Strike, Philip Christopher; (2005) Psychosocial factors in the triggering of acute coronary syndromes. Doctoral thesis , UCL (University College London).

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Abstract

There is evidence that emotional and behavioural (psychosocial) factors influence the natural history of coronary artery disease (CAD) and the incidence of acute coronary syndromes (ACS). However there are many inconsistencies in the methodologies and results of existing studies, and carefully controlled data are scarce. This thesis examines the theoretical background and mechanisms by which psychosocial factors influence ACS. The evidence assessing timing and triggering of ACS, mental stress-induced myocardial ischaemia and the role of psychosocial factors in the development of CAD and ACS is examined. This information is used to identify areas in which there is currently a lack of knowledge and generate several hypotheses which are tested in three studies. Firstly, a prospective, multi-centre cohort study was performed, interviewing ACS patients within 4 days of hospital admission. Case-crossover methodology was used to assess the impact of acute psychosocial factors on ACS triggering. Increased relative risk of ACS following acute mental stress, anger or depression was demonstrated, and these factors interacted with social and temporal factors affecting ACS incidence. Clinical, electrocardiographic and biochemical correlates were also analyzed, and an increased incidence of ST segment elevation and greater release of markers of myocyte necrosis was observed in patients exposed to acute psychosocial triggers. Secondly a laboratory study was conducted to assess the effects of mental stress upon haemostatic and haemodynamic responses in CAD patients compared with age-matched healthy controls. This demonstrated abnormal blood pressure, peripheral resistance and platelet responses to mental stress in CAD patients. The third study examined psychobiological reactivity in a sub-set of patients from the first cohort study, assessing correlations between laboratory stress-reactivity, clinical findings and psychosocial exposure at ACS onset. This demonstrated that social deprivation affects haemodynamic and platelet psychobiological reactivity, and that patients with trigger-induced ACS display greater platelet stress-reactivity than controls. The implications of these findings for future research and therapeutic interventions are discussed.

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