Behavioral cardiology

REVIEW TOPIC OF THE WEEK Behavioral Cardiology Current Advances and Future Directions Alan Rozanski, MD Growing epidemiological evidence identifies key domains relevant to behavioral cardiology, including health behaviors,emotions, mental mindsets, stress management, social connectedness, and a sense of purpose. Each of these domains exists along a continuum, ranging from positive factors that promote health, to negative factors, which are pathophysiological. To date, there has been relatively little translation of this growing knowledge base into cardiology practice. Four initiatives are proposed to meet this challenge: 1) promulgating greater awareness of the potency of psychosocial risks factors; 2) overcoming a current "artificial divide" between conventional and psychosocial risk factors;3) developing novel cost-effective interventions using Internet and mobile health applications, group-based counseling, and development of tiered-care behavioral management; and 4) in recognition that "one size does not fit all" withrespect to behavioral interventions, developing specialists who can counsel patients in multidisciplinary fashion and use evidence-based approaches for promoting patient motivation and execution of health goals. (J Am Coll Cardiol 2014;64:100–10) 2014 by the American College of Cardiology Foundation.
sion and chronic stress, have been linked in the following text.
to the pathogenesis of coronary heart dis- PHYSICAL HEALTH BEHAVIORS. The association be- ease (CHD) In 2005, on the basis of a review of tween CHD and physical inactivity, poor diet, and such associations, the emergence of a new field of smoking are well established. Emerging literature behavioral cardiology was predicted Indeed, also targets 2 other behavior-related factors: poor over the last decade, studies of psychosocial risk fac- sleep and inadequate rest and relaxation. With tors for CHD have increased exponentially. Accord- respect to sleep, recent meta-analyses have identified ingly, the present review explores new knowledge insomnia and duration of sleep, either long or regarding behavioral and psychosocial risk factors, short , as risk factors for CHD (Longer with particular emphasis on meta-analytic studies, duration of sleep could be a potential marker of which were nearly nonexistent before 2005. Second, depression or medical comorbidities. Shorter sleep the present review addresses a particular current duration may be multifactorial, including sleep that challenge for the field of behavioral cardiology: its is curtailed by worry and other causes of insomnia translation into a clinically integrated field within or that is curtailed voluntarily. Interest in shorter duration of sleep has risen based on investigations linking curtailed sleep to neuroendocrine and auto- EPIDEMIOLOGICAL ADVANCES nomic dysfunction, inflammation, and increasedappetite.
Based on epidemiological data, the behavioral risk The health value of relaxation is of growing inter- factors for CHD can be divided into five broad est in light of trends toward heavier workloads, faster From the Division of Cardiology and Department of Medicine, Mount Sinai St. Lukes and Roosevelt Hospital Center, New York, New York. Dr. Rozanski has reported that he has no relationships relevant to the contents of this paper to disclose.
Manuscript received December 26, 2013; revised manuscript received February 27, 2014, accepted March 11, 2014.
Advances in Behavioral Cardiology pace of living, and diminished boundaries between stressors that increase mortality risk, and work and leisure. On a theoretical basis, the potential isolated epidemiological studies also suggest benefits of relaxation are supported by a "paradigm a relationship between marital strain and CHD = coronary heart disease of flexibility" that appears to be beneficial for both PTSD = post-traumatic stress physiological and cognitive function . To date, There has been increasing interest in 2 however, epidemiological study in this arena has other stressors: adverse childhood experi- been relatively sparse.
ences and the stress associated with medical illness.
Regarding childhood adversities, the Nurses' Health EMOTIONAL DISORDERS AND NEGATIVE MENTAL Study 2, which involved a 16-year follow-up of 66,798 MINDSETS. D e p r e s s i o n . Studies have consistently women , is the largest study to date. Nearly demonstrated that depression is a potent risk factor one-fifth reported severe childhood abuse, and for CHD. A series of meta-analyses has confirmed the this group had an approximately 1.5-fold increase in prognostic significance of depression, the largest be- early-onset cardiovascular events. The development ing an analysis of 54 studies which showed an of medical illness is a potent stressor because of approximately 2-fold increase in risk among com- its ability to breed depression, anxiety, social isola- munity cohorts with a similar elevation noted tion, and loss of self-esteem (from a lost image of among patients with known CHD .
good health). In addition, studies have ascertained that PTSD, most commonly identified as a war-related years, the role of anxiety as a CHD risk factor has been disorder, also can result from a variety of medical clarified. Various meta-analyses have identified an illnesses. In a meta-analysis of 24 studies, Edmond- increased risk associated with symptoms of anxiety in son et al. found a 12% prevalence of PTSD among both community and patient cohorts Other patients with acute coronary syndrome.
recent studies have established that CHD event risk is Notably, one's perceived sense of stress also may be elevated among patients with generalized anxiety an important health determinant. One important disorder , panic attacks and post-traumatic study by Keller et al. evaluated 28,753 subjects stress syndrome (PTSD) both for their level of perceived stress and for their P e s s i m i s m . Mental outlook is also a health deter- perception of whether their stress was impairing minant. The strongest example comes from studies their health. Increased mortality in association with of optimism versus pessimism . Optimism stress was limited only to those who self-appraised is associated with a higher experience of positive emotions, enhanced social functioning, and better recovery from myocardial infarction and cardiac TABLE 1 Behavioral Risk Factors Associated With CHD procedures. Recent epidemiological studies have A. Physical health behaviors demonstrated that pessimism increases the risk for 1. Physical inactivity cardiac events, stroke, and/or all-cause mortality, 2. Poor diet and obesity whereas optimism exerts a buffering role ( 4. Poor or inadequate sleep 5. Inadequate rest and relaxation widely studied, stemming from original interest in B. Negative emotions and mental mindsets "type A personality," which is a triad of hostility, 1. Depressive symptoms impatience, and time urgency. However, a meta- analysis has found that the hazard ratio for cardiac events in association with anger and/or hostility 4. Anger and hostility was increased only 19% among 25 studies involving C. Chronic stress initially healthy subjects and 24% among 19 studies 1. Situational stressors involving populations with CHD
Social stressors stress have considered situational stressors. Work
Caregiver strain stress has been most widely studied, most commonly
Childhood and adult abuse according to a model of "job strain" (i.e., high job
Medical Illness demand with little latitude). In recent meta-analyses, 2. Perceived stress only a 1.23-fold increase in incident CHD was found D. Social isolation and poor social support in association with job strain , compared with a E. Lack of sense of purpose 1.63-fold increase in mortality with unemployment CHD ¼ coronary heart disease.
. Marital separation and divorce are other common Advances in Behavioral Cardiology Total CHD Follow-up 1.30 (0.97–1.74) 0.70 (0.29–1.65) 1.20 (0.37–3.88) 1.39 (1.06–1.83) 6.17 (1.29–29.6) 1.13 (0.66–1.91) Meisinger (women) 2007 2.97 (1.47–6.02) 1.70 (1.34–2.15) 1.43 (1.09–1.89) 0.29 (0.04–2.05) 2.32 (1.19–4.51) Combined effect: P<0.0001 1.48 (1.22–1.80) Heterogeneity: I2=44%; P=0.059 Egger's test: P=0.95 Relative Risk (Log Scale) Total CHD Follow–up 1.11 (0.81–1.51) 2.20 (1.05–4.64) 0.70 (0.101–5.05) 1.36 (1.021–.83) 1.30 (0.381–4.37) 15.96 (2.001–127.4) 1.07 (0.75 1–1.53) Meisinger (women) 2007 1.40 (0.751–2.63) 1.88 (1.481–2.38) 1.67 (1.241–2.23) 1.12 (0.771–1.62) 1.04 (0.631–1.73) Combined effect: P=0.0005 1.38 (1.15–1.66) Heterogeneity: I =49%; P=0.028 Egger's test: P=0.92 Relative Risk (Log Scale) FIGURE 1 Cardiovascular Risk Associated With Sleep Duration Relative risk for the development of coronary heart disease (CHD) or cardiac mortality is shown in association with short and long sleep versus normative sleep time.
CI ¼ confidence interval. Adapted with permission from Cappuccio et al.
their risk as harmful to their health. A complementary assessed in a recent meta-analysis of 148 studies study by Jamieson et al. suggests that instructing A combined measure of positive social integration subjects to perceive their stress symptoms in a posi- was associated with a nearly 2-fold increase in tive functional manner can lead to improved cogni- LACK OF SENSE OF PURPOSE. Observational studies Combined, these data suggest a need for more indicate that having a strong sense of life purpose is research into the subjective perception of stress and a core component of positive well-being, whereas a how its modification can affect health outcomes.
lack of life purpose is associated with boredom, SOCIAL ISOLATION AND POOR SOCIAL SUPPORT.
Epidemiological studies have consistently estab- diminished resilience during stress. Although only lished that small social networks, poor functional scant study has evaluated the pathophysiological support, loneliness, and/or a sense of poor emotional sequelae of a low sense of purpose, substantial support increase the risk for cardiac events As recent study has demonstrated an increased mor- with other psychosocial risk factors, a gradient rela- tality risk associated with a low sense of purpose tionship has been noted between the degree of (. For instance, in a study involving reduced social support and the likelihood of adverse 43,391 subjects followed for 7 years, the adjusted cardiac events. The role of various social factors was hazard ratio for all-cause mortality among those Advances in Behavioral Cardiology Unadjusted aetiological studies Adjusted aetiological studies RR (95% CI) (95% CI) Anda et al. (1993) Ferketich et al. (2000) Pratt et al. (1996) Whooley and Browner (1998) Cohen et al. (2000) Ford et al. (1998) Ferketich et al. (2003) Luukinen et al. (2003) Cohen et al. (2001) Laplane et al.(1995) Penninx et al. (2001) Chang et al. (2001) Joukamaa et al. (2001) Hallstrom et al. (1999) Mallon et al. (2002) Seson et al. (1998) Wassertheil et al. (1996) Cole et al. (1999) Pentinnen and Valonen (1999) 332 (83) Clouse et al. (2003) Yasuda et al. (2002) Summary unadjusteda Summary unadjustedb Summary unadjustedc Studies reporting an unadjusted effect estimate.
Studies reporting an unadjusted effect estimate that also reported an adjusted effect estimate.
Studies reporting an unadjusted effect estimate that do not reported an adjusted effect estimate.
FIGURE 2 Depression and Cardiovascular Risk Relative risk for prediction of coronary heart disease events (cardiac death or myocardial infarction) in association with depression among community cohorts for unadjusted and adjusted data. CI ¼ confidence interval; RR ¼ risk ratio. Adapted with permission from Nicholson et al. reporting a low versus high sense of life purpose produces an increased sense of well-being, better goal was 1.5 (95% confidence interval [CI]: 1.3 to 1.7) pursuit, and enhanced resilience The impor- tance of positive psychosocial function is supported by POSITIVE PSYCHOSOCIAL FUNCTIONING. As with a meta-analysis of 35 studies demonstrating increased physical behaviors, each domain of psychosocial risk longevity in association with positive emotions .
from positive to negative (). Negative psychoso- TABLE 2 Optimism and Pessimism as Predictors of Clinical Outcomes cial factors promote illness by fostering negative health behaviors and by their direct pathophysiolog- First Author (Ref. #) ical effects. These effects can vary according to the Pessimism as a risk factor type of psychosocial stress, but as a group they include 1.42 (1.13–1.77) induction of autonomic dysfunction, heightened car- Grossbart et al. 1.32 (1.13–1.77) diovascular reactivity, insulin resistance, central Optimism as a buffer obesity, increased risk for hypertension, endothelial Kubzansky et al. 0.44 (0.26–0.74) and platelet dysfunction, and unfavorable alterations 0.27 (0.12–0.57) 0.45 (0.29–0.68) in brain plasticity and cognitive function . By 0.76 (0.64–0.90) contrast, positive psychosocial factors are associated 0.52 (0.29–0.93) with more healthy behaviors and promote favorable 0.90 (0.84–0.97) physiologic effects, including enhanced immune, endothelial, and autonomic function . Further, *Risk ratios are primarily for first versus third tercile or fourth quartile. †For each unit increase in optimism.
ACM ¼ all-cause mortality; CI ¼ confidence interval; CV ¼ cardiovascular; RR ¼ risk ratio; MI ¼ myocardial positive psychosocial functioning helps promote vitality (i.e., an innate sense of energy), which in turn Advances in Behavioral Cardiology to look at the interaction between a chronic stressor TABLE 3 Sense of Purpose as a Predictor of All-Cause Mortality and the sense of meaning associated with that stressor. Specifically, implicit in the basic human First Author (Ref. #) Follow-Up Endpoint need for purpose is a desire to take on life challenges Low purpose as a risk factor ("good" stress). "Bad" or "toxic" stress is stress that 2.24 (1.17–4.26) becomes overwhelming, uncontrollable, or non- Gruenewald et al. 2007 3.13 (1.43–6.84) meaningful. This concept might help explain an High purpose as a buffer 0.62 (0.46–0.86) magnitude of experiential stress and clinical out- 0.74 (0.45–1.22) comes, as shown in a recent longitudinal study ) 0.60 (0.42–0.87) . Caregiver strain may represent an example of an 0.85 (0.80–0.90) arena where the interplay between a strong stressor 0.93 (0.86–1.00) and the meaning attached to the care giving in- 2013 1,546 CAD patients 0.73 (0.57–0.93) 0.78 (0.67–0.91) fluences clinical outcomes Potentially, themeaning attached to work stress could also be an CAD ¼ coronary artery disease; other abbreviations as in important modifier of clinical risk.
FUTURE DIRECTIONS IN These observations raise the need for future CLINICAL MANAGEMENT epidemiological research that examines how an un- favorable stimulus in one behavioral or psychosocial domain may be offset by favorable changes in study in behavioral cardiology is now quite advanced, other domains. An arena in which this complexity is clinical translation of this field is still in its relative amply evident is in the interaction between physical infancy. To date, there is no clear consensus on what fitness and psychosocial risk. Physical fitness reduces interventions may work best. Initial large behavioral heart rate, blood pressure, and cortisol responses trials produced conflicting results but potential to psychosocial stress buffers the relationship behavioral interventions have become more tailored, between depression and inflammation , and de- sophisticated, and multidimensional, with an in- creases the likelihood of impaired glucose metabolism creasing evidence base to support their use in cardiac in response to chronic stress .
practice. How best to integrate these approaches into Thus, future epidemiological studies should seek practical delivery of care, however, constitute a major to further investigate the synergistic interactions be- challenge. Four initiatives that could help meet this tween positive and negative psychosocial risk factors.
challenge are addressed here: A fruitful area for investigation in this regard may be A CALL TO ACTION. A greater recognition of theimportance of psychosocial risk factors must be promulgated. Various lines of evidence underscore this risk. First, comparison of large studies or meta- Having sense ofpurpose analyses demonstrates nearly comparable levels of risk between some conventional and psychosocial risk factors (. Second, psychosocialrisk factors tend to cluster, often leading to com- pounded risk, as may occur when anxiety and No sense of purpose depression are both present. Third, a strong dose- response relationship has been demonstrated for most psychosocial risk factors, with evidence that Probability of Sur adverse clinical effects may begin to occur with even minor levels of distress. This is illustrated by a meta- analysis of 10 large, community-based cohort studies Time Since Baseline Investigation (Years) that each assessed psychological distress by the 12-item General Health Questionnaire (GHQ-12) FIGURE 3 Sense of Purpose and Mortality Risk Even minor elevations in GHQ-12 scores were associ- ated with a 25% increase in cardiac mortality ().
Kaplan Meier curve of all-cause mortality associated with a high, uncertain, and low sense of life purpose. Adapted with permission from Sone et al.
Fourth, the risk associated with psychosocial risk factors is generally adjusted for behavioral risk Advances in Behavioral Cardiology Promotes Illness Promotes Health Negative health behaviors Positive health behaviors (e.g., sedentary, poor diet) (e.g., exercise, healthy diet) Negative emotions Positive emotions Sense of distress/ overwhelm Successful stress management Socially connected Weak sense of purpose Strong sense of purpose FIGURE 4 Behavioral and Psychosocial Factors Are Related to CHD Behavioral and psychosocial factors are related to coronary heart disease (CHD) along a continuum ranging from positive factors that promote health to negative factors which promote disease.
factors, but stimulation of adverse health behaviors is a key causative mechanism by which psychosocial factors increase clinical risk.
Functional Impairment ADDRESSING THE "ARTIFICIAL DIVIDE". Two health Life Satisfaction behaviors, physical activity and diet or weight man- agement, are commonly grouped with "conven-tional" risk factor management for CHD. Clinically, however, these behaviors are commonly separated from other behavioral and psychosocial risk factors.
Overcoming this divide could lead to the develop- ment of more integrated, effective behavioral in- terventions. For instance, there is growing interest in using exercise as medical therapy for depressive symptoms. This interest is supported by increasing epidemiological data , as well as by prospective randomized trials that have found exercise training to be comparable to the effects of antidepressant medication (In addition, as demonstrated by Win et al. , characterizing patients by both Cumulative Lifetime Adversity depressive symptoms and exercise may optimize risk stratification and help identify patient cohorts FIGURE 5 Quadratic Relationship Between Cumulative Adversity with the highest need for behavioral interventions Just as the use of exercise may help treat psycho- Results for 4 measures are shown: global distress, functional impairment, life satisfaction, and post-traumatic stress (PTS) symptoms, as assessed social risk factors, the converse is also true. This po- among 2,398 persons reporting lifetime exposure to negative events. Some tential is best understood according to a 3-component exposure versus no exposure to stress predicted lower distress and higher life model of behavioral goal pursuit (Motivating satisfaction. Adapted with permission from Seery et al.
patients to pursue health behaviors is critical for Advances in Behavioral Cardiology improving these behaviors and can be promoted in TABLE 4 Risk Factors for CHD-Related Outcomes Associated With Clinical Parameters, part by supporting patients' autonomy (i.e., helping Behavioral Risk Factors in Large Studies, or Meta-Analyses patients to identify their own reasons and prefer- ences for goal pursuit and execution), enhancing self-efficacy (e.g., setting goals according to patients' Conventional CHD risk factors beliefs about what they can achieve), using financial 2.80 (2.40–3.10) or other incentives, inspirational stories, and moti- 1.25 (1.17–1.32) vational interviewing. However, spurring motivation 1.50 (1.39–1.61) is frequently not sufficient. In fact, in a meta-analysis of 622 studies, motivation accounted for only 28% of Diabetes mellitus 2.32 (2.11–2.56) the variance in goal pursuit The remainder was 1.56 (1.39–1.79) largely the result of failure to execute or maintain BMI 30–34.9 kg/m2 1.44 (1.38–1.50) goals over time.
Various techniques can be applied to promote goal Psychosocial CHD risk factors execution, including the following: helping patients 1.45 (1.29–1.62) 1.48 (1.22–1.80) identify highly specific, measurable goals; commit- 1.90 (1.49–2.52) ment to verbal review and introspection on goals on a 1.48 (1.14–1.92) regular basis; promotion of patient self-monitoring Psychological distress 1.72 (1.44–2.06) (e.g., use of pedometers to promote exercise); appli- cation of time management techniques; and use of 1.19 (1.05–1.35) simple psychological techniques, such as imple- 1.91 (1.63–2.23) mentation intentions, in which patients are asked to identify an external cue to serve as a stimulus to *Risk estimates are varied, ranging from temporally adjusted hazard ratios to specific odds and/or relative risks ata particular point in time. †Adjusted risk in 113,752 women was 3.0 (95% CI: 2.7 to 3.3). ‡Improvement in odds of initiate a behavioral practice . A meta-analysis of survival with social integration.
94 studies showed that the use of implementation in- BMI ¼ body mass index; CHD ¼ incidence of coronary heart disease; CI ¼ confidence interval; CVD ¼ cardiovascular death; GHQ ¼ General Health Questionnaire; HDL-C ¼ high-density lipoprotein cholesterol; tentions has a moderate to large effect in inducing RFC ¼ Risk Factor Collaboration.
successful goal pursuit Mental contrasting is Death from all Causes Cardiovascular Disease Death FIGURE 6 Risk Associated With Psychological Distress in a Participant Pooled Analysis of 10 Prospective Studies Even mild elevations in 12-item General Health Questionnaire (GHQ-12) scores were associated with elevated all-cause and cardiac mortality.
CI ¼ confidence interval. Adapted with permission from Russ et al. Advances in Behavioral Cardiology another new technique that can promote behavioral With respect to goal maintenance, 2 principal pil- lars are the provision of feedback and social support.
In addition, contingency planning (i.e., prospective identification of a minimal base of action in thepresence to support stress management (i.e., teaching coping skills), and energy management (i.e., better sleep hygiene) can help foster goal maintenance. Tech- niques also can be combined, such as the use of obligation intentions, which combine social support with implementation intentions ().
COST-EFFECTIVE INNOVATIONS IN BEHAVIORALINTERVENTIONS. Health currently constrained with respect to providing the types of tools needed to assist patients in the inherent challenge of changing health behaviors. This chal- FIGURE 7 Reduction of HAM-D in 3 Treatment Groups lenge is compounded by current economic con- Comparison of reduction following randomization of patients with coronary heart disease to aerobic exercise, sertraline, or placebo. Both exercise and inexpensive interventions. One way to achieve this sertraline resulted in larger reductions than placebo. Adapted with permission mission is to capitalize on the capability of the from Blumenthal et al. HAM-D ¼ Hamilton Depression Rating.
Internet and mobile phone applications to support patient education and engagement, by making health information more readily available, inspirational, and address the difficulty in fostering behavioral change, personally relevant; by providing more varied, fre- programs should be comprehensive. Currently, many quent, and tailored patient counseling; and by types of behavioral intervention programs tend to delivering computer-generated feedback regarding reside in their own silos, including exercise training behavioral and self-monitoring efforts.
programs, nutritional counseling services, weight A second method is the development of tailored group programs to provide patients with practical behavioral information and techniques regarding diet, exercise, sleep hygiene, rest, relaxation, stress management, and time management practices. The High Depression Score Physically Inactive use of groups can be inspirational, provide social support, and complement one-on-one counseling and A third component is development of a tiered (or "stepped") model for behavioral health care. One 3-tiered model would have physicians serve as the first tier, responsible for triage of patients for Logrank P < 0.001 e Incidence of Cardio behavioral risk and provision of brief counseling. The second tier would involve physician referral of pa- tients to behavioral intervention programs designed to provide integrated intervention across the wide domains of behavioral factors. The third tier would involve the referral of patients to behavioral special- ists when depression, anxiety, stress, or other psy- FIGURE 8 Cumulative Incidence of Cardiovascular Death in the chosocial issues mandate.
Cardiovascular Health Study ONE SIZE DOES NOT FIT ALL. At the core of such Patients are grouped according to presence or absence of physical activity and proposed tiered care are the design and function of the presence or absence of depression. Adapted with permission from Win behavioral intervention programs. Optimally, these programs should address 2 key goals. First, to Advances in Behavioral Cardiology 1. Educate & inspire 1. Specific measurable plans 2. Promote self-efficacy 2. Verbal review of goals 2. Contingency plans 3. Promote autonomy 3. Self-monitoring 3. Social support 4. Time management 4. Stress management 5. Implementation intentions 5. Energy management 6. Motivational interviewing 6. Mental contrasting 6. Obligation intentions FIGURE 9 3-Component Model for Goal Achievement These techniques can be used to foster motivation, execution, or maintenance.
loss programs, and sleep centers. Psychological in- review reveals that John goes to sleep too late as a terventions also tend to be highly fractionated.
result of work pressure, has mild insomnia, and feels Second, although the treatment of most CHD risk a bit down and pessimistic about his work situation, factors is guideline driven, a high degree of flexibility which he believes is thwarting his sense of purpose.
and clinical judgment is required for the treatment of John is also socializing less. Thus, John's work situ- behavioral risk factors. To illustrate, consider the ation has led to dysfunction in each of the behavioral hypothetical example of John F., a 56 year-old busy midlevel executive of a company that is downsizing.
What, then, is the optimal first behavioral inter- John presents to his physician with nonanginal chest vention for assisting John? In the behavioral domain, pain that, following testing, is identified as func- "one size does not fit all." Life circumstances, current tional. Because John has gained weight and is highly habits, personal preferences, motivation, and coping sedentary, his physician establishes exercise and skills, for instance, may dictate varied alternatives to weight loss as health goals. A brief psychosocial initiating a specific behavioral intervention for John.
Rather, the "art" of optimizing behavioral interven-tion is based on clinical judgment that is derived from an experience base in providing coordinated, inte- grated care. Whereas many professionals are currently trained to provide specialized expertise in such areas as fitness instruction, dietary counseling, sleep hy- When it is "X", then I will When it is "X", then I will giene, rest and relaxation techniques, and psycho- logical counseling, few are trained in integrating these services. The development of such expertise would aid the growth of behavioral cardiology as a new, "When I finish my "When I finish work at distinct subspecialty within cardiology.
morning car pool, I will 5pm,I will head to the park to jog with Jim" Epidemiological studies over the last decade demon- FIGURE 10 Use of Implementation Intentions and Obligation Intentions strate generally strong dose-response relationships between an expanding number of psychosocial risk Implementation intentions require that subjects agree to have behavior cued factors and CHD. Increasing data also indicate that by an external cue (X) (specific time, place, or designated situational cue).
positive psychosocial functioning serves to improve Y represents the intended action. Obligation intentions add social support or health. To date, however, there has been relatively social pressure to implementation intentions by designating a companion or companions (Z) with whom the activity will be done.
little translation of these findings into cardiac prac-tice. The application of evidence-based approaches Advances in Behavioral Cardiology CENTRAL ILLUSTRATION The Clinical Basis for Behavioral Cardiology Both negative health behaviors and a variety of psychosocial risk factors increase the risk for CHD, often in synergistic fashion. An increasing number of evidence-based techniques have been developed as management strategies for promoting healthy behaviors and the enhancement of psychosocial well-being. CHD ¼ coronary heartdisease.
toward promoting patient motivation and goal exe- more difficult, including trends toward a faster pace of cution, innovative applications of technology, group- living, increasing job and time stress, reduced sleep, based interventions, and the development of a tiered increasing obesity, and declining physical activity.
behavioral care delivery system are needed to help behavioral cardiology develop into a mature field (The need for this maturation Dr. Alan Rozanski, Division of Cardiology, Mount is highlighted by the general challenge of eliciting Sinai St. Lukes and Roosevelt Hospital Center, behavioral change in cardiac practice, as well as soci- 1111 Amsterdam Avenue, New York, New York 10025.
etal trends that may now be making this challenge Advances in Behavioral Cardiology KEY WORDS behavioral cardiology, coronary disease, psychology, stress

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