Psychosocial variables and coronary heart disease

Psychosocial variables emerge slowly as independent risk factors for CHD as well as prognostic factors in CHD patients. Part of the pathophysiological mechanisms is explained by unhealthy lifestyles and bad compliance with counselling or drug treatment. Physicians in general should be aware of the emergence of psychosocial variables as independent coronary risk factors, the key pathophysiological mechanism being an increase of sympathetic stimulation, a decrease in vagal control or both of them. A recent, randomised control trial of rehabilitation in unselected myocardial infarction patients comprising psychological therapy, relaxation training and stress management reported the absence of benefit of those programmes in terms of reported anxiety or depression as well as clinical complications and mortality over a 12 month period14. On the other hand, a meta-analysis of 23 randomised trials concerning the benefits of the addition of psychosocial interventions showed favourable effects on stress, blood pressure, heart rate and cholesterol level as well as a decrease in recurrence and CHD mortality during a two year follow-up with respective odd-ratios of 1.84 and 1.7015. This divergence in the efficacy of specific treatment of psychosocial variables and the difficulty of modifying overactivity of the sympathetic nervous system (except maybe by beta-blockade) emphasises again the need for a multifactorial approach in the primary and secondary prevention of CHD focusing on the major modifiable coronary risk factors by non-pharmacological as well as pharmacological means.