Heart Disease, Hypertension, and Stroke

1. Heart Disease, Hypertension, and Stroke

2. 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?

3. 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

4. Mortality RatesLeading causes of death • Middle age • Sudden death due to heart attack or stroke • Cancer • Elderly • Heart disease • Cancer • Stroke

5. Why do women live longer than men?

6. 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

7. 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)

8. 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

9. How do people adapt to chronic illness?

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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

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

17. 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.

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

19. 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.

20. Effects of Stress On Cardiac Risk

21. Psychosocial Predictors of Sudden Cardiac Death (BDI>10) 1.00 0.95 0.90 0.85 Proportion Surviving Placebo, BDI <10 Placebo, BDI >10 AMIO, BDI <10 AMIO, BDI >10 0 200 400 600 800 Survival in days

22. 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.

23. 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

24. 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

25. Rehabilitation • Promote recovery and reduce risk of another attack • Heart disease is chronic condition requiring ongoing management.

26. 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

27. 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.

28. 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

29. 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.

30. Causes of Strokes • Infarction – blockage in cerebral artery that cuts off or reduces blood supply • Thrombosis – blood clot • Embolus – piece of plaque becomes lodged in the artery. • Hemorrhage – happens suddenly. Less frequent than infarction but more damaging and more likely to cause death.

31. 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

32. 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)

33. 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.

34. 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.

35. 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.

36. 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.