to obtain indirect markers of sympathetic and of vagal (respectively, low-frequency and high-frequency components, both expressed in normalized units) oscillatory modulation of sinoatrial node, as well as of sympathetic vasomotor regulation (low-frequency component of systolic arterial pressure variability) and of cardiac baroreflex sensitivity ( -index). Higher values of systolic and diastolic arterial pressure (respectively, 124±1 versus 117±1 mmHg and 80±1 versus 75±1 mm Hg; both P<0.001), altered markers of autonomic regulation (increased normalized low-frequency and reduced high-frequency component of RR variability, P<0.005; increased-low frequency component of systolic arterial pressure variability, P<0.002), and reduced baroreflex sensitivity (19.3±1.4 versus 23.0±2.0 ms/mm Hg; P<0.05) were observed in patients compared with controls. Autonomic responses to active standing were also blunted in stressed patients. Autonomic markers were significantly correlated to stress perception score and were capable of discriminating between controls and patients with a high degree of accuracy. Chronic real-life stress in humans appears associated to increased arterial pressure and to impaired autonomic regulation of cardiovascular functions. The combination of sympathetic predominance, vagal withdrawal, and blunted baroreflex sensitivity might represent a treatable mechanistic link between psychosocial factors and future incidence of hypertension.

Matthews, Karen A./ Raikkonen, Katri/ Sutton-Tyrrell, Kim/ Kuller, Lewis H. Optimistic Attitudes Protect Against Progression of Carotid Atherosclerosis in Healthy Middle-Aged Women. Psychosomatic Medicine 2004, 66, 640–644.
Objective: Optimistic people report a higher quality of life, engage in more active coping and adopt more health-promoting behaviors than people low in optimism, ie, pessimism. We evaluated whether pessimists are more likely to show progression in carotid disease than optimists.
Methods: A total of 209 middle-aged healthy premenopausal women enrolled in an epidemiological study of cardiovascular risk factors and had carotid scans 10.4 years and 13.5 years later when they were at least 5 years postmenopausal. Women completed the Life Orientation Test (LOT), a measure of pessimistic and optimistic attitudes, at study entry and at the time of the first carotid scan. Analyses evaluated the association of LOT scores and change in carotid intima medial thickness (IMT) across 3 years.
Results: Multiple linear regression analyses showed that the higher the pessimism scores at study entry, the greater the increase in mean IMT (β= 0.17, p < .007). A comparison of those in the lowest quartile of LOT scores (most optimistic) with those in the other three quartiles showed that the most optimistic group had less progression than the remaining more pessimistic women (mean percent increase = 1.3 and 6.0 for mean IMT, F = 15.4, p < .001). Women who were chronically optimistic at study entry and at the first carotid scan (bottom quartiles at both times) had less progression in mean IMT than did those who were chronically pessimistic (top quartiles at both times).
Conclusions: Optimistic women are less likely to show progression of carotid disease in mid-life than are pessimists.

Niaura, Raymond/ Todaro,  John F./ Stroud, Laura/ Spiro III, Avron/ Ward, Kenneth D./ Weiss, Scott. Hostility, the Metabolic Syndrome, and Incident Coronary Heart Disease. Health Psychology 2002, 21(6), 588–593.
This investigation examined the impact of hostility and the metabolic syndrome on coronary heart disease (CHD) using prospective data from the Normative Aging Study. Seven hundred seventy-four older, unmedicated men free of cardiovascular disease were included in the study. The total Cook–Medley Hostility (Ho) Scale score, anthropometric data, serum lipids, fasting insulin concentrations, blood pressure, cigarette smoking, alcohol consumption, and total dietary calories were used to predict incident CHD during a 3-year follow-up interval. Multivariate analysis indicated that only Ho positively predicted and high-density lipoprotein cholesterol level negatively predicted incident CHD. Ho’s  effects on CHD may be mediated through mechanisms other than factors that constitute the metabolic syndrome.

Rainville, Pierre/ Bechara, Antoine/ Naqvi, Nasir/ Damasio, Antonio R. Basic Emotions are Associated with Distinct Patterns of Cardiorespiratory Activity. International Journal of Psychophysiology 2006, 61, 5 – 18. www.elsevier.com/locate/ijpsycho
Abstract
The existence of specific somatic states associated with different emotions remains controversial. In this study, we investigated the profile of cardiorespiratory activity during the experience of fear, anger, sadness and happiness. ECG and respiratory activity was recorded in 43 healthy volunteers during the recall and experiential reliving of one or two potent emotional autobiographical episodes and a neutral episode. Univariate statistics indicated that the four emotions differed from each other and from the neutral control condition on several linear and spectral indices of cardiorespiratory activity. Dependent variables were further reduced to five physiologically meaningful factors using an exploratory principal component analysis (PCA). Multivariate analyses of variance and effect size estimates calculated on those factors confirmed the differences between the four emotion conditions. A stepwise discriminant analyses predicting emotions using the PCA factors led to a classification rate of 65.3% for the four emotions (chance=25%; p =0.001) and of 72.0–83.3% for pair-wise discrimination (chance=50%; p’s<0.05). These findings may be considered preliminary in view of the small sample on which the multivariate approach has been applied. However, this study emphasizes the need to better characterize the multidimensional factors involved in cardio-respiratory regulation during emotion. These results are consistent with the notion that distinct patterns of peripheral physiological activity are associated with different emotions.

Schartz, Amy R./ Gerin, William/ Davidson, Karina W./ Pickering, Thomas G./ Brosschot, Jos. F./ Thayer, Julian F./ Christenfeld, Nicholas/ Linden, Wolfgang. Toward a Causal Model of Cardiovascular Responses to Stress and the Development of Cardiovascular Disease. Psychosomatic Medicine 2003, 65, 22–35.
Objective: Cardiovascular reactivity is hypothesized to mediate the relationship between stress and cardiovascular disease. We describe three considerations that are crucial for a causal model of cardiovascular responses to stress: the need for laboratory-life generalizability, the role of interactions between environmental exposures and individual response predispositions, and the importance of the duration of both stressor exposure and cardiovascular
responding.
Methods: We illustrate current understanding of stress–cardiovascular disease relationships with examples from the human and animal psychophysiology, epidemiology, and genetics literature.
Results: In a causal model of reactivity, the usefulness of laboratory assessment rests on the assumption that laboratory-based cardiovascular reactivity predicts responses in the natural environment. We find only limited generalizability and suggest that cardiovascular responses to stress can be better understood when examined in the natural environment. The interaction of individual response predispositions and stressor exposures contributes to the development and progression of cardiovascular disease; stress-disease relationships could therefore be better understood if predispositions and exposures were assessed simultaneously in interactive models. Cardiovascular responses to stress are likely to be most deleterious when responses are prolonged. Responses may vary in their magnitude, frequency, and duration; however, reactivity captures only response magnitude. The assessment of anticipatory and recovery measures, with response magnitude, may therefore lead to a more useful model of the stress-disease relationship.
Conclusions: A causal model of cardiovascular responses to stress should generalize to the real world, assess interactions between individual predispositions and environmental exposures, and focus on sustained pathogenic exposures and responses.

Sendelbach, Sue E./ Halm, Margo A./ Doran, Karen A./ Hogan Miller, Elaine/ Gaillard, Philippe. Effects of Music Therapy on Physiological and Psychological Outcomes for Patients Undergoing Cardiac Surgery. Journal of Cardiovascular Nursing 2006, 21(3), 194 -200.
Background: Cardiac surgery is a common interventional procedure for ischemic and valvular heart disease. Cardiac surgery is accompanied by postoperative pain and anxiety. The use of music therapy has been shown to reduce pain, anxiety, and physiological parameters in patients having surgical procedures.
Objectives: To compare the effects of music therapy versus a quiet, uninterrupted rest period on pain intensity, anxiety, physiological parameters, and opioid consumption after cardiac surgery. Subjects and methods: An experimental design was used. A total sample of 86 patients (69.8% males) were randomized to 1 of 2 groups; 50 patients received 20 minutes of music (intervention), whereas 36 patients had 20 minutes of rest in bed (control). Anxiety, pain, physiologic parameters, and opioid consumption were measured before and after the 20-minute period.
Results: A significant reduction in anxiety (P < .001) and pain (P = .009) was demonstrated in the group that received music compared with the control group, but no difference was observed in systolic blood pressure (P = .17), diastolic blood pressure (P = .11), or heart rate (P = .76). There was no reduction in opioid usage in the 2 groups. Conclusions: Patients recovering from cardiac surgery may benefit from music therapy.

Suarez, Edward C. Joint Effect of Hostility and Severity of Depressive Symptoms on Plasma Interleukin-6 Concentration. Psychosomatic Medicine 2003, 65, 523–527.
Objective: Although interleukin (IL)-6 plays a significant role in cardiovascular disease, little is known about its relation to psychological risk factors, such as hostility and severity of depressive symptoms.  The current study examined the joint effects of severity of depressive symptoms and hostility on plasma IL-6 in a sample of 90 healthy, nonsmoking men.
Methods: After an overnight fast, blood samples for plasma IL-6 and fasting lipids were collected on the same day that the Beck Depression Inventory (BDI) and the Cook-Medley hostility (Ho) scale were administered. Plasma IL-6 was determined using enzymatic-linked immunosorbent assay (ELISA).
Results: Analyses of logarithmically normalized plasma IL-6 adjusting for age, body mass index (BMI), fasting total cholesterol, high density lipoprotein (HDL), and resting diastolic blood pressure (DBP) revealed a significant BDI by Ho interaction (p = .026). Post hoc decomposition revealed that Ho was correlated with log-normalized plasma IL-6 (r = 0.59, p = .025) but only among men with BDI scores of 10 and above. Alternatively, BDI was correlated with log-normalized plasma IL-6 (r = 0.61, p = .003) but only among men with Ho scores of 23 and higher. Comparisons among BDI/Ho groups indicated that men with high scores on both the BDI and the Ho exhibited the highest median levels of plasma IL-6.
Conclusion: Hostile men who exhibited above normal levels of depressive symptoms had higher plasma levels of IL-6 suggestive of a subpopulation at increased risk for future cardiac events.

VanOyen Witvliet, Charlotte/ Ludwig, Thomas E./ Vander Laan, Kelly L. Granting Forgiveness or Harboring Grudges: Implications for Emotion, Physiology, and Health. American Psychological Society 2001, 12(2), 117-123.
Abstract
Interpersonal offenses frequently mar relationships. Theorists have argued that the responses victims adopt toward their offenders have ramifications not only for their cognition, but also for their emotion, physiology, and health. This study examined the immediate emotional and physiological effects that occurred when participants (35 females, 36 males) rehearsed hurtful memories and nursed grudges (i.e. were unforgiving) toward real-life offenders. Unforgiving thoughts prompted more aversive emotion, and significantly higher corrugator (brow) electromyogram (EMG), skin conductance, heart rate, and blood pressure changes from baseline. The EMG, skin conductance, and heart rate effects persisted after imagery into the recovery periods. Forgiving thoughts prompted greater perceived control and comparatively lower physiological stress responses. The results dovetail with the psychophysiology literature and suggest possible mechanisms through which chronic unforgiving response may erode health whereas forgiving responses may enhance it.

Villagomeza, Liwliwa R. Mending Broken Hearts The Role of Spirituality in Cardiac Illness: A Research Synthesis, 1991–2004. Holist Nurs Pract 2006, 20(4), 169–186.
This research synthesis analyzed research on spirituality in cardiac illness from 1991 to 2004 to identify progress, gaps, and priorities for research. Articles were retrieved from PubMed and CINAHL. Twenty-six studies met inclusion criteria. Moody’s Research Analysis Tool, Version 2004, was used to analyze studies. Lack of conceptual model and universal definition of spirituality are major knowledge gaps. A proposed conceptual model is presented.

Van Doornen, Lorenz J.P./ Orlebeke, K.F. Stress, Personality and Serum-Cholesterol Level. Journal of Human Stress December 1982, 8(4), 24-29.
It appears that serum-cholesterol level may serve as an important mediator between psychological variables and coronary heart disease (CHD). From a review of the literature it is concluded that (1) psychological stressors significantly elevate serum-cholesterol level and (2) psychological characteristics like the Type A-pattern and depression are positively correlated with serum-cholesterol levels. This suggests that the relationship between CHD and stress and coronary prone behavior may be partially explained by the mediating role of serum-cholesterol. A more careful consideration of psychological variables may be helpful in reducing the substantial amount of unexplained variance in cholesterol levels.

Wittstein, Ilan S./ Thiemann, David R./ Lima, Joao A.C./ Baughman, Kenneth L./ Schulman, Steven P./ Gerstenblith, Gary/ Wu, Katherine C./ Rade, Jeffrey J./ Bivalacqua, Trinity J./ Champion, Hunter C. Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress. N Engl J Med 2005, 352(6), 539-548.
Abstract
Background Reversible left ventricular dysfunction precipitated by emotional stress has been reported, but the mechanism remains unknown.
Methods We evaluated 19 patients who presented with left ventricular dysfunction after sudden emotional stress. All patients underwent coronary angiography and serial echocardiography; five underwent endomyocardial biopsy. Plasma catecholamine levels in 13 patients with stress-related myocardial dysfunction were compared with those in 7 patients with Killip class III myocardial infarction.
Results The median age of patients with stress-induced cardiomyopathy was 63 years, and 95 percent were women. Clinical presentations included chest pain, pulmonary edema, and cardiogenic shock. Diffuse T-wave inversion and a prolonged QT interval occurred in most patients. Seventeen patients had mildly elevated serum troponin I levels, but only 1 of 19 had angiographic evidence of clinically significant coronary disease. Severe left ventricular dysfunction was present on admission (median ejection fraction, 0.20; interquartile range, 0.15 to 0.30) and rapidly resolved in all patients (ejection fraction at two to four weeks, 0.60; interquartile range, 0.55 to 0.65; P<0.001). Endomyocardial biopsy showed mononuclear infiltrates and contraction-band necrosis. Plasma catecholamine levels at presentation were markedly higher among patients with stressinduced cardiomyopathy than among those with Killip class III myocardial infarction (median epinephrine level, 1264 pg per milliliter [interquartile range, 916 to 1374] vs. 376 pg per milliliter [interquartile range, 275 to 476]; norepinephrine level, 2284 pg per milliliter [interquartile range, 1709 to 2910] vs. 1100 pg per milliliter [interquartile range, 914 to 1320]; and dopamine level, 111 pg per milliliter [interquartile range, 106 to 146] vs. 61 pg per milliliter [interquartile range, 46 to 77]; P<0.005 for all comparisons).
Conclusions Emotional stress can precipitate severe, reversible left ventricular dysfunction in patients without coronary disease. Exaggerated sympathetic stimulation is probably central to the cause of this syndrome.

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