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Stress, Health and Performance: Stress, Health and Performance: The The Heart Heart of the Matterof the Matter

CSAHU Symposium 2009CSAHU Symposium 2009

Bruce C. Wilson, MDBruce C. Wilson, MD

Medical Director, HeartMathMedical Director, HeartMath

22

Psychological Stress and DiseasePsychological Stress and Disease

Sheldon Cohen, PhDDenise Janicki-Deverts, PhDGregory E. Miller, PhD

JAMA, October 10, 2007—Vol 298, No. 14 1685

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Psychological Distress as a Risk Factor for Psychological Distress as a Risk Factor for Cardiovascular EventsCardiovascular Events

Pathophysiological and Behavioral MechanismsPathophysiological and Behavioral Mechanisms Mark Hamer, PhD*, Gerard J. Molloy, PhD andMark Hamer, PhD*, Gerard J. Molloy, PhD and

Emmanuel Stamatakis, PhDEmmanuel Stamatakis, PhD

6576 Scottish men and women >306576 Scottish men and women >30Follow up 7 yearsFollow up 7 yearsStressed or depressed individuals at 50% greater CV riskStressed or depressed individuals at 50% greater CV riskRisk is mainly behavioralRisk is mainly behavioralSmoking and decreased activity 65% of riskSmoking and decreased activity 65% of riskRx: Behavior modificationRx: Behavior modification

JACCJACC.2008;52:2156-62.2008;52:2156-62

44

Terrorism, Acute Stress, and Cardiovascular HealthTerrorism, Acute Stress, and Cardiovascular Health

A 3-Year National Study Following the September 11th AttacksA 3-Year National Study Following the September 11th Attacks

E. Alison Holman, FNP, PhD; Roxane Cohen Silver, PhD; Michael Poulin, PhD;E. Alison Holman, FNP, PhD; Roxane Cohen Silver, PhD; Michael Poulin, PhD;Judith Andersen, PhD; Virginia Gil-Rivas, PhD; Daniel N. McIntosh, PhDJudith Andersen, PhD; Virginia Gil-Rivas, PhD; Daniel N. McIntosh, PhD

People without known heart disease who responded with People without known heart disease who responded with acute and ongoing stress to 9/11 had a 3-4x incidence of acute and ongoing stress to 9/11 had a 3-4x incidence of

cardiac events over 3 yearscardiac events over 3 years

Arch Gen PsychiatryArch Gen Psychiatry. 2008;65(1):73-80. 2008;65(1):73-80

55

Leor J et al. N Engl J Med 1996;334:413-419

Daily numbers of Deaths Listed by the Department of Coroner of Los Angeles County from January 10 through 23, 1991, 1992, 1993, and 1994

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Anxiety Characteristics Independently and Anxiety Characteristics Independently and Prospectively Predict Myocardial Infarction in MenProspectively Predict Myocardial Infarction in Men

The Unique Contribution of Anxiety Among The Unique Contribution of Anxiety Among Psychologic Factors Psychologic Factors

Biing-Jiun Shen, PhD*,*, Yael E. Avivi, MS , John F. Todaro, PhD , Avron Biing-Jiun Shen, PhD*,*, Yael E. Avivi, MS , John F. Todaro, PhD , Avron Spiro, III, PhD , Jean-Philippe Laurenceau, PhD Spiro, III, PhD , Jean-Philippe Laurenceau, PhD

Kenneth D. Ward, PhD and Raymond Niaura, PhDKenneth D. Ward, PhD and Raymond Niaura, PhD

Conclusions: Anxiety-prone dispositions appear Conclusions: Anxiety-prone dispositions appear to be a robust and independent risk factor of MI to be a robust and independent risk factor of MI

among older men.among older men.

JACC 2008; 51: 113-9JACC 2008; 51: 113-9

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Job Strain and Risk of Acute Recurrent Coronary Heart Job Strain and Risk of Acute Recurrent Coronary Heart Disease EventsDisease 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 More than 2 years of job stress doubles risk of events. Equivalent to smoking or high cholesterolor high cholesterol

JAMA. 2007;298:1652-1660.

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Prospective Study on Occupational Stress and Risk Prospective Study on Occupational Stress and Risk of Strokeof Stroke

TsutsumiTsutsumi A A, , Kayaba KKayaba K, , KarioKario K K, , Ishikawa SIshikawa S..

  Occupational stress related to job strain was associated with Occupational stress related to job strain was associated with 2x incident strokes among Japanese men (demand/control 2x incident strokes among Japanese men (demand/control model)model)

Arch Intern Med.Arch Intern Med. 2009 Jan 12;169(1):56-61. 2009 Jan 12;169(1):56-61.

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Living Alone After Myocardial InfarctionLiving Alone After Myocardial Infarction

Impact on PrognosisImpact on PrognosisRB Case, AJ Moss, N Case, M McDermott, S EberlyRB Case, AJ Moss, N Case, M McDermott, S Eberly

JAMA JAMA 1992;267;515-191992;267;515-19

1010

Marital Status, Marital Strain, and Risk of Coronary Marital Status, Marital Strain, and Risk of Coronary Heart Disease or TotalHeart Disease or Total

Mortality: The Framingham Offspring StudyMortality: 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 Differences exist for men and women regarding cardiovascular events and mortality in situations of marital conflictsituations of marital conflict

Psychosomatic Medicine 69:509–513 (2007)

1111

Negative Aspects of Close Relationships and Heart Negative Aspects of Close Relationships and Heart DiseaseDisease

Roberto De Vogli, PhD, MPH; Tarani Chandola, DPhil; Michael Gideon Roberto De Vogli, PhD, MPH; Tarani Chandola, DPhil; Michael Gideon

Marmot, PhD, FRCPMarmot, PhD, FRCP

There is an increased relative risk of cardiac events (1.3) in people There is an increased relative risk of cardiac events (1.3) in people

who are in poor relationships.who are in poor relationships.This is independent of other risk factors.This is independent of other risk factors.

.. Arch Intern Med.Arch Intern Med. 2007;167:1951-1957 2007;167:1951-1957

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Mortality after Bereavement:Mortality after Bereavement:A Prospective Study of 95,647 Widowed PersonsA Prospective Study of 95,647 Widowed Persons

JAAKKO KAPRIO, MD, MARKKU KOSKENVUO, MD, AND HELI RITA, MPOLSCJAAKKO KAPRIO, MD, MARKKU KOSKENVUO, MD, AND HELI RITA, MPOLSC

95,647 Finns widowed ’72-’7695,647 Finns widowed ’72-’76

7635 deaths in first week after spouse died (2X expected)7635 deaths in first week after spouse died (2X expected)

IHD leading cause of death in surviving spouseIHD leading cause of death in surviving spouse•Men RR = 2.3Men RR = 2.3•Women RR = 3.4Women RR = 3.4

Violent causes for first spouse=2X expected in first monthViolent causes for first spouse=2X expected in first month

Am J Public HealthAm J Public Health 1987; 77:283-287. 1987; 77:283-287.

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The Association of Anger and Hostility With Future The Association of Anger and Hostility With Future Coronary Heart DiseaseCoronary Heart Disease

A Meta-Analytic Review of Prospective EvidenceA Meta-Analytic Review of Prospective Evidence

Yoichi Chida, MD, PhD* and Andrew Steptoe, DPhilYoichi Chida, MD, PhD* and Andrew Steptoe, DPhil Meta-analysis of 44 studiesMeta-analysis of 44 studiesAnger, hostility associated with CHD eventsAnger, hostility associated with CHD events

•Initially healthy subjectsInitially healthy subjects•Pts with CADPts with CAD

Men>women (coping mechanisms?)Men>women (coping mechanisms?)Behaviors vs. Autonomic dysregulationBehaviors vs. Autonomic dysregulation

•Inflammation (CRP, IL-6,)Inflammation (CRP, IL-6,)•Hypercoagulability (fibrinogen)Hypercoagulability (fibrinogen) JACCJACC. 2009; 53:936-46. 2009; 53:936-46

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Depression and 18-Month Prognosis After Depression and 18-Month Prognosis After AcuteAcute Myocardial Infarction Myocardial Infarction

Nancy Frasure-Smith, PhD, Francois L’esperance, MD, Mario Talajik, MDNancy Frasure-Smith, PhD, Francois L’esperance, MD, Mario Talajik, MD

Depression following heart attack significantly increases the Depression following heart attack significantly increases the mortality over the next 18 months, and is correlated with mortality over the next 18 months, and is correlated with

abnormal heart beats (PVC’s), suggesting sudden death as a abnormal heart beats (PVC’s), suggesting sudden death as a mechanism.mechanism.

CirculationCirculation 1999;91:999-1005 1999;91:999-1005

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Copyright ©2005 American College of Cardiology Foundation. Restrictions may apply.

Rozanski, A. et al. J Am Coll Cardiol 2005;45:637-651

The risk ratios for traditional risk factors reported for men in the Framingham study (28)

1616

Copyright ©2005 American College of Cardiology Foundation. Restrictions may apply.

Rozanski, A. et al. J Am Coll Cardiol 2005;45:637-651

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)

1717

Copyright ©2005 American College of Cardiology Foundation. Restrictions may apply.

Rozanski, A. et al. J Am Coll Cardiol 2005;45:637-651

Pathophysiologic mechanisms by which chronic stress and affective disorders, such as depression, appear to promote atherosclerosis

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Anger Management May Save Your LifeAnger Management May Save Your Life

New Insights Into Emotional Precipitants of Ventricular New Insights Into Emotional Precipitants of Ventricular ArrhythmiasArrhythmias

Eric J. Rashba, MD, FACCEric J. Rashba, MD, FACC

Anger and other mental stress can cause T Wave Alternans Anger and other mental stress can cause T Wave Alternans and predict ventricular arryhthmiasand predict ventricular arryhthmias

JACCJACC 2009; 53:779-781 2009; 53:779-781

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The HERO StudyThe HERO StudyComparing Modifiable Health Risk Comparing Modifiable Health Risk

CostsCosts •22 organizations: Chevron, Marriott, Michigan, 22 organizations: Chevron, Marriott, Michigan, Hoffman-La Roche Inc.

•47,500 workers47,500 workers•HRAs and Health ClaimsHRAs and Health Claims

•High Blood PressureHigh Blood Pressure •DepressionDepression•DiabetesDiabetes•SmokingSmoking•StressStress

•ObesityObesity

•Lack of exerciseLack of exercise

2020

Percent Difference in Medical Percent Difference in Medical Expenditures:Expenditures:

High-Risk versus Lower-Risk High-Risk versus Lower-Risk EmployeesEmployees

Sedentary Lifestyle

10.4%

Blood Pressure

11.7%

Smoking

14.5%

Overweight

21.4%

Blood Sugar Control

34.8%

Stress

46.3%

Depression

70.2%

2121

The Real CostsThe Real Costs

2222

What We Know for SureWhat We Know for Sure

Nationally, total health plan average costs Nationally, total health plan average costs increased 6.7%, increased 6.7%, now totalnow total $7,983 per $7,983 per employee per year.employee per year.

In Wisconsin, annual per employee costs are In Wisconsin, annual per employee costs are $10,097$10,097

The cost of health care is still 1.5x higher The cost of health care is still 1.5x higher than overall inflation and worker earnings.than overall inflation and worker earnings.

Stress, and stress related diseases are the Stress, and stress related diseases are the driving force behind these increases AND we driving force behind these increases AND we have the ability to stop it.have the ability to stop it.

2323

Forces Driving Up CostsForces Driving Up Costs

Consolidation, consolidation, consolidationConsolidation, consolidation, consolidation• Insurance carriersInsurance carriers• Pharmacy companiesPharmacy companies• Providers Providers • HospitalsHospitals

Medical technology increases utilization as well Medical technology increases utilization as well as priceas price

Pharmacy costs: biotech, nanotech, specialty Pharmacy costs: biotech, nanotech, specialty and lifestyle drugsand lifestyle drugs

Baby Boomers raising average age of labor Baby Boomers raising average age of labor forceforce

Increased chronic disease states; stress and Increased chronic disease states; stress and stress-related diseasesstress-related diseases

2424

Employer Reactions: working or not Employer Reactions: working or not working?working?

Eliminate coverageEliminate coverage Cost shift to employeesCost shift to employees

• Increase contributionIncrease contribution• Increase deductibles, co-pays, co-insurance Increase deductibles, co-pays, co-insurance

Offer dual choice or only HDHPOffer dual choice or only HDHP Restrict eligibility and carve-out plansRestrict eligibility and carve-out plans

What Else Can They Do?What Else Can They Do?

2525

What Successful Companies Do What Successful Companies Do DifferentlyDifferently

High performers are significantly more aggressive High performers are significantly more aggressive and systematic in managing their health care and systematic in managing their health care programs.programs.

They identify problems early and take advantage They identify problems early and take advantage of opportunities for improvementof opportunities for improvement

They are the most competitive, profitable, and They are the most competitive, profitable, and growth focused companies of our time.growth focused companies of our time.

2626

High PerformingHigh Performing Cost increases at CPI Cost increases at CPI

(4%)(4%) Per employee per year Per employee per year

costs - $8,532costs - $8,532 High productivity and High productivity and

presenteeismpresenteeism High profits, culture of High profits, culture of

growthgrowth

Low PerformingLow Performing Cost increases over Cost increases over

CPI (10%+)CPI (10%+) Per employee per Per employee per

year costs - $10,200year costs - $10,200 High turnover, time High turnover, time

offoff High costs related to High costs related to

business, negative business, negative cultureculture

2727

What Employers Need to Know What Employers Need to Know FOR SURE…..FOR SURE…..

Recognize Recognize theythey are in the health care are in the health care businessbusiness

Embrace health strategies and Embrace health strategies and managementmanagement

Utilize data informatics to target your Utilize data informatics to target your highest cost areas: disease, turnover, highest cost areas: disease, turnover, productivityproductivity

Attack their biggest culprit -- Attack their biggest culprit -- STRESSSTRESS

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Are Positive and Negative Affect Independently Associated With Are Positive and Negative Affect Independently Associated With Health in a Representative Sample of the World?Health in a Representative Sample of the World?

Sarah D. Pressman1,2 , Matt W. Gallagher1, & Shane Lopez2

1University of Kansas, 2 Gallup

150,000 adults in 140 countries150,000 adults in 140 countries Represent 95% of world populationRepresent 95% of world population Positive emotions linked to better health even without food, Positive emotions linked to better health even without food,

sheltershelter Negative emotions associated with poor health outcomesNegative emotions associated with poor health outcomes

Published Research

American Journal of Cardiology

Journal of Stress Medicine

J. American College of Cardiology

Modern Healthcare

Harvard Business Review

Wall Street Journal

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

Selected Clients

High Cortisol:Low DHEA

• Obesity (Marin 1992)

• Diabetes (Nestler 1992)

• Hypertension (Shafagoj 1992)

• Heart Disease (Barrett-Connor 1986)

• Cancer (Bhatavdekar 1994)

• Alzheimer’s (Nasman 1995)

• HIV-related disease (Wisniewski 1993)

36

Case Study—Hormonal Changes

0

50

100

150

200

250

before after

nM

0

2

4

6

8

10

12

14

before after

ng/

ml

DHEAS Total Free Cortisol

n=28

23%23%100%100%

37

• Source of the heart beatis within the heart.

• Generates 40 to 60 timesmore electrical amplitudethan the brain.

• Its electrical signal can bemeasured anywhere on thebody.

The Heart• Source of the heartbeat is within the heart.

• Generates 40 to 60 times more electrical amplitude than the brain.

• Its electrical signal can be measured anywhere on the body.

The Heart

© 2004 HeartMath LLC40

Changing Heart Rhythms

49

$1179

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

55

Questions?