While people with the aggressive, competitive personality traits known as Type A behavior have an increased risk of developing heart disease, new evidence suggests that they are also likely to survive a heart attack better than their calmer -- and slower-paced -- Type B counterparts.
Recent findings from a 22-year research project found that Type A's were twice as likely as Type B's to develop coronary heart disease, Dr. Ray H. Rosenman reported at a special symposium on the interactions between the heart and the brain at the American Psychiatric Association's annual meeting here this week. Rosenman, associate chief of medicine at the Mt. Zion Hospital and Medical Center in San Francisco, wrote the study of 257 people with Dr. David Tagland and Dr. Richard Brand of the University of California at Berkeley.
Anxiety causes the release of adrenalin in the body, which "has adverse effects" for coronary heart disease, Rosenman says, and "can be a trigger for sudden death." Type A's are known for being anxious, stressed and almost always in a hurry, and this probably helps explain their special susceptibility to having a heart attack. The highly competitive nature found in Type A people also increases the likelihood that important warning signs of heart disease -- such as chest pains -- will be denied.
But Type A's "also survived better than Type B's," says Rosenman, who speculates that this may have something to do with the Type A's adeptness at denial.
Once a heart attack has occurred, Type A people tend to deny their symptoms, he says, and may be better at suppressing the health anxieties that often accompany recovery from a heart attack. With less anxiety there is less adrenalin release and a greater feeling of control over their lives -- something else that Type A's relish, Rosenman says.
"We're finding a rather complex interaction between the brain and the heart," says Dr. James W. Jefferson, a psychiatrist who heads the Center for Affective Disorders at the University of Wisconsin Center for Health Sciences in Madison.
Among the newest links between emotions and heart disease is an association between panic disorders and a cardiac abnormality known as mitral valve prolapse (MVP).
MVP involves a defect in the valve that separates the left upper chamber of the heart (the atrium) from the left lower chamber (the ventricle). Normally, the mitral valve opens and then snaps shut to prevent backward flow of blood. But with MVP, the valve does not shut completely and blood seeps backwards, causing a heart murmur. Between 6 and 20 percent of Americans have MVP, estimates the American Heart Association. It is about twice as common in women as in men.
People who suffer from panic attacks may be at increased risk of developing one type of MVP, suggest new studies by Dr. David L. Dunner and Dr. Robert Reichler of the University of Washington in Seattle. "There are different types of MVP, and most of them are cardiac-related, not anxiety-related," Dunner said in an interview. "But in patients who have an anxiety disorder and not intrinsic heart disease, the cause of MVP might be reversible by treating the anxiety disorder."
"Our suggestion is that having an anxiety attack causes a lot of cardiac stress and blows out the mitral valve," says Donner, who has a grant from the National Institute of Mental Health to study MVP and panic or anxiety disorders. On-going studies of panic attack patients and their children support the theory that these attacks of anxiety and panic can, over time, trigger the development of MVP.
"There needs to be more interaction between cardiology and psychiatry," Donner says.
Another area of overlap between psychiatry and cardiology is in the treatment of heart attack victims. Dr. Thomas P. Hackett, chief of psychiatry at the Massachusetts General Hospital in Boston, described the two- or three-month long depression that cardiac patients commonly experience following a heart attack.
"Depression is a universal response to heart attacks," says Hackett. "It occurs in virtually everybody." Typically the depression begins, he says, about three days after the attack, when the patients' relief at being alive is replaced by questions of whether they will be able to return to their normal activities.
After several weeks of bed rest in the hospital, the heart attack patient returns home in a weakened condition. Simple activities like walking around the yard take a lot of effort after so much bed rest -- a fact that the patient doesn't expect. "Often," Hackett says, "they being to wonder if my heart is worse off than they told me."
These feelings help fuel what Hackett calls "homecoming depression," a syndrome that closely parallels feelings of grief.
"The majority of people some 85 percent get over this depression in three months and go back to work," Hackett says. "But the period is very hard on the family and the patient.
"What heart attack patients are feeling is quite normal, yet if they had been told that they would feel this, they might not get as depressed. It really helps to let the family and the patient know that this kind of depression is not unique to them."