Clear links between mental health and cardiovascular disease

A number of studies, like INTERHEART, state clearly how critical both positive and negative psychological states are to cardiovascular health and prognosis.

Cardiovascular diseases should not be seen as an isolated phenomenon

Although Takotsubo cardiomyopathy, or stress-related cardiomyopathy, is the most obvious example of how a psychological state can have an immediate negative impact on cardiac function, a growing body of evidence suggests that there is also a broader, long-term relationship between the psyche and cardiovascular health, risk of cardiovascular events, and cardiovascular prognosis. The potentially toxic effects of psychopathology and poorly regulated emotions on physical health have long been recognised, but how large the effect of a healthy psyche can be on physical health is less often highlighted in the literature.

The American Heart Association position paper references a long list of studies, mostly based on large databases, showing that pessimism, depression, anxiety, chronic stress, trauma, social stressors, anger, and hostility, significantly increase the risk of cardiovascular events. The relative risk increases for myocardial infarction, CHD, heart failure, apoplexy, obesity, hypertension, diabetes and cardiovascular mortality calculated by the studies are comparable here to those caused by established risk factors such as smoking or malnutrition. Just two examples from the compiled data for the negative side: social isolation and loneliness were associated with a 1.5-fold increased risk of cardiovascular events in one of the meta-analyses.2 And a large, prospective, long-term study over 11 years illustrated how negativity can disrupt health: strong pessimism was linked to a more than doubled risk of cardiovascular mortality (OR 2.2).3

How much could interventions to improve mental health benefit cardiovascular outcomes?

But what prompted me to pick up this review in particular is the ray of hope, otherwise rarely presented in the literature, of how strongly positive a good mental state can influence the so-called "hard" parameters. A similarly large body of work documents how optimism, sense of purpose, contentment, mindfulness, and psychological well-being are associated with a lower risk of cardiovascular disease and mortality, as well as with behavioural and biological factors that may act as mediators of these observed associations (such as smoking, physical activity, fasting glucose, or weight). The results of the pooled studies were quite consistent with each other and most of them applied different statistical methods to exclude bias and reverse causality due to poorer health status.

For example, nearly five thousand older adults in the English Longitudinal Study of Ageing who experienced higher levels of psychological well-being were more likely to maintain parameters conducive to cardiovascular health (defined as not smoking, not having diabetes, and having healthy blood pressure, cholesterol, and body mass index) at each of the three time points during the 8-year follow-up period.4

Furthermore, a meta-analysis with data from 229,400 people found a significantly lower risk of cardiovascular events (RR 0.65) and all-cause mortality (RR 0.86) in people who were happy or satisfied.5

As a third remarkable example from the long list, a population-based prospective study of over six thousand adults who did not have CHD at baseline and were followed up for an average of 15 years, reported that individuals with higher emotional vitality (encompassing drive, well-being, and the ability to regulate emotions effectively) had a significantly lower risk of developing CHD than those with lower levels of emotional vitality (RR 0.81), with a significant dose-response relationship evident.6

Finally, smaller clinical studies were also mentioned, which, for example, demonstrated improvements in blood pressure, sleep, inflammatory biomarkers and heart rate variability after gratitude interventions (such as keeping gratitude diaries).1

Conclusion for medical practice

Most patients know that exercise, healthy eating etc. can reduce the risk of cardiovascular disease, but few perceive mental health as the independent modifiable risk factor that it is. We know from learning research that positive reinforcement establishes new pathways and behaviours much faster than negative reinforcement. Consequently, holding out to patients the prospect of what there is to "gain" in concrete terms by practising good behaviours is often a more powerful motivator than simply explaining to them that a particular lifestyle change might help them avoid a negative consequence.

Simple screening measures can be used to assess mental health, and their greater inclusion is advisable in the care of patients at risk of CVD, as mental well-being is causally linked to biological processes and behaviours that may lead to, or at least contribute to, cardiovascular disease.

More information on cardiology and neurology:

  1. Levine, G. N. et al. Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association. Circulation 143, e763–e783 (2021).
  2. Steptoe, A. & Kivimäki, M. Stress and cardiovascular disease: an update on current knowledge. Annu Rev Public Health 34, 337–354 (2013).
  3. Pänkäläinen, M., Kerola, T., Kampman, O., Kauppi, M. & Hintikka, J. Pessimism and risk of death from coronary heart disease among middle-aged and older Finns: an eleven-year follow-up study. BMC Public Health 16, 1124 (2016).
  4. Boehm, J. K. et al. Psychological Well-being’s Link with Cardiovascular Health in Older Adults. Am J Prev Med 53, 791–798 (2017).
  5. Rozanski, A., Bavishi, C., Kubzansky, L. D. & Cohen, R. Association of Optimism With Cardiovascular Events and All-Cause Mortality: A Systematic Review and Meta-analysis. JAMA Netw Open 2, e1912200 (2019).
  6. Kubzansky, L. D. & Thurston, R. C. Emotional vitality and incident coronary heart disease: benefits of healthy psychological functioning. Arch Gen Psychiatry 64, 1393–1401 (2007).

    Date of last access: 21.03.2023