Heart Disease, Hypertension, and Stroke

Psychological Issues in Advanced and Terminal Illness

Average life expectancy in North America is 76 years.

Leading causes of death in adults are chronic illness

What are the leading causes of death across the life span?

Mortality RatesLeading causes of death

< 1 year congenital abnormalities; sudden infant death syndrome (SIDS)

Children > 1 year old Accidents (40% of all deaths) Cancer (especially leukemia)

Adolescence Unintentional injury Homicide AIDS

Mortality RatesLeading causes of death

Middle age Sudden death due to heart attack or

stroke Cancer

Elderly Heart disease Cancer Stroke

Why do women live longer than men?

Potential Reasons for Gender Differences in Mortality

Females are more hardy Males engage in riskier behaviours (factor after

birth and infancy) Men engage in riskier sports Males tend to hold high stress or higher risk

jobs Men tend to have poorer health habits (e.g.,

drink more alcohol) Social support may be more protective in

women

Risk Factors Family history Marital status (adds 10 yrs in men; 4 yrs

in women) Economic status Body weight Exercise Alcohol (add 2 years if drink 1-3

drinks/day)

Risk Factors - continued Smoking Disposition (add 2 yrs if reasoned, practical) Education Environment (add 4 yrs if rural) Sleep (more than 9 hours subtract 5 years) Temperature (add 2 yrs if thermostat is <

68) Health care – regular check ups add 3 yrs

How do people adapt to chronic illness?

Adapting Under Good Circumstances First concern upon hearing

diagnosis is fears about mortality. Optimistic but tentative about plans May try to normalize activities

Risk is they may over-extend May have feelings of helplessness

Risk is to become overly dependent

Three Themes of Adaptation Find meaning: why illness

happened or rethink priorities Gain sense of control

control symptoms and treatment Restore self-esteem

Often by comparison with worse off others

Adapting Under Bad Circumstances Relapse seen as a bad sign with

poor prognosis Re-focuses one on the illness Need to undergo the coping

process again but likely less hopeful than before.

Heart Disease Due to narrowing or blocking of the

coronary arteries. Angina pectoris

painful cramp in chest, arm, neck, or back due to brief blockage of oxygenated blood to the heart.

More often during exercise, stress, cold temperature, digesting large fat meal.

Little or no permanent damage

Heart Disease Myocardium

Muscle tissue around the heart Myocardium infarction (heart attack)

Prolonged blockage of blood to an area of the heart resulting in muscle tissue damage.

Symptoms of a heart attack Pressure in chest, fullness, squeezing pain. Pain spreading to shoulders, neck, or arms Lightheadedness, fainting, sweating, nausea

Who Is At Risk of Heart Disease?

Prevalence increases with age, particularly after 45 years of age

Prior to 50s, 60s, men at greater risk than women but increases in women after menopause.

More women than men are likely to die from a heart attack

Blacks at higher risk, Asians at lower risk

Heart Disease Risk Factors High blood pressure Family history Cigarette smoking High LDL and total cholesterol levels Physical inactivity Diabetes Obesity Stress

Why high blood pressure a risk factor?

Heart has to work harder. Since heart muscle is working harder,

it can become enlarged. Wear and tear on the arterial wall can

increase the likelihood of lipid and calcium deposits adhering to the arterial wall. This leads to hardening of the arteries.

Type A Behaviours Hostile, cynical Judgmental (opinionated) Competitive Time urgent Uses gestures while talking Nodding of head while others are talking Intense

Physiological Reactivity Physiological and cardiovascular

reactivity to acute stress (“hot reactors”). Exaggerated increases in blood pressure,

heart rate, catecholamines, corticosteroids High levels of these hormones can

damage heart and blood vessels Presence of epinephrine (a

catecholamine) increases the formation of clots.

Effects of Stress On Cardiac Risk

Psychosocial Predictors Psychosocial Predictors of Sudden Cardiac Death (BDIof Sudden Cardiac Death (BDI>>10)10)

0 200 400 600 8000 200 400 600 800

1.001.00

0.950.95

0.900.90

0.850.85

Survival in daysSurvival in days

Placebo, BDI <10Placebo, BDI <10

Placebo, BDI Placebo, BDI >>1010

AMIO, BDI <10AMIO, BDI <10

AMIO, BDI AMIO, BDI >>1010

ProportionProportionSurvivingSurviving

When do heart attacks occur?

Less likely during sleep. Among the employed, more often on

a Monday between 6 and 11 am. In part due to waking and becoming

active shortly after dreaming which increases BP.

In part because of circadian rhythm effects, increases in arousal hormones and blood pressure.

Medical Treatment Initial treatment may involve clot-

dissolving medication and close monitoring

Balloon angioplasty Tiny balloon is inserted into blocked vessel

and inflated to open blood vessel Bypass surgery

Use grafted vessel (e.g., piece from leg) to bypass blockage in artery to the heart

Medical Treatment Medications (e.g., beta blockers,

calcium channel blockers) to protect heart and improve function.

Risk management Control of high blood pressure Control of lipid abnormalities

Rehabilitation Promote recovery and reduce risk of

another attack

Heart disease is chronic condition requiring ongoing management.

Rehabilitation Includes: Exercise

Physiological and psychological benefits Weight management Smoking cessation Lipid and BP management include

dietary changes to control lipids Reduce excessive alcohol intake Stress management

Rehabilitation Exercise is the key component but:

50% drop-out rate within first 6 months For those who continue benefits include:

Improved self concept, perceived health, sexual activity, involvement in social activities.

Those who stop are more likely to: Smoke, have poorer cardiac function, have

higher body weight, be more sedentary, experience greater anxiety and depression.

Symptoms of a Stroke Sudden

weakness or numbness of the face, arm, or leg (usually on one side of the body)

dimness or loss of vision (usually one eye)

Loss of speech or trouble talking or understanding speech

Unexplained, severe headache Dizziness, unsteadiness, or sudden fall

What is a stroke?

Tissue damage to area of the brain due to disruption in blood supply, depriving that area of the brain of oxygen.

Causes of Strokes

1. Infarction – blockage in cerebral artery that cuts off or reduces blood supply

a) Thrombosis – blood clotb) Embolus – piece of plaque becomes

lodged in the artery.

2. Hemorrhage – happens suddenly. Less frequent than infarction but more damaging and more likely to cause death.

Stroke Risk Factors Rare up to age 55, than risk increases

sharply with age (doubling with each decade).

More common in men but women more likely to die from them.

Rates highest among blacks and lowest among Asians.

Family history

Stroke Risk Factors High blood pressure Cigarette smoking Heart disease, diabetes, and their

risk factors such as obesity and physical inactivity.

High red blood cell count (making the blood thicker and likelier to clot).

Mini-strokes – transient ischemic attacks (TIA)

Effects of a Stroke Some motor, sensory, cognitive, or

speech impairment usually occurs Limitations may be permanent but

lessen in severity over time. Younger patients recover better Impairments caused by hemorrhages

more easily overcome than those caused by infarctions.

Effects of Stroke Motor impairments often due to

paralysis on one side of the body (side opposite to brain damage). After about 6 weeks of rehab about 50%

of patients can perform independently (many with cane or walker).

Language, learning, memory, and perception problems depend on location of the injury.

Effects of Stroke Left-hemisphere damage more

commonly associated with language problems called aphasia. Receptive aphasia – difficulty

understanding verbal information. Expressive aphasia – difficulty producing

and using language. Damage to right side of brain often

associated with difficulties in visual processing and emotions.

Psychosocial Aspects of Stroke

Denial is common Unclear whether psychological or

physiological basis. This ambiguity also applies to depression

when it occurs after a stroke. Less than ½ of the patients return to

work following a stroke.