stress as a risk factor by soliman ghareeb, md professor of cardiovascular medicine cairo university

Stress As A Risk Factor BY

Soliman Ghareeb, MD

Professor of Cardiovascular MedicineCairo University

o Definition of stresso Symptomso Individuals at high risk o Types of stresso How to assess?o Types of personalityo Effects of stresso Evidence based medicine : - International - Egyptian experienceo How to Cope?

what is stress ?

The stress response of the body is somewhat like an airplane readying for take-off. Virtually all systems (heart and blood vessels, the immune system ,lungs, the digestive system, the sensory organs and brain) are modified to meet the perceived danger

Not all stress is bad, and we all need

a certain amount to function

effectivel.

Circulation February 1998 Vol 2. No. 2

Stress as a Risk Factor: How to cope?

Symptoms of Stress

• Aches and pains. Particularly common are chest,

shoulder, back and neck pains. Things that used to be

fun or pleasurable do not seem enjoyable anymore.

Lack of sleep, fatigue, aches and pains makes life not

enjoyable anymore.

• The patient may cry easily.

• The patient feels quite anxious and feels as if he can

not catch his breath. He may even get light-headed

and have stomach upset and diarrhea.Circulation February 1998 Vol 2. No. 2


• Brain- Fatigue.

• Migarine, backache, neck and shoulder pain.

• Cardiovascular- High blood pressure, heart attack, angina abnormal, heart beat, stroke.

• Skin- Itchy skin rashes.

• Temperature may rise to 38.2Cº .

Individuals at high risk

Young adults

Women in general as women > men in :• stress related non specific chest pain

Working mothers ( married or single)

Less educated individuals why?

Divorced or widowed individuals

Individuals at high risk (CONT)

- Unemployed

- Isolated individuals

- Those without health insurance

- People who live in cities

Stressors

External Internal

Acute Chronic

Mental Physical

External stressors

Include adverse physical conditions stressful psychological environments

Such as pain , hot or cold temperatures. poor working conditions or abusive relationships.

Human, like animals, can

experience external stressors

Internal stressors

Physical : infection , inflammation

Psychological intense worry about harmful events that may or may not occur

Internal stressors are present only in humans

Acute stress is the reaction to an immediate threat, commonly known as the fight or flight response. Common acute stressors include:

– Noise– Crowding– Isolation– Hunger – Danger– Infection and – Imaging in a threat or remembering a dangerous event

Acute stress

Chronic stress

Modern life poses on-going stressful situations that are not short-lived and the urge to act (to fight or to flee) must be suppressed. Stress, then becomes chronic. Common chronic stressors include:

– On-going highly pressured work– Long-term relationship problems– Loneliness and persistent financial worries

How to assess the response to stress?

Cardiovascular stress responsively

was indexed by changes in:

Blood pressure

Heart rate

Heart rate variability

The magnitude of acute BP stress

reactions has been forward to predict:1. Future hypertension

2. LVH of LV mass

3. Progression of atherosclerosis

While impaired post-stress recovery is

associated with heightened1. Cardiovascular disease

2. mortality in patients with CAD

What is “personality”?

Behavior patterns, due to

- InternalInternal “structure(s)” or “given” – “ Organization

within the person.”

- Driven by externalexternal environment (or cognitions).


Type A/B Personality

Type A pattern:

- Domineering, (overly) competitive (I win, and you lose- rub it in).

- Perfectionists, without joy in accomplishment.

- Time urgency, over schedule– the “hurry sickness”.

- Always “on”

- Easily aroused to anger/hostility

- With or without expressing it overtly.



• Physical manifestations:

– Facial tension.

– Rapid speech.

– Interruption of others’ speech.

– Tongue and teeth clicking.

– Audible forced inspiration of air.


- Type B:

- “Opposite” ??

BMJ 1998; 317:775-780 (19 September)


Type A Behavior ChecklistAnswer “yes” or “no” to the following questions (and hurry, don’t make me

wait!)

1. Do you find it difficult to restrain yourself from hurrying other’s speech (finishing their sentences for them)?

2. Do you often try to do more than one thing at a time (such as eat and read simultaneously)?

3. Do you often feel guilty if you use extra time to relax?

4. Do you tend to get involved in great numbers of projects at once?

5. Do you find yourself running through yellow lights when you drive?


Type A Behavior Checklist (cont.)

6. Do you need to win in order to derive enjoyment from games

and sports?

7. Do you generally move, walk, and eat rapidly?

8. Do you agree to talk on too many responsibilities?

9. Do you detest waiting in line?

10. Do you have an intense desire to better your position in life and

impress others?


Try it on yourself,

Then have someone else do it on you ….

If there is much differences … think

No fixed key,But if you answered more than half “yes”

You are on the way to Tape A


Routes to illness

Stress

Immune System Heath Compromising

Suppression Behavior

Disease


What are the negative effects of stress?

1. ↑Pumping action & HR→ ↑ work load

2. ↑ Vaso-constriction → ↑↑ afterload

3. ↑Likelihood of an artery clogging blood clot

4. ↑Signals to the body to raise blood cholesterol

5. In women chronic stress may reduce estrogen level → CAD

6. Increase cytokines → damage to the cells and ↑inflammation

7. Recent evidence confirms association between repeated stress and development of hypertension

STROKE

One big survey revealed that men who had stressful situations e.g. Problem at work or waiting in line are likely to have

STROKES

European heart journal Nov 2002

Susceptibility to infection

Chronic stress appears to blunt the immune response to stressful situations→

1. ↑ risk for infection

2. impair person’s response to

immunization

Susceptibility to infection (cont )

Number of studies show that subject

under chronic stress :

• Have low white blood cells count

• More vulnerable to cold • HIV infected men progress more

rapidly to AIDS

Cancer

Current evidence does not suppress the

idea that stress causes cancer Yet: two small studies on melanoma and

breast cancers showed improved survival with therapy that offered emotional support

Immune disorders

The year 2001 studies reported that : short term stress→ no negative effect

chronic stress→ major risk factor for

flare ups .

Diabetes mellitus

Chronic stress has been associated with :

1. The development of insulin resistance

which is the primary factor in diabetes

2. Exacerbation of existing diabetes due

to high level of cortisone that

antagonise the effect of insulin

Sleep disturbances insomnia in patient with already

existing heart problems ↓

aggravate the condition

↓↓

Pain

Psychological stress showed to :

1. increase back pain

2. increase already present joint pain

o these factors will increase uptake of

NSAIDS → with its salt and water

retaining effect

Eating problems

Stress can have varying effects on eating problems and Weight gain :

- people develop craving for : salt ,fat and sugar to counter act tension ↓ Weight gain

Eating problems ( cont)

Weight gain

-can occur even with

healthy diet

- Often abdominal fat

which is predictor of CAD, Diabetes

and heart problems.

Stress in elderly

Ability to achieve relaxation after stressful event become more difficult i.e. they are more born to complication from stressors

On healthy life style

people under chronic stress frequently seek relief through :DrugsTobacco useAbnormal eating patterns Passive Activities Sedentary life Unhealthy diet

All are known to be or prone to be risk factors for cardiovascular disease .

EVIDANCE BASED

MEDECIN

TO PROVE

STRESS AS A RISK FACTOR

There is over 2 million

researches about stress.

1. Socio-economic status (SOS) and

its relation to cardiovascular risk

Experience of low social position elicited sustained activation of :

– Autonomic– Neuro endocrinal

– Immunical responses

– Promote atherogenous

CAD Bp

Post stress recovery:

Complete recovery of systolic Bp 27%

Diastolic BP 20%

Incomplete recovery was more prevalent in low socio-economic status

Heart rate and heart rate variability

• HR reaction to task slightly higher in high than low

social economic status

• Complete recovery of HR variability to base line

level was evident in (82.5%)

• Incomplete recovery was more in low socio-

economic status

• Women showed greater BP reactivity in low social-

economic status i.e. sex difference is another variable

in responsivty to stress in different social classes

Three employments grades high, medium and low which reflect the Socio-economic status showed:

1. Systolic and diastolic pressure remained more elevated during recovery in medium and low grade than in high grade group (P < 0.02)

2. Systolic and diastolic Bp reaction to tasks were smaller in higher than low grade women but did not differ in men

i.e. there is a gender difference

Post-Stress recovery of blood pressure and heart rate variability in relation to grade of employment

Employment grade

Percentage showing incomplete recovery

Systolic pressure

Diastolic pressure

Heart rate variability

High58.3%70.9%9.4%

Medium85.9%83.3%17.1%

Low78.1%87.7%28.6%

2. Stress as Risk Factor for

Atherosclerosis

study correlated the degree of carotid arterial

atherosclerosis with exaggerated response to mental

stress in men under the age of 55. Patients whose

↑blood pressure responses to stressful situations were

found to have significantly more advanced

atherosclerosis in the carotid arteries than those whose

blood pressure responses were sailent.



3. Blood pressure reactions to acute

psychological stress and future blood pressure

status :

a 10-year follow-up in the whitehall II study

psychosomatic medicine 63:737-743(2001)

Aim

Aim of the study was to examine whether BP reaction to mental stress predicted future BP and hypertension

Results

in addition to the age , two variables are studied in follow up

1- base line blood pressure 2- reaction of SBP & DBP to stress The conclusion:1. The results provides modest support for

hypothesis that high tented BP reaction to mental stress contribute to the development of high BP

2. SBP and to the lesser extent DBP were positively correlated with mental stress

3. They questioned the clinical utility of stress testing as a prognostic device

4. Studies of psychological stress in monkeys demonstrated

1. Increase number of injured endothelial cells in the thoracic Aorta

2. Rapid and significant elevation in the plasma homocystein level

3. Exacerbated atherosclerosis4. Exacerbated poor circulation

In human : anger and irritability in heart diseased patients cause ischemia more than half of the time

journal of anti-aging research 2002

5. Study done in medical college of Georgia (2001) found :

that impaired Na˚ excretion after stress

contributes to the development of

hypertension in blacks

6. Mental Stress as a Risk Factor for

Myocardial Ischemia

-Various studies have suggested that mental stress

can trigger myocardial ischemia in 40 to 70 percent

of patients with stable CAD.

-Stone and colleagues questioned whether patients

at risk for mental stress induced ischemia could be

identified.

J Am Coll Cardid. May 1999; 33: 1476-84


196 Patients Developed Ischemia During

-Mental Stress

- Speech Test.

- Color- word match test.

-Physical Stress

- Treadmill exercise test.


Patients were evaluated with

-24-hour ambulatory ECG.

-HR of BP vanabilely.

-Neurohormonal vasopressor material levels.


They Found

1. Mental stress can provoke episodes of myocardial ischemia and

may precipitate cardiac events in patients with CAD.

2. Mental stress triger myocardial ischemia in 40 to 70% of

patients with stable CAD.

3. There was no difference between patients with and without

stress induced ischemia during Treadmill exercise test.

4. Patients with mental stress had more episodes of ischemia during

daily activity.


7. Working hours as a risk factor for

acute myocardial infarction in Japan:

case-control study

BMJ 1998; 317:775-780 (19 September)


Objective: To clarify the extent to which working

hours affect the risk of acute myocardial

infarction.

BMJ 1998; 317:775-780 (19 September)


Results: Compared with men with mean working hours of

> 7-9 hours, the odds ratio of acute myocardial

infarction for men with working hours of >11 hours

was 2.44 and for men with working hours of < 7 hours

was 3.07.

Conclusion: There seemed to be a trend for the risk of

infarction to increase with greater increases in mean

working hours.

BMJ 1998; 317:775-780 (19 September)


8.The Effect of Stress on Acute

Myocardial Infarct during Intensive

Care

Circulation 2000, 102: 2473-8


-stress was an independent predictor for the development

of complications

-Arrhythmia was the most common complication in AMI

-Other complications chest pain, pericarditis, cardiac

failure, cardiogenic shock, even death was also higher

in AMI patients under stress during intensive care.

N.B.: Patients with stress suffer from 2-3 times more

complications than those without stress.

Circulation 2000, 102: 2473-8


9. Memory and reproductive aspect of stress

Researches shows that stress reduces memory, and may

even be associated with the loss of brain cells in an

important memory region of the brain called the

hippocampus.

Cortisol inhibits reproductive hormones, which in turn

leads to reproductive dysfunction (infertility) and, in

females, disturbances in the menstrual cycle.

BMJ 1998; 317:775-780 (19 September)


Egyptian Experience

TOTAL

05

1015

2025

3035

25-34 35-44 45-54 55-64 65-74 >/75Age Group

%Mild Moderate Severe

Egyptian ExperienceLOW SES

0

5

10

15

20

25

30

35

25-34 35-44 45-54 55-64 65-74 >/75Age Group


Egyptian ExperienceMID SES

0

5

10

15

20

25

30

25-34 35-44 45-54 55-64 65-74 >/75Age Group


Egyptian ExperienceHIGH SES

05

10152025303540

25-34 35-44 45-54 55-64 65-74 >/75Age Group


Egyptian ExperienceLow HDL <35

0

2

4

6

8

10

12

Low Mid HighSES

% Mild Moderate Severe

Egyptian ExperienceHIGH LDL >160

0

1

2

3

4

5

6

Low Mid High

SES

%MildModerateSevere

Egyptian ExperienceHyper TG >150

0

5

10

15

20

Low Mid High

SES

%MildModerateSevere

Egyptian ExperienceDM (FBS>=126 mg%)

0

1

2

3

4

5

6

Low Mid High

SES

%MildModerateSevere

Egyptian ExperienceMI

0

1

2

3

4

5

6

Low Mid High

SES

%MildModerateSevere

Egyptian ExperienceObesity BMI>30 kg/m

0

5

10

15

20

25

Low Mid High

SES

%MildModerateSevere

Egyptian ExperienceCurrent cig. smoking

0

2

4

6

8

10

Low Mid High

SES

%MildModerateSevere

How to cope ?

1. Healthy life style: identify source of stress and try to solve ,avoid or keep low reaction with them

2. Healthy diet : a diet rich in variety of whole grains , and vegetables and fruits by avoiding excessive alcohol , caffeine and tobacco

How to cope ? (CONT)

3. Exercise :

Exercise with stress management is extremely important for many reasons: -exercise is an effective distraction from stressful events . -employees who follow an active lifestyle need fewer sick and disability days than sedentary workers -stress itself poses significantly less danger to overall health in the physically active individual

How to cope ? (CONT)

4. Adding stress reduction activities:

- Take long weekends or ideally vacations

- If the source of stress is in the home,

plane times away, even if it is only an

hour or two a week

- Make time for recreation

- Learn to focus on positive outcomes

How to cope ? (CONT)4. Adding stress reduction activities (cont.):

- Sign up for aerobics c lasses at a gym

- Brisk walking is an excellent aerobic exercise that is free and available to nearly anyone

- Swimming is an ideal exercise for many people including pregnant women

- Yoga or tai chi can be very effective numerous studies have found it beneficial for many conditions in which stress is an important factor as anxiety, headaches, high blood pressure and asthma .

How to cope ?

Deep relaxation Technique- Aim for a 20-minute session

1. Relax the body. Sit in a quiet comfortable position.

2. Breathe deeply.

3. Create a sentence that you can repeat that emphasizes

warmth and relaxation.

4. Always end with several deep breaths.

5. In religious people praying and sitting alone usually

cause relaxation.


Thank you

stress as a risk factor by soliman ghareeb, md professor of cardiovascular medicine cairo university

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