GR2011-10 Reversing CAD - Drs. Cort and Kappagoda

Coronary artery disease can be reversed: 

Coronary artery disease can be reversed Tissa Kappagoda M.D., Ph.D., D.Sc University of California, Davis

Slide 2: 

DISCLOSURE: Dr. Doug Cort and I have no relevant financial interest/arrangement or affiliation with any organizations related to Commercial Products or Services to be discussed at this program.

What is meant by reversing coronary artery disease: 

What is meant by reversing coronary artery disease “Clean up” diseased coronary arteries a) relieve spasm b) reduce lesions Improve the long-term outlook for patients

Who needs this type of care: 

Who needs this type of care Those who have recovered from: a) a heart attack b) coronary artery bypass surgery c) placement of stents in arteries Those who have disease in the coronary arteries not amenable to above procedures Those considered to have coronary artery disease (heart attack) equivalents such as Type 2 diabetes and metabolic syndrome Those considered to have greater that 1 in 5 chance of having a heart attack or dying from one over the next 10 years (i.e. high risk by Framingham Criteria).

Why is this issue important?: 

Why is this issue important?

The problems that define future healthcare in the U.S. (1) Metabolic Syndrome (MS): 

The problems that define future healthcare in the U.S. (1) Metabolic Syndrome (MS) Diagnosis based on presence of 3 out of 5 Factors Factor NCEP (U.S.) Abdominal Obesity (M/W) >102/88 cm Triglycerides (mg/dl) ≥150 HDL (mg/dl) (M/W) <40/<50 Blood Pressure (mmHg) 130/85 Fasting glucose (mg/dl) ≥110

Prevalence of the MS in the U.S. (Based on NCEP III definition): 

Prevalence of the MS in the U.S. (Based on NCEP III definition) 43.3 80+ 42.6 70–79 41.5 60–69 30.6 50–59 Age group (years) 35.9 Other 43.5 Mexican American 34.6 Non-Hispanic black 38.2 Non-Hispanic white Race/ethnicity Overall prevalence 37.9 % in people > 20 yr ~ 79 million people.

The problems that define future healthcare in the U.S. (2) Type 2 Diabetes: 

The problems that define future healthcare in the U.S. (2) Type 2 Diabetes 50% of the attributable risk of developing type 2 diabetes is accounted for by MS Diabetes affects 25.8 million people of all ages 8.3 percent of the U.S. population DIAGNOSED 18.8 million people UNDIAGNOSED 7.0 million people Source :CDC/Framingham Data Over 30 years, the risk of CVD among normal-weight women with diabetes was 54.8% and 78.8% among obese women. For men, the corresponding figures were 78.6% and 86.9%.

Slide 9: 

Revascularization Procedure Rates of CABG Surgery, Bare Metal Stents, Drug-Eluting Stents, and Angioplasty per Million Adults per Quarter Between 2001 and 2008 Epstein, A. J. et al. JAMA 2011;305:1769-1776 Copyright restrictions may apply. CABG Angioplasty BMS DES

Slide 10: 

Annual Rates of Coronary Revascularization Procedures Epstein, A. J. et al. JAMA 2011;305:1769-1776 Copyright restrictions may apply.

Demand for Coronary Revascularization Procedures: 

Demand for Coronary Revascularization Procedures Population evaluated = 45 million (20% of the adult U.S. population) Procedures per year/ million people CABG 1081 PCI 3667 Bare Metal 1167 Drug eluting 2383 Angioplasty 117 TOTAL 4748 Epstein, A. J. et al. JAMA 2011;305:1769-1776 ~ 5000 procedures are performed/million people There are ~20 million people in the U.S. with >20% risk of MI

Demonstrating Reversal of Coronary Artery Disease: 

Demonstrating Reversal of Coronary Artery Disease Improvement in tendency to develop spasm Reduction in lesions in coronary arteries Increase in life expectancy

Beneficial Effects of Cholesterol-Lowering Therapy on the Coronary Endothelium in Patients with Coronary Artery Disease Treasure C.B. et al. N Engl J Med 1995; 332:481-487 : 

Beneficial Effects of Cholesterol-Lowering Therapy on the Coronary Endothelium in Patients with Coronary Artery Disease Treasure C.B. et al. N Engl J Med 1995; 332:481-487 Improving Spasm by Cholesterol Lowering

Slide 14: 

Endothelium Dependent Relaxation Furchgott and Zawardski, 1980, Nature Volume 288, page 373 37 0 C water 37 0 C water Drainage 95 % O 2 + 5 % CO 2 Over flow Krebs buffer

Effect of atherosclerosis on EDR Cholesterol fed rabbit: 

Effect of atherosclerosis on EDR Cholesterol fed rabbit Jayakody et al (1985) Circ. Res.

Cholesterol fed rabbit model continued: 

Cholesterol fed rabbit model continued Reversal of lesions by a Ca++ channel blocker Skepper JN, Kappagoda CT. The effect of isradipine administration on existing fatty streaks in the cholesterol-fed rabbit: a morphometric study. Atherosclerosis. 1996 Jan 26;119(2):247-60. Prevention of lesions by a Ca++ channel blocker Skepper JN, Kappagoda CT. The effect of concurrent administration of isradipine on the development of fatty streaks in the cholesterol-fed rabbit: a morphometric study. Atherosclerosis. 1992 Sep;96(1):17-31. Protection of endothelial function and prevention of lesions by a statin. Senaratne MP, Thomson AB, Kappagoda CT. Lovastatin prevents the impairment of endothelium dependent relaxation and inhibits accumulation of cholesterol in the aorta in experimental atherosclerosis in rabbits. Cardiovasc Res. 1991 Jul;25(7):568-78.

Spasm in Arteries Malfunction of Nitric Oxide Synthase (NOS) Pathway in endothelial cells: 

Spasm in Arteries Malfunction of Nitric Oxide Synthase (NOS) Pathway in endothelial cells L-Arginine + Nitric oxide synthase + Oxygen Nitric oxide L-citrulline Relaxation (Amino acid) (Enzyme) By product

Improving Spasm by Cholesterol Lowering: 

Subjects: 30 to 81 years olds who had a clinical requirement for coronary angioplasty at a non-occluded site and a total serum cholesterol concentration ranging from 160 to 300 mg per deciliter and no prior statin therapy. Procedures: The branch of the left coronary artery not undergoing angioplasty was studied. Infusions of acetylcholine chloride and nitroglycerin were administered through the infusion catheter and coronary arteriography was performed at the end of each infusion. Angiography: Upon completion of the infusions, lovastatin or a placebo was administered for 5 ½ m after which an identical infusion was performed with the initial angiographic views and the position of the infusion catheter reproduced exactly. Analysis: For each patient, the arterial segment with the most constriction in response to acetylcholine in the initial study was studied at follow-up, and the two values were compared; in addition, the responses in all study-vessel segments were compared. Improving Spasm by Cholesterol Lowering N Engl J Med 1995; 332:481-487

Effect of Acetylcholine: 

Effect of Acetylcholine Tot. Chol 210/LDL 144 (mg/dL) Tot. Chol 158/LDL 110 (mg/dl) Placebo Lovastatin Control Max Ach Control Max Ach Infusion Infusion Infusion Infusion

Summary of results: 

Summary of results Mean (±SE) Responses in All Segments of the Epicardial Coronary Artery to Serial Infusions of Acetylcholine in the Two Groups at the Follow-up (51/2 Months) Study.

Can atherosclerosis be stopped? JAMA. 2004 Mar 3;291(9):1071-80. : 

Can atherosclerosis be stopped ? JAMA. 2004 Mar 3;291(9):1071-80. Objective: To compare the effect of intensive (80 mg of atorvastatin ) or moderate lipid lowering (40 mg of pravastatin ) on coronary artery atheroma burden and progression. Drugs administered for 18 months. Intravascular ultrasound was used to measure progression of atherosclerosis. Main Outcome was the percentage change in atheroma volume.

Intravascular Ultrasound: 

Intravascular Ultrasound

Can atherosclerosis be stopped? JAMA. 2004 Mar 3;291(9):1071-80. : 

LDL cholesterol level was reduced to 110 mg/dL in the pravastatin group and to 79 mg/dL in the atorvastatin group. The atheroma volume showed a significantly lower progression rate in the atorvastatin (intensive) group. Coronary atherosclerosis progressed in the pravastatin group (2.7 %) compared with baseline. Progression did not occur in the atorvastatin group compared with baseline. For patients with coronary heart disease, intensive lipid-lowering treatment reduced progression of coronary atherosclerosis Can atherosclerosis be stopped ? JAMA. 2004 Mar 3;291(9):1071-80.

Slide 24: 

JAMA. 2006 Apr 5;295(13):1556-65. 2006 Mar 13. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. Nissen et al

High-intensity statin therapy on regression of coronary atherosclerosis: 

High-intensity statin therapy on regression of coronary atherosclerosis OBJECTIVE: To assess whether very intensive statin therapy could regress coronary atherosclerosis Coronary atheroma burden at baseline and after 24 months of treatment was assessed with ultrasound (US) 507 patients had a baseline US examination and after 24 months. 349 patients had evaluable examinations. All patients received therapy with rosuvastatin, 40 mg/d. The changes in atheroma volume were measured.

High-intensity statin therapy on regression of coronary atherosclerosis: 

High-intensity statin therapy on regression of coronary atherosclerosis The mean LDL-cholesterol level declined from 130.4 mg/dL to 60.8 mg/dL. Mean HDL-Cholesterol level increased from 43.1 mg/dL to 49.0 mg/dL. The mean change in atheroma volume was -0.98%. Change in atheroma volume in most diseased 10 mm segment was -14.7 mm 3 . CONCLUSIONS : Very high-intensity statin therapy using rosuvastatin 40 mg/d achieved an average LDL-C of 60.8 mg/dL and increased HDL-C by 14.7%, resulting in significant regression of atherosclerosis .

So, why don’t we just take a pill?: 

So, why don’t we just take a pill? Drugs don't work in patients who don't take them. — C. Everett Koop, M.D. Adherence to Medication Lars Osterberg, M.D., and Terrence Blaschke, M.D. N Engl J Med 2005; 353:487-497

So, why don’t we just take a pill?: 

So, why don’t we just take a pill? A Systematic Review of Adherence With Medications for Diabetes Cramer: Diabetes Care (2004) vol. 27 no. 5 1218-1224 Adherence to oral meds. ranged from 36 to 93% in patients remaining on treatment for 6–24 months Insulin adherence among patients with type 2 diabetes was 62–64%.

It isn’t always easy…….: 

It isn’t always easy……. Promoting Medication Adherence in Older Adults … and the Rest of Us. Kocurek B. Diabetes Spectrum March 20, (2009) vol. 22 no. 2 80-84

Dr. Koop was right!: 

Dr. Koop was right! Cardiovascular events in statin recipients: impact of adherence to treatment in a 3-year record linkage study. Poluzzi E , Eur J Clin Pharmacol . 2011 Apr;67(4):407-14 Patients non-adherent to a statin during a 3-year period (76% of the cohort) had higher odds of events, irrespective of risk factors, by more than 40% when compared with adherent patients.

Covering all the bases: 

Covering all the bases Intensive Lifestyle Changes for Reversal of Coronary Heart Disease Ornish et al. JAMA. 1998;280:2001-2007.

Risk Factors for Coronary Artery Disease: 

Risk Factors for Coronary Artery Disease Age, Gender, Family history Diabetes Obesity PATIENT Serum lipids Blood pressure Sedentary lifestyle Smoking Stress PATIENT lifestyle

Traditional Risk Factors for Coronary Artery Disease: 

Traditional Risk Factors for Coronary Artery Disease Age, Gender, Family history Diabetes Obesity PATIENT Serum lipids Blood pressure Sedentary lifestyle Smoking Stress Endothelial Dysfunction

The Basis of the Interaction Between Risk Factors: 

Endothelial Dysfunction Oxidative Stress/ Inflammation The Basis of the Interaction Between Risk Factors Age, Gender, Family history Diabetes Obesity PATIENT Serum lipids Blood pressure Sedentary lifestyle Smoking Stress

Plan for managing risk factors in the population : 

Endothelial Dysfunction Oxidative Stress/ Inflammation Plan for managing risk factors in the population Age, Gender, Family history Diabetes Obesity PATIENT Serum lipids Blood pressure Sedentary lifestyle Smoking Stress New Strategies in Nutrition

Change in Lifestyle and Reversal: 

Change in Lifestyle and Reversal Design. Randomized controlled trial conducted from 1986 to 1992. Forty-eight patients with moderate to severe coronary heart disease were randomized to an intensive lifestyle change group or to a usual-care control group, and 35 completed the 5-year follow-up quantitative coronary arteriography . Intervention. Intensive lifestyle changes (10% fat whole foods vegetarian diet, aerobic exercise, stress management training, smoking cessation, group psychosocial support) for 5 years. Main Outcome Measures. Adherence to intensive lifestyle changes, changes in coronary artery percent diameter stenosis, and cardiac events.

Lifestyle and Regression: 

Lifestyle and Regression Experimental group patients (20 [71%] of 28 patients completed 5-year follow-up) made and maintained comprehensive lifestyle changes for 5 years, whereas control group patients (15 [75%] of 20 patients completed 5-year follow-up) made more moderate changes. In the experimental group, the average percent diameter stenosis at baseline decreased by 3.1 % after 5 years. In contrast, the average percent diameter stenosis in the control group increased by 11.8 percentage points after 5 years . Twenty-five cardiac events occurred in 28 experimental group patients vs 45 events in 20 control group patients during the 5-year follow-up. Conclusions.— More regression of coronary atherosclerosis occurred after 5 years in the experimental group. In contrast, in the control group, coronary atherosclerosis continued to progress and more than twice as many cardiac events occurred.

Lifestyle and Regression: 

Lifestyle and Regression Control Treatment

Progression of Calcified Lesions (Agatston Scores): 

Progression of Calcified Lesions ( Agatston Scores) A - Untreated control (Historical) B - Statins +meaningful life-style modification C - Statin drugs + Lifestyle change + strict risk factor modification. A further 20.4% demonstrated actual regression of plaque burden as well Medical therapy also yielded a remarkably low adverse event rate during the follow-up period --- 2 deaths, 2 strokes and only 1 case requiring PCI. A B C Goh et al. Cardiovascular Ultrasound 2010 8:5 Increase in Agatston Score/year

Optimum Medical Therapy for Chronic CAD: 

Optimum Medical Therapy for Chronic CAD 0 20 40 60 80 100 120 Months Patients (%) 100 90 80 Patients (%) 100 90 80 Partial compliance Log rank p<0.02 Patients (%) 100 90 80 Patients (%) 100 90 Compliant Log rank p<0.02 COURAGE TRIAL (PCI+ OMT/OMT)

Courage Lifestyle Outcomes: Patient Targets by Age Group (60-Month Follow-Up): 

Courage Lifestyle Outcomes: Patient Targets by Age Group (60-Month Follow-Up) Age <65 yr Age >65 yr OMT PCI P OMT PCI P P for age P for Inter. SBP <130 mm Hg 71 67 0.41 57 52 0.35 <0.001 0.84 DBP <85 mm Hg 93 91 0.38 94 98 0.11 0.03 0.08 LDL <85 mg/dl 69 66 0.41 78 71 0.15 0.04 0.49 AHA step II diet 76 73 0.46 77 82 0.25 0.09 0.17 Exercise: >30 min moderate activity 5/wk 35 41 0.10 37 43 0.30 0.50 0.87 BMI <25 kg/m 2 or 90% of baseline 14 15 0.63 24 30 0.26 <0.001 0.63 Angina: none 72 73 0.83 73 80 0.16 0.22 0.31 Smoking: none 72 73 0.82 90 94 0.19 <0.001 0.28 Journal of the American College of Cardiology Volume 54, Issue 14, 29 September 2009, Pages 1303-1308

Slide 42: 

Percentage of Patients Achieving Optimal Medical Therapy Before and After PCI by Procedural Month Borden, W. B. et al. JAMA 2011;305:1882-1889 Copyright restrictions may apply. Before PCI After PCI

So, why don’t we just take a pill?: 

So, why don’t we just take a pill? As much as I'd like to meet the tooth fairy on an evening walk, I don't really believe it can happen. Chris Van Allsburg

Comparison with Courage Cohort: 

Comparison with Courage Cohort UCDMC Cohort Courage Cohort Variable Age(year)* 61 ± 10 61 ±10 Female (%) 32 25 Body Mass Index 29 ± 0.51 28.9 ±.17 History of MI (%) 42 39 CABG (%) 40 11 History of PCI (%) 40 16 No. of major vessels 1.85 1.65 Ejection fraction (%) 58.2 60.9 Duration of history (yr)* 5.4 ± 6.6 0.5 Current smoker (%) 2 23 History of hypertension 67 67 Diabetes mellitus (%) 30 35 Medication Lipid lowering meds (%) 43 89 Beta-blockers (%) 35 89 Ca++blockers (%) 49 43 Nitrates (%) 36 72 Ace inhibitors (%) 19 60 Anti-platelet ( %) 75 95 Total Cholesterol (mg/dl) 195 ± 3.4 177 ± 1.4 LDL (mg/dl) 121 ± 2.1 102 ± 1.22 HDL (mg/dl) 41.8 ± 1.2 39 ± 0.37 Triglycerides 197 ± 16 149 ± 3.03 Systolic B.P. (mmHg) 123 ± 2.0 130 ± 0.66 Diastolic B.P. (mmHg) 73 ± 1.2 74 ± 0.33

So, why don’t we just resort to OMT: 

So, why don’t we just resort to OMT As much as I'd like to meet the tooth fairy on an evening walk, I don't really believe it can happen. Chris Van Allsburg

10 – year survival after secondary prevention program (UC Davis): 

10 – year survival after secondary prevention program (UC Davis) Years Proportion surviving 36 sessions 1 session No rehab.

Human cost of doing nothing (MediCare Population): 

Human cost of doing nothing (MediCare Population) 0 1 2 3 4 5 6 Years 100 80 60 40 20 0 Expected Actual Survival %

Lifestyle Change – The possibilities: 

Lifestyle Change – The possibilities Quit smoking Weight Blood Pressure Diabetes Cholesterol Exercise Manage your stress

Risk of CVD and Type 2 Diabetes: 

Risk of CVD and Type 2 Diabetes Women Men Non-diabetic Diabetic Non-diabetic Diabetic Original cohort 10 year 6.9 21.6 15.0 28.2 20 year 21.7 50.0 36.0 57.7 30 year 38.0 67.1 54.8 78.0 Offspring 10 year 3.9 15.9 8.7 13.3 20 year 11.0 29.3 23.7 43.8 30 year 26.0 48.6 37.8 61.6 Framingham Data

Impact of MS on Healthcare (U.K. Data): 

Impact of MS on Healthcare (U.K. Data) Association of Metabolic Syndrome and coronary artery disease, stroke and diabetes Characteristic Metabolic syndrome absent Metabolic syndrome present Major cardiac event 13.0 % 20.4 % Major stroke 5.0 % 7.6 % Type 2 diabetes 3.7 % 12.1% In people with the MS, the incidence of a major cardiac event, stroke and overt diabetes is twice that of people without MS.

Psychology and Heart Disease The Vitality of the Biopsychosocial Approach Doug Cort, Ph.D. : 

Psychology and Heart Disease The Vitality of the Biopsychosocial Approach Doug Cort, Ph.D.

What does the Biopyschosocial Model Mean? (a la Engel and Schwartz): 

What does the Biopyschosocial Model Mean? (a la Engel and Schwartz) Single factor, or even single domain explanations are likely to be inadequate A change in one domain necessarily results in changes in other domains (unless proven wrong) Medical dx which considers interaction of biological, psychological and social factors should lead to improved diagnosis Practice interventions & policy involving all these should fare better than those grounded in any single class of variables.

The INTERHEART study Lancet, 2004; 364: 937- 952 : 

The INTERHEART study Lancet, 2004; 364: 937- 952 Standardized case-control study of acute myocardial infarction undertaken in 52 countries drawn from every inhabited continent . 15152 cases and 14820 controls were enrolled. The relationship of smoking, history of hypertension and diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, apoliproteins and psychosocial factors to myocardial infarction were studied.

The INTERHEART study: 

The INTERHEART study Worldwide, abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low consumption of fruit and vegetables, (alcohol) and lack of physical activity accounted for 90% of the risk of myocardial infarction in men and 94% in women.

INTERHEART Study: 

INTERHEART Study Smk DM HTN APOB/A1 1+2+3 All 4 +Obes +PS ALL RF’s 1 2 3 4 Odds Ratio (99% CI)

INTERHEART Study Lancet, 2004; 364: 953-962 Psychosocial factors are ready for prime time: 

INTERHEART Study Lancet, 2004; 364: 953-962 Psychosocial factors are ready for prime time General psychological stress at work and home (feeling irritable, insomnia, anxiety) Financial Stress Loss of locus of control Depression Stressful life events

Population attributable risk Psychosocial Factors: 

Population attributable risk Psychosocial Factors General stress 12% Financial stress 11% Stressful life events 11% Locus of control 16% Depression 9% If all present PAR is 28%!

Major Cardiovascular Risk Factors : 

Major Cardiovascular Risk Factors Diabetes Obesity Serum lipids Blood pressure Sedentary lifestyle Smoking Diabetes Obesity Patient Serum lipids Blood pressure Sedentary lifestyle Smoking CAD Psych. Stress

Major Psychological Issues in CAD: 

Major Psychological Issues in CAD Anger/Hostility Patient’s Life Stress Depression Lack of Social Support CAD Anxiety Stewart,J.C. (2010) Ann. Behav. Med.

Let’s Look At Anxiety: 

Let’s Look At Anxiety

Anxiety: 

Anxiety Overestimation of threat, underestimation of coping skills Sense of uncontrollability focused largely on possible future threats, danger, or other upcoming potentially negative events. Helplessness due to inability to predict, control, or obtain desired results or outcomes (in personally important contexts). Suggests anxious apprehension because all anxiety is anticipatory. Barlow 2000

Anxiety Increases Risk of Death in people with CAD JACC May 2007: 

Anxiety Increases Risk of Death in people with CAD JACC May 2007 N=516 over 3 years Those in highest 1/3 on anxiety measure had 2X risk of heart attack or death vs. those in lowest 1/3. Every 1-point increase in anxiety score increased risk of death or MI by 6%. Cumulative score (over time) was vital. E.g. start out highly anxious but later found inner calm reduced risk markedly Concluded “the era of ‘its all in your head’ is over.

Affect and Illness-Anxiety: 

Affect and Illness-Anxiety Anxiety has a U-shaped relationship with mortality, both high and low levels linked to increased risk. Some anxiety may make people less likely to indulge in risky behavior and push them to seek proper healthcare. Adding anxiety to depression decrease risk vs. depression alone Depression –passivity, hopelessness Anxiety – restlessness, want to act immediately.

What About Stress?: 

What About Stress?

Stress Defined: 

Stress Defined A bodily or mental tension resulting from factors that tend to alter an existent equilibrium (homeostasis)

Developing the elements of a treatment plan: 

Developing the elements of a treatment plan

“I’m allergic to all blood pressure lowering medications”: 

“I’m allergic to all blood pressure lowering medications” 73 y/o Caucasian male, married, well educated (PhD), extremely good athlete, elevated BP, status post stroke Tried and disliked BP meds, feared side affects and addiction and wanted to try non-pharmacological methods. Also, believes he has extreme ‘white coat fever’ and thus medical practitioners unable to get accurate readings

“I’m allergic to all blood pressure lowering medications” Part 2: 

“I’m allergic to all blood pressure lowering medications” Part 2 Pt was similarly reactive to family stressors. We engaged in a number of ‘experiments’, trained in mindfulness and other behavioral stress reduction methods Working closely with cardiologist agreed to try meds in conjunction with behavioral methods and therapy, increasing usage should experiments fail.

“I’m allergic to all blood pressure lowering medications” Part 3: 

“I’m allergic to all blood pressure lowering medications” Part 3 Surprisingly the experiments worked very well and he required minimal medical supplementation. Continues to monitor BP regularly and has agreed to third party verification.

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Things Addressed by Psychologists: 

Things Addressed by Psychologists Smoking Anger Depression Anxiety Behavior Change “Stress” Lack of social support

What We Often Do May Include: 

What We Often Do May Include CBT Family Therapy Supportive Individual Therapy Lifestyle Interventions (including smoking cessation, interpersonal skill building etc.) Stress reduction interventions, including one of my favorites………

Meditation... The Mother of All Methods: 

Meditation... The Mother of All Methods Improves concentration Decreases reactivity Helps patient “let things go” Works at level of appraisal processes Yoga and meditation appear to improve endothelial function in subjects with CAD (Sivansnkaran et al., Clin Cardiol 2006.

A final Reality Check: The Role of Psychologists in the Management of Chronic Medical Diseases such as CAD: 

A final Reality Check: The Role of Psychologists in the Management of Chronic Medical Diseases such as CAD Is there a patho-physiological link between “stress” and the disease ( Animal/Human data)? Do behavioral issues affect the impact of conventional risk factors for the disease (Interheart Data)? Do behavioral/social issues influence self care (diet, lack of exercise, compliance with medications)? Question for the Audience: How much teaching did you have on Psychological and Behavioral issues as medical students?

Slide 75: 

Thank You!