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Psychological Aspects of Coronary Heart Disease:
45 Studies Published in 2016-2022
Kenneth S. Pope, Ph.D. ABPP
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The purpose of the web page is to help clinicians, researchers, and others to keep abreast of the evolving research on psychological factors related to the causes of, treatments for, and recovery from coronary heart disease.
I gathered the following
citations for and excerpts from 45 studies of the psychological aspects of coronary heart disease development, treatment, and recovery published during the last 7 years (2016-2022):
Armond, R., et al. (2020). "Spiritual well-being and its association with coronary artery disease." J Relig Health: published online in advance of print publication.
"Statistically, there was no significant difference between categories and levels of spiritual well-being in any of the groups. Both had high rates, driven by the high level of religious well-being. There was no difference between the rates attributed to the items on the subscale of religious well-being, in the case or control groups.... However, the existential well-being subscale revealed variability between the scores attributed to each item in both groups (p < 0.001). The results revealed a high level of spiritual well-being in the analyzed sample. There was no correlation between the levels of spiritual, religious, and existential well-being with coronary artery disease, possibly due to the reduced ability of the religious well-being subscale to discriminate between groups."
Bremner, J. D., et al. (2019). Effects of a mental stress challenge on brain function in coronary artery disease patients with and without depression. US, American Psychological Association. 38: 910-924.
“These findings are consistent with dysfunction in a network of brain regions involved in the stress response in patients with comorbid CAD and depression that has direct and indirect links to the heart, suggesting a pathway by which stress and depression could lead to increased risk of heart disease related morbidity and mortality.”
Byrne, C. J., et al. (2018). Hopelessness and cognitive impairment are risk markers for mortality in systolic heart failure patients. Netherlands, Elsevier Science. 109: 12-18.
“Hopelessness and cognitive impairment are stronger risk markers for all-cause mortality than other symptoms of depression in systolic heart failure. These data will allow more specific risk assessment and potentially new targets for more effective treatment and management of depression in this population.
Cheng, M.-y., et al. (2022). "Relationship between cognitive emotion regulation strategies and coronary heart disease: An empirical examination of heart rate variability and coronary stenosis." Psychology & Health 37(2): 230-245.
"Patients with more serious diseases exhibited increased maladaptive emotion regulation, which was associated with lower HRV and severe coronary stenosis. Further, adaptive emotion regulation was associated with higher HRV and moderate coronary stenosis."
Cigerci, Y., et al. (2021). "Does the technique used in coronary artery bypass graft surgery affect patients' anxiety, depression, mental and physical health? First 3-month outcomes." Perspectives in Psychiatric Care: published online in advance of print publication.
"Anxiety, depression, and mental health showed significant differences in different time measurements, and combined effects of surgical technique and time factor.... Preoperative routine evaluations can speed up recovery, reduce cost, and improve quality of life by preventing the possible negative effects of anxiety and depression."
Cui, R., et al. (2022). "Cardiac disease, depression, and suicide risk by age: A cross-sectional survey." GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry: published online in advance of print publication.
"Older adults had more cardiovascular diagnoses, whereas younger adults with cardiovascular diagnoses had more depression symptomatology and suicide risk. Associations between cardiovascular disease (one or more diagnoses vs. no diagnoses) and mental health were moderated by age (p < .05 for Age × Cardiovascular interaction predicting depression and predicting suicide risk). The findings highlight the importance of assessing and addressing mental-health concerns among cardiovascular patients, especially in younger demographics."
Eisenberg, R., et al. (2022). "Cardiac-disease-induced posttraumatic stress symptoms (CDI-PTSS) among cardiac patients’ partners: A longitudinal study." Health Psychology: published online in advance of print publication.
"A mild level of CDI-PTSS was detected among partners, 4 and 8 months after patients’ cardiac event. Partners’ distress as measured during patients’ hospitalization, and their fear of patients’ illness progression, contributed to the manifestation of CDI-PTSS over time."
Euteneuer, F., et al. (2022). "Does psychological treatment of major depression reduce cardiac risk biomarkers? An exploratory randomized controlled trial." Psychological Medicine: published online in advance of print publication.
"CBT increased overall HRV in patients with MD. Initially more depressed patients showed the most pronounced cardiovascular improvements through CBT."
Fan, Y., et al. (2020). "Depression, anxiety, perceived stress, and their changes predicted medical adherence over 9 months among patients with coronary heart disease." British Journal of Health Psychology.
"Baseline depression and its changes over time significantly predicted greater decline in both medication adherence (βs = .15–.20, ps < .05) and specific adherence (βs = −.21 to −.15, ps < .05). Anxiety showed a similar trend. For perceived stress, baseline and its change significantly predicted specific adherence over 9 months (βs = −.30 to −.23, ps < .01), but did not predict medication adherence at 3 and 9 months.... Findings underline the necessity of tracking various forms of psychological distress over time for CHD patients to promote medical adherence and further improve the disease prognosis."
Feig, E. H., et al. (2020). "Association of midlife status with response to a positive psychology intervention in patients with acute coronary syndrome." Psychosomatics: Journal of Consultation and Liaison Psychiatry.
"Across 164 participants, midlife participants showed larger improvements in depression, positive affect, and physical activity, but not anxiety or optimism, than older participants; session completion rates did not significantly differ. CONCLUSIONS: Midlife patients post-ACS may be particularly responsive to a telephone-delivered positive psychology intervention. Clinically, the post-ACS period may be uniquely motivating for midlife patients to improve their physical and psychological health."
Fulda, K. G., et al. (2021). "Physical aggression and coronary artery calcification: A north texas healthy heart study." International Journal of Behavioral Medicine.
"Regression analyses indicated that only the physical aggression parameter was related to CAC: a 5% increase in odds of CAC presence was indicated for every point increase in physical aggression. The association remained significant in adjusted analyses. Other factors associated with CAC in adjusted analyses included: age, gender, race/ethnicity, BMI, and dyslipidemia.... Psychosocial factors, such as physical aggression, are emerging factors that need to be considered in cardiovascular risk stratification."
García-Encinas, A., et al. (2020). "Predictors of posttraumatic stress symptoms and perceived health after an acute coronary syndrome: The role of experiential avoidance, anxiety sensitivity, and depressive symptoms." Psychology & Health 35(12): 1497-1515.
"Anxiety sensitivity and depressive symptoms but not experiential avoidance contributed significantly to posttraumatic stress symptoms. Depressive symptoms and posttraumatic symptoms but neither anxiety sensitivity nor experiential avoidance had a significant association on perceived health. Acute coronary syndrome posttraumatic symptoms significantly mediated the association of depressive symptoms with perceived health. That is, increased depressive symptoms was significantly associated with higher levels of posttraumatic symptoms, which in turn predicted lower levels of perceived health."
Gerber, M. R., et al. (2018). "Association between mental health burden and coronary artery disease in U.S. women veterans over 45: A national cross-sectional study." Journal of Women's Health 27(3): 238-244.
“Women Veterans over age 45 accessing VA care exhibited a high degree of mental health burden, which is associated with elevated odds of CAD; those with depression alone had 60% higher odds of CAD. For women Veterans using VA, mental health diagnoses may act as CAD risk factors that are potentially modifiable. Novel interventions in primary care and men
tal health are needed to address heart disease in this growing and aging population.”
Gentile, C., et al. (2021). "Mindfulness-based stress reduction in older adults at risk for coronary artery disease: A pilot randomized trial." Clinical Gerontologist: The Journal of Aging and Mental Health.
"Completion rate of MBSR was 72% and overall attendance was 96%. Reported benefits included increased relaxation, greater interpersonal connection, and increased body awareness. MBSR led to a decrease of 15% in LDL cholesterol and 10% in total cholesterol versus 4.5% and 1%, respectively, in the waitlist. Within group analyses showed notable decreases in LDL, triglycerides, and waist circumference post-MBSR and 2 months later."
Gomez, M. A., et al. (2020). "Psychological stress, cardiac symptoms, and cardiovascular risk in women with suspected ischaemia but no obstructive coronary disease." Stress and Health: Journal of the International Society for the Investigation of Stress 36(3): 264-273.
"Results showed that home/work stress predicted greater depression, functional impairment, CAD symptoms, and lower self-rated health in WISE but was inconsistent as a predictor in WISE-CVD. In contrast, >60% of WISE-CVD women reported moderate or severe financial stress. Financial stress levels predicted more CAD risk factors and cardiac symptoms, poorer self-rated health, and greater depression and functional impairment. Among women with INOCA, psychological stress was associated with CAD symptoms and CAD risk factors."
Husain, M. I., et al. (2019). Depression and congestive heart failure: A large prospective cohort study from Pakistan. Netherlands, Elsevier Science. 120: 46-52.
“The rate of depression was high among Pakistani patients with CHF. Severity of depression correlated with increased mortality.”
Khan, A., et al. (2020). "Association of depressive symptom severity with coronary artery calcium: The Dallas Heart Study." J Affect Disord 276: 267-271.
"Regression results indicated that QIDS does not statistically significantly predict whether one does or does not have CAC, when controlling for age, sex, and ethnicity.... Depressive symptoms were not associated with presence or severity of CAC in a multiethnic population based sample."
Khandaker, G. M., et al. (2019). "Shared mechanisms between coronary heart disease and depression: Findings from a large uk general population-based cohort." Molecular Psychiatry: published online in advance of print.
“Our analyses suggest that comorbidity between depression and CHD arises largely from shared environmental factors. IL-6, CRP and triglycerides are likely to be causally linked with depression, so could be targets for treatment and prevention of depression.”
Kong, D., et al. (2022). "Gender-based depression trajectories following heart disease onset: Significant predictors and health outcomes." Aging & Mental Health 26(4): 754-761.
"Longitudinal course of depression following onset of heart disease is heterogeneous in later life. Unfavorable depression trajectories (i.e. moderate, chronic, and emerging) were associated with higher disability risk compared to the minimal depression trajectory. Study findings characterize risk stratification regarding depression after heart disease onset, which can inform the development of interventions to improve health outcomes among older adults with heart conditions."
Lee, S. Y., et al. (2022). "Perceived posttraumatic growth in cardiac patients: A systematic scoping review." Journal of Traumatic Stress: published online in advance of print.
"The findings suggested that appraisal and coping may mediate and psychosocial resources (e.g., social support) may moderate the effects of a cardiac condition on PPTG."
Lin, P., et al. (2018). "Type D personality, but not Type A behavior pattern, is associated with coronary plaque vulnerability." Psychology, Health & Medicine 23(2): 216-223.
“Our results show that Type D personality was associated with plaque vulnerability, independent of clinical factors. Measurement of negative affectivity and social inhibition will increase our understanding of the progressive phase of the plaque vulnerability, which can contribute to the early identification of high risk patients and reduce the incidence of MACE.”
Lin, S., et al. (2018). The association between depression and coronary artery calcification: A meta-analysis of observational studies. Journal of Affective Disorders, 232: 276-282.
“Our study indicated that diagnosed depression was associated with higher odds of CAC. Systematic screening for CAC may be useful to identify clinically depressed patients at higher risk of future cardiovascular diseases.”
Liu, R. T., Hernandez, E. M., Trout, Z. M., Kleiman, E. M., & Bozzay, M. L. (2017). Depression, social support, and long-term risk for coronary heart disease in a 13-year longitudinal epidemiological study. Psychiatry Research, 251, 36-40.
“Social support was found to moderate the relationship between depression and the occurrence of CHD 13 years later. Specifically, among individuals with low social support, depression was prospectively associated with CHD. In contrast, depression was not prospectively associated with CHD among individuals with high social support. The results indicate that social support may function as a resilience factor against the long-term cardiovascular risk associated with depression. Clinical interventions focusing on the development of social support systems are important not only for addressing depression itself, but also for associated long-term physical health outcomes.”
Liu, H., et al. (2019). Relationship between major depressive disorder, generalized anxiety disorder and coronary artery disease in the US general population. Journal of Psychosomatic Research, 119: 8-13.
“Existence of MDD/GAD, MDD, or GAD increase the risk of new-onset CAD. Positive change in MDD and GAD is associated with reduced risk of incident CAD, which highlights the importance of treating MDD and GAD in preventing the development of CAD”
Moazzami, K., et al. (2020). "Association between symptoms of psychological distress and cognitive functioning among adults with coronary artery disease." Stress and Health: Journal of the International Society for the Investigation of Stress.
"After adjusting for demographic and cardiovascular risk factors, a higher psychological distress score was independently associated with worse memory and executive functioning. Each standard deviation increase in psychological distress score was associated with 3% (95% confidence interval [CI], 1%–5%) to 5% (95% CI, 3–7%) worse cognitive performance (higher Trail A and Trail B, and lower verbal and visual memory scores). Among individuals with CAD, a higher level of psychological distress is independently associated with worse cognitive performance. These findings suggest that psychological risk factors play a role in cognitive trajectories of persons with CAD."
Moradi, M., et al. (2022). "The effect of cognitive-behavioral therapy on death anxiety and depression in patients with heart failure: A quasi-experimental study." Perspectives in Psychiatric Care: published online in advance of print.
"The overall scores of death anxiety and depression in posttest were significantly lower than those at the follow-up stage in the intervention group.... CBT could significantly reduce death anxiety and depression in patients with heart failure. Therefore, it is recommended to equip nurses with CBT trainings to manage patients with heart failure better."
Natt och Dag, Y., et al. (2022). "Life satisfaction and coronary atherosclerosis: The SCAPIS study." Journal of Psychosomatic Research 152.
"In this population-based sample, life satisfaction was associated with better coronary artery health. However, this association was largely explained by cardiovascular risk factors, indicating that life satisfaction is linked to coronary atherosclerosis through a decreased load of cardiovascular risk factors."
Nejati, M., et al. (2020). "Comparison of the effectiveness of cognitive-behavioral group intervention for coronary heart disease and cognitive therapy in groups on type d personality and psychological distress on coronary heart patients- a randomized clinical trial." Current Psychology: A Journal for Diverse Perspectives on Diverse Psychological Issues.
"The results showed that there was no statistically significant difference in TDP and depression variables between CTG and GBGI-CHD treatments (P > 0.05). But there was a significant difference in anxiety and stress between CTG and CBGI-CHD Treatments (P ≤ 0.05). CTG is more effective in reducing anxiety and stress than GBGI-CHD. Finally, it’s possible to conclude that both CTG and GBGI-CHD are useful interventions in patients with CHD. However, the effect of CTG was more important than GBGI-CHD in anxiety and stress variables."
Oldham, M. A., et al. (2018). "Depression predicts delirium after coronary artery bypass graft surgery independent of cognitive impairment and cerebrovascular disease: An analysis of the neuropsychiatric outcomes after heart surgery study." The American Journal of Geriatric Psychiatry: published online in advance of print
“We established that the risk of delirium attributable to depression extends beyond the potential moderating influence of cognitive impairment and cerebrovascular disease alone. Even mild depression and cognitive impairment before CABG deserve recognition for their effect on post-CABG cognitive health.”
Oldham, M. A., et al. (2018). "Cognitive outcomes after heart valve surgery: A systematic review and meta-analysis." Journal of the American Geriatrics Society 66(12): 2327-2334.
“Heart valve surgery is associated with cognitive decline over the 6 months after surgery, but outcomes beyond 6 months are unclear. These findings highlight the cognitive vulnerability of this population, especially older adults with aortic stenosis.”
Oldham, M. A., et al. (2020). "Depression predicts cognitive and functional decline one month after coronary artery bypass graft surgery (neuropsychiatric outcomes after heart surgery study)." International Journal of Geriatric Psychiatry.
"CDR-SB decline occurred in 18 (14.5%) subjects. Older age, depression, baseline CDR-SB, and postoperative delirium were associated with 1-month decline on univariate analysis. Older age (OR 1.1 [1.0–1.2]) and depression (OR 6.2 [1.1–35.0]) remained significant on multivariate regression. In separate models, baseline performance on visual Wechsler memory scale (delayed), Hopkins verbal learning test (immediate and delayed), controlled oral word fluency test, and Trails B predicted CDR-SB decline....Roughly one in seven patients experienced CDR-SB decline 1 month after CABG surgery. Also, preoperative depression deserves recognition for being a predictor of CDR-SB decline one month post-CABG."
Ossola, P., et al. (2018). Anxiety, depression, and cardiac outcomes after a first diagnosis of acute coronary syndrome. Health Psychology, 37: 1115-1122.
“Developing a first-ever depressive episode, in a proportional hazard model, was associated with almost 3 times the risk of a recurrent cardiac event (odds ratio = 2.590, 95% confidence interval [CI] [1.321, 5.078], p = .006). Furthermore, a moderation analysis revealed that increasing levels of baseline anxiety had opposing effects on cardiac outcomes, being protective only in those who did not develop incident depression (B = −0.0824, 95% CI [−0.164, −0.005], p = .048)…. Our results confirm the detrimental effect of depression on cardiac prognosis in a selected population and suggest that anxiety after the first diagnosis of ACS might have different roles depending on the illness’ course.”
Oyeyemi, D. M., et al. (2022). "Relationship between depression/anxiety and cognitive function before and 6 weeks after major non-cardiac surgery in older adults." Journal of Geriatric Psychiatry and Neurology 35(1): 145-154.
"Greater depression and anxiety severity were each associated with poorer cognitive performance both before and after surgery in older adults. Yet, neither baseline depression or anxiety symptoms, nor postoperative change in these symptoms, were associated with postoperative cognitive change."
Parker, G. B., et al. (2019). Depression and poor outcome after an acute coronary event: Clarification of risk periods and mechanisms. Australia/New Zealand Journal of Psychiatry, 53: 148-157.
“Lifetime depression may increase the risk of depression around the time of an acute coronary syndrome but not influence cardiac outcomes. We suggest that poor sleep quality may be causal or indicate high anxiety/neuroticism, which increases risk to depression and contributes to poor cardiac outcomes rather than depression being the primary causal factor.”
Presciutti, A., et al. (2022). "Mindfulness is inversely associated with psychological symptoms in long-term cardiac arrest survivors." Journal of Behavioral Medicine: published online prior to print.
"Mindfulness was inversely associated with psychological symptoms in long-term CA survivors"
Raykh, O. I., et al. (2020). "Association of type D personality and level of coronary artery calcification." Journal of Psychosomatic Research 139.
"CAC score differed significantly between the groups: 689.3 ± 53.7 in patients with type D and 546.5 ± 47 without type D (p = 0.04). The greatest differences of calcium score were found in the left coronary artery system, namely left anterior descending artery (p = 0.01) and circumflex artery (p = 0.03). Patients with type D had higher levels of clinically significant anxiety (p = 0.04) and depression (p = 0.02). Type D personality is associated with high levels of CAC score independently from age, sex, diabetes mellitus status, smoking, alcohol consumption, body mass index, arterial hypertension status, cholesterol level, history of brain stroke, myocardial infarction, coronary artery disease, HADS-A and HADS-D scores....Type D personality is associated with higher average values of the CAC score, and type D may represent a potentially modifiable risk factor CAD. But it is unclear whether type D can affect the progression of CAC score."
Shen, B.-J., et al. (2019). "Depression, anxiety, perceived stress, and their changes predict greater decline in physical health functioning over 12 months among patients with coronary heart disease." International Journal of Behavioral Medicine: published online prior to print.
“Perceived social support predicted greater improvement in physical functioning at 12 months (β = 0.13, p = 0.050), but it did not buffer impact of psychological distress…. Findings underscore the importance of monitoring various forms of psychological distress continuously over time for CHD patients.”
Shestakova, M. V., et al. (2019). "Cognitive impairment and treatment compliance in patients with chronic heart failure." Neuroscience and Behavioral Physiology 49(4): 429-433.
“Treatment regime violations were seen in 62% of cases. Decreases in compliance were associated with increases in the severity of subcortical (frontal lobes) and periventricular leukoaraiosis, slowing of decision-taking processes (increases in the latency of the ERP P300 peak), and degradation of test performance for assessment of speech activity, optical-spatial, frontal-dysregulatory functions, and memory. Among patients with low treatment compliance, 58% showed frontal-dysregulatory cognitive disorders, 21% combined disorders, and 40% amnestic disorders. Risk factors for progression of cognitive disorders and low treatment compliance were a reduced fractional output and the restrictive type of diastolic cardiac dysfunction.”
Sin, N. L., et al. (2016). "Direction of association between depressive symptoms and lifestyle behaviors in patients with coronary heart disease: The heart and soul study." Annals of Behavioral Medicine.
"Among patients with coronary heart disease, depressive symptoms were linked to a range of lifestyle risk factors and predicted further declines in physical activity, medication adherence, and sleep quality."
Stewart, T. L., et al. (2016). "Attributing heart attack and stroke to "old age": Implications for subsequent health outcomes among older adults." Journal of Health Psychology 21(1): 40-49.
"Endorsement of 'old age' as a cause of heart attack/stroke negatively predicted lifestyle behavior change, and positively predicted frequency of physician visits and likelihood of hospitalization over the subsequent 3 years."
Suchy-Dicey, A., et al. (2022). "Psychological and social support associations with mortality and cardiovascular disease in middle-aged american indians: The strong heart study." Social Psychiatry and Psychiatric Epidemiology: The International Journal for Research in Social and Genetic Epidemiology and Mental Health Services: published online in advance of print publication.
"Depression symptoms were correlated with anger, cynicism, poor quality of life, isolation, criticism; better social support was correlated with lower cynicism, anger, and trauma. Adjusted time-to-event regressions found that depression, (poor) quality of life, and social isolation scores formed higher risk for mortality and cardiovascular events, and social support was associated with lower risk. Social support partially explained risk associations in causal mediation analyses.ConclusionAltogether, our findings suggest that social support is associated with better mood and quality of life; and lower cynicism, stress, and disease risk—even when said risk may be increased by comorbidities."
Tran, H. V., et al. (2019). Clinically significant ventricular arrhythmias and progression of depression and anxiety following an acute coronary syndrome. Journal of Psychosomatic Research, 117: 54-62.
“The average age of the study population (n = 2074) was 61.1 years, 33.5% were women, and 78.3% were white. VAs developed in 105 patients (5.1%). Symptoms of depression and anxiety were present in 22.2% and 23.5% of patients at baseline, respectively, and declined to 14.1% and 12.6%, respectively, at 1-month post-discharge. VAs were not significantly associated with the progression of symptoms of depression (adjusted relative risk [aRR] = 1.29, 95% confidence interval [CI] = 0.94–1.77) and anxiety (aRR = 1.22, 95% CI = 0.86–1.72), or with change in average scores of PHQ-2 and GAD-2 over time, both before and after risk adjustment…. The prevalence of symptoms of depression and anxiety was high after an ACS but declined thereafter and may not be associated with the occurrence of major in-hospital VAs.”
Vaillancourt, M., et al. (2022). "Severity of psychological distress over five years differs as a function of sex and presence of coronary artery disease." Aging & Mental Health 26(4): 762-774.
" Women with CAD reported more symptoms of depression compared to other participants at both evaluations (p’s s p = 0.001). CAD women fell within the clinical range for depression (p p = 0.001), and stress (p = 0.030) more frequently compared to others at T1, and for depression (p = 0.009) and stress (p = 0.002) at T2. Conclusions: The evolution of patient distress differed as a function of the measure examined, their sex, and/or CV status. While psychological distress was prevalent among these patients with diverse health conditions, women with CAD were particularly and chronically vulnerable."
Vargas, E. A., et al. (2022). "Psychosocial profiles and longitudinal achievement of optimal cardiovascular risk factor levels: The Coronary Artery Risk Development in Young Adults (CARDIA) study." Journal of Behavioral Medicine 45(2): 172-185.
"Eleven psychosocial variables reflecting psychological health, personality traits, and social factors were included. Optimal levels were deemed achieved if: Hemoglobin A1c (HbA1c) < 7.0%, low-density lipoprotein (LDL) cholesterol < 100 mg/dl, and systolic blood pressure (SBP) < 140 mm Hg. Latent profile analysis revealed three psychosocial profile groups “Healthy”, “Distressed and Disadvantaged” and “Discriminated Against”. There were no significant differences in achievement of CVDRF levels of the 3 targets combined across profiles. Participants in the “Distressed and Disadvantaged” profile were less likely to meet optimal HbA1c levels compared to individuals in the “Healthy” profile after demographic adjustment. Associations were attenuated after full covariate adjustment. Distinct psychosocial profiles exist among individuals with CVDRF, representing meaningful differences."
Wittbrodt, M. T., et al. (2019). "Early childhood trauma alters neurological responses to mental stress in patients with coronary artery disease." Journal of Affective Disorders 254: 49-58.
“Compared to ETI-, ETI + experienced greater (p p p < 0.005) positive correlations between brain activation and ETI-SR-SF scores were observed within the left hippocampus, bilateral frontal lobe, left occipital cuneus, and bilateral temporal lobe…. Early childhood trauma exacerbated activations in stress-responsive limbic and cognitive brain areas with direct and indirect connections to the heart, potentially contributing to adverse outcomes in CAD patients.”
Zhao, Z., et al. (2022). "Relationship between stressful life events and coronary plaque vulnerability among patients with acute coronary syndrome: A moderated mediation model of psychological distress and physiological indices." Psychology, Health & Medicine: published online prior to print.
"The moderated mediation model revealed that there were significant indirect effects of stressful life events on TCFA through total cholesterol, and the path between stressful life events and TCFA can be moderated by depression. Stressful life events increase the risk of vulnerable plaque in ACS patients. The relationship could be moderated by depression and mediated by physiological indices."