Transcript Stress, Health and Performance

Stress, Health and Performance:
The Heart of the Matter
CSAHU Symposium 2009
Bruce C. Wilson, MD
Medical Director, HeartMath
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Psychological Stress and Disease
Sheldon Cohen, PhD
Denise Janicki-Deverts, PhD
Gregory E. Miller, PhD
JAMA, October 10, 2007—Vol 298, No. 14 1685
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Psychological Distress as a Risk Factor for
Cardiovascular Events
Pathophysiological and Behavioral Mechanisms
Mark Hamer, PhD*, Gerard J. Molloy, PhD and
Emmanuel Stamatakis, PhD
6576 Scottish men and women >30
Follow up 7 years
Stressed or depressed individuals at 50% greater CV risk
Risk is mainly behavioral
Smoking and decreased activity 65% of risk
Rx: Behavior modification

JACC.2008;52:2156-62
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Terrorism, Acute Stress, and Cardiovascular Health
A 3-Year National Study Following the September 11th Attacks
E. Alison Holman, FNP, PhD; Roxane Cohen Silver, PhD; Michael Poulin, PhD;
Judith Andersen, PhD; Virginia Gil-Rivas, PhD; Daniel N. McIntosh, PhD
People without known heart disease who responded with
acute and ongoing stress to 9/11 had a 3-4x incidence of
cardiac events over 3 years
Arch Gen Psychiatry. 2008;65(1):73-80
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Daily numbers of Deaths Listed by the Department of Coroner of Los Angeles County from
January 10 through 23, 1991, 1992, 1993, and 1994
Leor J et al. N Engl J Med 1996;334:413-419
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Anxiety Characteristics Independently and
Prospectively Predict Myocardial Infarction in Men
The Unique Contribution of Anxiety Among
Psychologic Factors
Biing-Jiun Shen, PhD*,*, Yael E. Avivi, MS , John F. Todaro, PhD ,
Avron Spiro, III, PhD , Jean-Philippe Laurenceau, PhD
Kenneth D. Ward, PhD and Raymond Niaura, PhD
Conclusions: Anxiety-prone dispositions appear
to be a robust and independent risk factor of MI
among older men.
JACC 2008; 51: 113-9
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Job Strain and Risk of Acute Recurrent Coronary Heart
Disease Events
Corine Aboa-Éboulé, MD, PhD; Chantal Brisson, PhD;
Elizabeth Maunsell, PhD; Benoît Mâsse, PhD;
Renée Bourbonnais, PhD; Michel Vézina, MD, MPH; Alain Milot, MD, MSc;
Pierre Théroux, MD; Gilles R. Dagenais, MD
More than 2 years of job stress doubles risk of events. Equivalent to smoking
or high cholesterol
JAMA. 2007;298:1652-1660.
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Prospective Study on Occupational Stress and Risk
of Stroke
Tsutsumi A, Kayaba K, Kario K, Ishikawa S.
Occupational stress related to job strain was associated with
2x incident strokes among Japanese men (demand/control
model)
Arch Intern Med. 2009 Jan 12;169(1):56-61.
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Living Alone After Myocardial Infarction
Impact on Prognosis
RB Case, AJ Moss, N Case, M McDermott, S Eberly
JAMA 1992;267;515-19
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Marital Status, Marital Strain, and Risk of Coronary
Heart Disease or Total
Mortality: The Framingham Offspring Study
ELAINE D. EAKER, SCD, LISA M. SULLIVAN, PHD, MARGARET KELLY-HAYES, EDD, RN, RALPH B. D’AGOSTINO, SR, PHD,
AND EMELIA J. BENJAMIN, MD, SCM
Differences exist for men and women regarding cardiovascular events and mortality in
situations of marital conflict
Psychosomatic Medicine 69:509–513 (2007)
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Negative Aspects of Close Relationships and Heart
Disease
Roberto De Vogli, PhD, MPH; Tarani Chandola, DPhil; Michael Gideon
Marmot, PhD, FRCP
There is an increased relative risk of cardiac events (1.3) in people
who are in poor relationships.
This is independent of other risk factors.
Arch Intern Med. 2007;167:1951-1957
.
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Mortality after Bereavement:
A Prospective Study of 95,647 Widowed Persons
JAAKKO KAPRIO, MD, MARKKU KOSKENVUO, MD, AND HELI RITA, MPOLSC
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95,647 Finns widowed ’72-’76
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7635 deaths in first week after spouse died (2X expected)
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IHD leading cause of death in surviving spouse
•Men
•Women
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RR = 2.3
RR = 3.4
Violent causes for first spouse=2X expected in first month
Am J Public Health 1987; 77:283-287.
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The Association of Anger and Hostility With Future
Coronary Heart Disease
A Meta-Analytic Review of Prospective Evidence
Yoichi Chida, MD, PhD* and Andrew Steptoe, DPhil
Meta-analysis of 44 studies
Anger, hostility associated with CHD events
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•Initially healthy subjects
•Pts with CAD
Men>women (coping mechanisms?)
Behaviors vs. Autonomic dysregulation
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•Inflammation (CRP, IL-6,)
•Hypercoagulability (fibrinogen)
JACC. 2009; 53:936-46
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Depression and 18-Month Prognosis After
Acute Myocardial Infarction
Nancy Frasure-Smith, PhD, Francois L’esperance, MD, Mario Talajik, MD
Depression following heart attack significantly increases the
mortality over the next 18 months, and is correlated with
abnormal heart beats (PVC’s), suggesting sudden death as a
mechanism.
Circulation 1999;91:999-1005
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The risk ratios for traditional risk factors reported for men in the Framingham study (28)
Rozanski, A. et al. J Am Coll Cardiol 2005;45:637-651
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Copyright ©2005 American College of Cardiology Foundation. Restrictions may apply.
Post-myocardial infarction (MI) patients were recruited and assigned to one of four
categories based on the Beck Depression Inventory (BDI), ranging from no depressive
symptoms (BDI <5) to moderate to severe depressive symptoms (BDI >19)
Rozanski, A. et al. J Am Coll Cardiol 2005;45:637-651
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Copyright ©2005 American College of Cardiology Foundation. Restrictions may apply.
Pathophysiologic mechanisms by which chronic stress and affective disorders, such as
depression, appear to promote atherosclerosis
Rozanski, A. et al. J Am Coll Cardiol 2005;45:637-651
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Copyright ©2005 American College of Cardiology Foundation. Restrictions may apply.
Anger Management May Save Your Life
New Insights Into Emotional Precipitants of Ventricular
Arrhythmias
Eric J. Rashba, MD, FACC
Anger and other mental stress can cause T Wave Alternans
and predict ventricular arryhthmias
JACC 2009; 53:779-781
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The HERO Study
Comparing Modifiable Health Risk Costs
•22 organizations: Chevron, Marriott, Michigan,
Hoffman-La Roche Inc.
•47,500 workers
•HRAs and Health Claims
•
High Blood Pressure
Diabetes
•Smoking
•Stress
•
•
Depression
•
Obesity
•
Lack of exercise
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Percent Difference in Medical Expenditures:
High-Risk versus Lower-Risk Employees
70.2%
46.3%
34.8%
21.4%
10.4%
11.7%
Sedentary
Lifestyle
Blood
Pressure
14.5%
Smoking
Overweight
Blood Sugar
Control
Stress
Depression
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The Real Costs
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What We Know for Sure
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Nationally, total health plan average costs
increased 6.7%, now total $7,983 per
employee per year.
In Wisconsin, annual per employee costs are
$10,097
The cost of health care is still 1.5x higher
than overall inflation and worker earnings.
Stress, and stress related diseases are the
driving force behind these increases AND we
have the ability to stop it.
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Forces Driving Up Costs

Consolidation, consolidation, consolidation
•
•
•
•
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Insurance carriers
Pharmacy companies
Providers
Hospitals
Medical technology increases utilization as well
as price
Pharmacy costs: biotech, nanotech, specialty
and lifestyle drugs
Baby Boomers raising average age of labor
force
Increased chronic disease states; stress and
stress-related diseases
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Employer Reactions: working or not
working?
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Eliminate coverage
Cost shift to employees
• Increase contribution
• Increase deductibles, co-pays, co-insurance
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Offer dual choice or only HDHP
Restrict eligibility and carve-out plans
What Else Can They Do?
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What Successful Companies Do
Differently
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High performers are significantly more aggressive
and systematic in managing their health care
programs.
They identify problems early and take advantage
of opportunities for improvement
They are the most competitive, profitable, and
growth focused companies of our time.
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High Performing
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Cost increases at CPI
(4%)
Per employee per year
costs - $8,532
High productivity and
presenteeism
High profits, culture of
growth
Low Performing

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Cost increases over
CPI (10%+)
Per employee per
year costs - $10,200
High turnover, time
off
High costs related to
business, negative
culture
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What Employers Need to Know
FOR SURE…..
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Recognize they are in the health care
business
Embrace health strategies and
management
Utilize data informatics to target your
highest cost areas: disease, turnover,
productivity
Attack their biggest culprit -- STRESS
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Are Positive and Negative Affect Independently Associated With
Health in a Representative Sample of the World?
Sarah D. Pressman1,2 , Matt W. Gallagher1, & Shane Lopez2
1University of Kansas, 2 Gallup
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150,000 adults in 140 countries
Represent 95% of world population
Positive emotions linked to better health even without food,
shelter
Negative emotions associated with poor health outcomes
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Published Research
 American Journal of Cardiology
 Journal of Stress Medicine
 J. American College of Cardiology
 Modern Healthcare
 Harvard Business Review
 Wall Street Journal
Selected Clients
Published Research
Ø American Journal of Cardiology
Ø Journal of Stress Medicine
Ø American College of Cardiology
Ø Modern Healthcare
Ø Harvard Business Review
Ø Wall Street Journal
High Cortisol:Low DHEA
• Obesity
(Marin 1992)
• Diabetes
(Nestler 1992)
• Hypertension
(Shafagoj 1992)
• Heart Disease
• Cancer
(Barrett-Connor 1986)
(Bhatavdekar 1994)
• Alzheimer’s
(Nasman 1995)
• HIV-related disease
(Wisniewski 1993)
Case Study—Hormonal Changes
DHEAS
Total Free Cortisol
250
14
100%
12
23%
200
150
8
nM
ng/ml
10
6
100
4
50
2
0
0
before
after
n=28
before
after
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The Heart
The Heart
• Source of the heartbeat is within
• Source
of the heart beat
the heart.
is within the heart.
• Generates 40 to 60 times more
• Generates
to 60 times
electrical40
amplitude
than the brain.
more electrical amplitude
than
the brain.
• Its electrical signal can be measured
the body.
• Itsanywhere
electricalon
signal
can be
measured anywhere on the
body.
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Changing Heart Rhythms
© 2004 HeartMath LLC
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$1179
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Published Research
Ø American Journal of Cardiology
Ø Journal of Stress Medicine
Ø American College of Cardiology
Ø Modern Healthcare
Ø Harvard Business Review
Ø Wall Street Journal
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Questions?