The importance, consequences and treatment of psychosocial risk factors in heart disease: less conversation, more action!

By arguing a mind-body dualism, Descartes demythologised the body and paved the way for three centuries of progress in medicine, shaping the biomedical model of health and disease. Simultaneously, by isolating the mind, dualism denied its significance in individuals’ experiences of health [1]. More directly, it denied the option that, for example, personality, emotions, and behaviours could affect physiology, and vice versa. When, in 1947, the World Health Organisation defined health as a state of complete physical, mental, and social well-being, a new understanding of health emerged, challenging the hegemony of biomedicine. A multidimensional approach, including biological, psychological, and social factors, is essential to understand the dynamic nature of cardiovascular health and disease, to practice patient-centred care and to develop effective interventions, ultimately increasing health and satisfaction with contemporary medicine and care [1].

The current paper embraces this multidimensional approach and summarises extant literature linking psychosocial risk factors with common cardiovascular conditions: coronary heart disease (CHD), heart failure (HF), and atrial fibrillation (AF). We also provide a state-of-the-art overview of psychosocial screening and treatment, in the context of cardiac rehabilitation (CR). The rationale for the current endeavour is that there are multiple compelling, evidence-laced reasons for cardiologists to be skilled in recognising and managing psychosocial risk (Tab. 1, right panel). In addition to reiterating the current state of the art [2], our paper is a call to action for clinicians working in cardiology and ends with concrete recommendations.

Psychosocial risk factors for heart disease may be divided into two categories: emotional factors and stress-related factors (Tab. 1, left panel; [3]). Patients with emotional problems will show symptoms of anxiety, depression, anger, and hostility, or are overwhelmed with acute severe emotions (e.g., causing Takotsubo or stress cardiomyopathy) or develop post-traumatic stress disorder (PTSD) after the event. Patients with stress-related problems though will report strain in the context of work, relationships, life circumstances (early life events, trauma, lack of social support), have a generalised distressed disposition or poor socioeconomic position. Psychosocial risk factors tend to cluster within patients in a tightly knit network of behavioural and cardiovascular risk factors [4], and recent research has identified specific within-person profiles [5]. Figure 1 illustrates how psychosocial risk factors affect cardiovascular risk factors and illness through behavioural and biological pathways.

Screening for psychosocial risk prior to CR is becoming increasingly common [26] and is recommended upon entering CR [27]. Throughout the Western world, this has been advocated in scientific statements (e.g., [2]) and by secondary prevention guidelines (e.g., [28]), as this may not only be indicative of whether an evaluation by a psychologist or psychiatrist is advisable, but screening could also identify a patient’s unique needs [27] and lay bare the barriers that need to be overcome to successfully change health behaviour. Consequently, it is advised in current Dutch CR guidelines that a mental health professional helps decide which level of psychosocial care is needed [29]. Furthermore, patients should also be screened upon completion of CR with follow-up assessments at six and twelve months. However, in practice this recommended protocol is not consistently followed [26].

One reason why screening is limited pertains to the feasibility of screening [30]. Current methods that are deemed as reliable screening practices for the assessment of psychosocial risk are standardised structured interviews [26] and validated questionnaires [31]. Screening interviews may increase the opportunity to provide more context surrounding psychosocial risk [31]. However, they are highly unpractical in cardiological practice: too time-consuming, expensive and require knowledge on when and how to take further action (e.g., referring to a psychologist), which is often lacking. As for self-reported screening assessments, the process often involves utilising full-scale instruments that focus on assessing a single risk factor. In 2015, a position paper by the ESC CR Section listed psychometric assessment options for each of the psychosocial risk factors [32]. However, combining multiple scales results in a lengthy screening process. To improve the feasibility of screening, we need a comprehensive, quick and stepped screening approach to evaluate psychosocial risk factors simultaneously, adding a clinical interview with a psychologist when necessary.

Psychosocial screening currently predominantly focuses on depression and generalised anxiety [26, 30], which is in contrast with ESC guidelines [6, 28] recommending to assess and treat the set of risk factors reviewed above. Screening for this broader set should be followed up by a more extensive care pathway. For this to crystallise, research into the effectiveness of screening and risk factor specific effects of psychological treatment on medical outcomes (morbidity and QoL) is needed. A first step was recently taken. We validated a comprehensive psychosocial screening instrument that includes all psychological risk factors recommended to screen for among the Dutch general population, Dutch CHD patients and German coronary angiography patients (e.g. [33]). The one-page instrument quickly and reliably screened for psychosocial risk factors and can serve as a risk triage in a stepped care approach within the realms of CR and medical psychological care [33].

Several recommendations arise for the screening phase, pertaining to the screening instrument, care pathway and eligibility considerations. In particular, echoing recent insights in CR, psychosocial screening prior to CR should be done in all cardiac patients. There is sufficient evidence that patients with AF, HF and non-obstructive CHD are in need of psychosocial help. In addition, to truly be effective in treating psychosocial risk, we should also expand routine psychosocial screening in cardiac outpatient and primary care practices, whereas in the Netherlands it now only takes place in the context of CR, predominantly tailored at acute and chronic coronary syndrome patients. An evidence-based harmonisation effort should take place with respect to the instruments, timing and risk factors assessed. Research is needed to examine the clinical effectiveness and cost-effectiveness of comprehensive screening for psychosocial risk. Finally, screening instruments should be made to fit people with reduced health literacy, poorer language understanding and lower digital skills (Tab. 2).

CR is a fundamental strategy in the further prevention after a cardiovascular event, and carries a class IA recommendation in international guidelines for improving outcome after an acute coronary event or revascularisation. Across centres and countries, CR differs enormously in terms of the eligible population and CR methods. A recent meta-regression analysis demonstrated that exercise-based CR provides important benefits to patients following ACS or revascularisation in terms of morbidity, mortality, hospitalisation, costs and HRQoL [34].

Stepped care approaches are becoming increasingly popular in CR (e.g., [35]), as they effectively differentiate patients’ individual needs based on risk assessment. By aligning care delivery with the specific needs and treatment responsiveness of each patient, stepped care ensures a patient-centred approach. Regular monitoring and evaluation of treatment outcomes allow for adjustments to be made. This approach ultimately prevents overtreatment of patients who require less care and undertreatment of those in need of more psychosocial attention [35].

Future research on psychological risk factors in the context of cardiology should focus on routine screening in outpatient and primary care practices and broadening the screening scope in CR. Implementation studies should take heed of research on barriers and facilitators and design effective care pathways. In addition, the scope with respect to social determinants of heart disease needs to be broadened as well to include, for example, sex and gender, race/ethnicity, financial resources, health literacy and the environmental context ((rural vs. residential vs. inner city) in terms of accessibility of care, driving distance, level of air pollution, and heat exposure). In terms of screening, large heterogeneity exists in which psychosocial risk is screened for and which instruments are used to screen. It is essential to reach consensus about screening instruments. To date, no clinical trial has tested the efficacy of the PEP module in CR, one of the reasons being that its heterogeneity makes comparison difficult, if not futile. There is evidence though (reviewed above) for individual treatments that may be extrapolated to the PEP/CR context. For psychological treatment within the context of CR to have more impact and a broader uptake, an adaptive clinical trial that seeks to identify the most effective and clearly defined intervention and tools among a wide variety of possible strategies would be recommended. In such a trial, treatment should be tailored to the individual patient’s risk profile, and the outcome assessment should predominantly be focused on patient-reported outcomes. The current review provides some recommendations for screening and treatment (see Tab. 1, 2 and 3).

Despite the evidence and increased knowledge of the relationships and mechanisms between psychosocial risk factors and heart disease, the inclusion in international guidelines, and despite thorough dissemination of this research in top-tier medical journals, the science of heart-mind interaction has only limitedly been assimilated in cardiac clinical practice. There may be several reasons for this, an important one pertaining to physician/cardiologist educational programmes, which are lacking multidisciplinary focus; another pertaining to the fact that most practising clinicians are trained and operate under models of care that emphasise biomedical and physiological risk factors. It will be easier to acknowledge the presence, suffering, and impact of psychosocial risk factors in your patients by routinely screening for those factors (Fig. 2).

In conclusion, psychosocial risk factors have a large clinical relevance for cardiological practice. International and national guidelines include psychological risk factors and recommend assessing and treating these factors. Nevertheless, implementation of guideline recommendations trails behind, high-quality studies on the additional effectiveness of psychological treatment in CR are lacking due to a lack of clarity in treatment definition and delivery, and cardiologists are still being trained under dualistic models of care, lacking knowledge and insight on psychosocial risk. We need improvements in all these aspects, to treat the heart and the mind together, and to deliver true patient-centred care.