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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