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CHAPTER 9
Behavioral Factors in Cardiovascular Disease
Lecture Outline
I. The Cardiovascular System
The cardiovascular system, consisting of the heart and blood vessels, transports blood
throughout the body, providing a means of delivering oxygen and nutrients and also removing
Cardiovascular disease is a general term that includes coronary artery disease, coronary
heart disease, and stroke.
A. The Coronary Arteries
The coronary arteries deliver blood to the myocardium, the heart muscle (see Figure
9.2). Their proximity to the heart muscle makes them vulnerable to damage. The formation
of atheromatous plaque restricts the flow of blood to the myocardium, resulting in
occlusion of the arteries called atherosclerosis (see Figure 9.3). Arteriosclerosis, sometimes
referred to as hardening of the arteries, describes the loss of elasticity of the arteries.
B. Coronary Artery Disease
The buildup of plaque in the coronary arteries causes coronary artery disease (CAD),
which may restrict the supply of blood to the myocardium and cause coronary heart disease
(CHD). This restriction can result in ischemia—that is, restricted blood flow to the heart.
C. Stroke
When atherosclerosis and arteriosclerosis affect the arteries that deliver blood to the
brain, stroke may occur (see Figure 9.5). A restriction of the blood supply to the brain or to
part of the brain results in the death of neurons and the loss of function performed by those
neurons.
D. Blood Pressure
The pumping action of the heart muscle exerts pressure on the blood vessels, and the
measure of blood pressure reflects the health of the cardiovascular system. Blood pressure is
measured by two numbers, systolic (pressure exerted by ventricular contractions) and
diastolic (pressure between contractions). Hypertension, high blood pressure, may result
from several different causes. Essential hypertension, or chronic elevation of blood
pressure, is a risk factor for cardiovascular disease (CVD) (see Figure 9.6). Systolic blood
pressure that exceeds 140 mg Hg is considered a risk factor for cardiovascular disease.
Hypertension may occur without symptoms, so many people who have hypertension are
unaware of either their condition or their risk for cardiovascular disease.
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II. Changing Rates of Cardiovascular Disease
Cardiovascular disease is the leading cause of mortality in the United States, but death rate
from cardiovascular disease is now slightly lower than it was in 1920 (see Figure 9.7). Currently,
34% of all deaths in the United States are from CVD.
A. Reasons for the Decline in Death Rates
The decline in cardiovascular death rates has been due mostly to two factors: better
medical care and healthier lifestyles. These altered lifestyles were prompted by results from
the Framingham Heart Study and the 1964 Surgeon General’s report on the dangers of
smoking.
B. Heart Disease Mortality throughout the World
The United States is but one of many industrialized countries that have experienced lower
III. Risk Factors in Cardiovascular Disease
Much information about risk factors for cardiovascular disease has come from two
studies—the Framingham Heart Study begun in 1948 and the 1964 Surgeon General’s report.
Results of the Framingham Heart Study and the 1964 Surgeon General’s report helped popularize
the concept of risk factor. Risk factors do not establish causation but simply provide information
concerning which conditions are associated with a particular disease. Risk factors include
inherent risks, physiological conditions, and various behavioral factors.
A. Inherent Risk Factors
Inherent risk factors result from genetic or physical conditions that cannot be changed
through modification of lifestyle.
1. Advancing Age
Advancing age is the primary risk factor for almost all diseases, including both
2. Family History
People who have a parent who has suffered from a heart attack are more likely to
3. Gender
Men now have a greater likelihood than women to develop heart disease before age
4. Ethnic Background
African Americans have nearly a twofold risk for cardiovascular deaths compared to
B. Physiological Conditions
Physiological risk factors include hypertension, serum cholesterol level, problems in
glucose metabolism, and inflammation.
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1. Hypertension
2. Serum Cholesterol Level
High serum cholesterol levels are a serious risk factor for CVD. Serum cholesterol
3. Problems in Glucose Metabolism
People who have Type 1 or Type 2 diabetes are more likely to die of heart disease
4. Inflammation
Inflammation is one of the responses of the immune system. Chronic inflammation
1. Smoking
Smoking is the leading behavioral risk factors for cardiovascular disease; smoking
2. Weight and Diet
Diet is separate from obesity as a risk factor for cardiovascular disease. Indeed,
3. Physical Activity
The benefits of physical activity are well established in protecting against CVD, and
physical inactivity is a risk. The risks that come from inactivity apply throughout the
entire lifespan.
D. Psychosocial Factors
The psychosocial factors of educational and income level, marriage and social support,
stress, anxiety, depression, cynical hostility, and anger have some relationship to CVD.
1. Educational Level and Income
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Low educational level and low income are risk factors for heart disease. Both men
and women with low educational levels are at risk, which may link to CVD risk through
2. Social Support and Marriage
3. Stress, Anxiety, and Depression
Stress, anxiety, and depression are positively related to cardiovascular disease, but
4. Hostility and Anger
In the 1950s, Friedman and Rosenman began doing research on a possible link
between CHD and the Type A behavior pattern, research that tended to support this
relationship for both men and women. However, since the mid-1980s, evidence for Type
A behavior as a coronary risk has become more complex and less supportive of the
original hypothesis.
a. Anger and Cardiovascular Reactivity
Anger may produce cardiovascular reactivity, which increases blood pressure.
African American men show higher cardiovascular reactivity than other groups,
which may relate to high blood pressure in this group. For other groups, no clear
picture has emerged concerning reactivity.
b. Suppressed Anger
Although expressing anger puts people at increased risk, suppressing anger is not
a healthy alternative. Research indicates that acknowledging one’s anger in a calm,
quiet, and controlled fashion seems to be the safest alternative.
IV. Reducing Cardiovascular Risks
Psychologists contribute to treating cardiovascular disease mainly by helping people change
behaviors to lower their risk for CVD.
A. Before Diagnosis: Preventing First Heart Attacks
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Most interventions to prevent heart disease center around reducing hypertension,
lowering serum cholesterol, and modifying psychological risk factors. However, getting
people to change behaviors is a challenge because people tend to have an optimistic bias,
leading them to believe that the risks do not apply to them.
1. Reducing Hypertension
Hypertension is difficult to reduce because feedback systems in the body act to
2. Lowering Serum Cholesterol
Serum cholesterol is also resistant to changes through behavioral means, and statin
drug therapies have become a very common intervention. However, these drugs should
be combined with a low-cholesterol diet and exercise rather than relying on drugs alone
3. Modifying Psychosocial Risk Factors
Some health psychologists have called for the development of behavioral cardiology
so that psychosocial risks could be the targets of interventions. For example, a number of
intervention programs have been designed to modify cynical hostility and anger,
including relaxation techniques, avoiding provocative situations, and the calm, slow
expression of anger.
B. After Diagnosis: Rehabilitating Cardiac Patients.
After people have been diagnosed with cardiovascular disease, they typically enter a
cardiac rehabilitation program to change their lifestyle and thereby avoid subsequent CVD.
Patients recovering from heart disease, as well as their spouses, often experience depression
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Exploring Health on the Web
With cardiovascular disease as the leading cause of death in the United States and other industrialized
countries, a great deal of information is available on the Internet about this disorder.
The National Heart, Lung, and Blood Institute is part of the U.S. National Institutes of Health,
and their webpage can be accessed through a link to that webpage or directly. The site for the National
Heart, Lung, and Blood Institute offers several interesting options under the Health Assessment Tools
option. One of the features is an assessment that gives a 10-year risk prediction for heart attack; another
assessment calculates body mass index. The site also contains tutorials and more technical information
oriented toward professionals.
Suggested Activities
Personal Health Profile—Assessing Heart Attack Risk
If you were to ask your students to predict their own cause of death, you might find that
the most frequently reported answer would be some form of unintentional injury. And indeed,
unintentional injuries are the leading cause of death for people under the age of 40. However,
most of your students will live past 40, and only a very few will die from an unintentional injury.
Unless your students are quite different from the total population, their most frequent cause of
death will be heart disease.
Although a risk factor analysis is not completely accurate in predicting cardiovascular
disease, this type of analysis can alert people who are at high risk for this and other chronic
diseases. Several Internet sites offer risk screenings. One is the National Heart, Lung, and Blood
Institute, which offers an online quiz based on information from the Framingham Heart Study.
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Heart Disease and Et hnicity
Your students can gather information about the various ethnic groups in the United States
and their heart disease risks, trying to trace these risks according to the division in the textbook,
which includes inherent risks (such as age), physiological conditions (such as hypertension),
behavioral factors (such as diet and exercise), and psychosocial factors (such as education and
income level). This division allows for an analysis of the types of risks that each ethnic group
experiences, which your students should try to connect to the degree of risk for the various ethnic
groups. For example, Hispanic Americans tend to have low educational and income levels but do
not experience the rate of heart disease that African Americans do. Are their behavioral risks
lower?
Cholesterol Level and Fat Intake
The relationship between dietary cholesterol and serum cholesterol is far from perfect,
but this correlation is positive. Students will be better informed of their CVD risks if they knew
both pieces of information. Cholesterol testing is no longer inaccessible or expensive. Although
the testing procedure that reveals the components of cholesterol is more expensive, this
information is more useful in determining CVD risk. Urge your students to have their cholesterol
tested so that they will know at least their total cholesterol levels.
Designing a Low-Fat Diet
The American Heart Association recommends a diet in which no more than 30% of
calories come from fat, but many people do not adhere to these recommendations. Young people
are particularly likely to ignore dietary warnings, yet the basis for coronary artery disease begins
during adolescence and young adulthood. Beginning a healthy diet during the college years is a
good prevention strategy.
You may wish to have your students design a diet that would provide 30% or less of its
calories from fat. Information about the fat and calories in foods is readily available on produce
labels, and many restaurants have this information available on request. Thus, you can assign
your students the project of designing a diet that follows these recommendations for fat content.
Make the activity realistic by instructing them to choose a diet that they would find acceptable
and would eat. This diet is what they should be eating, so have them compare this heart-healthy
diet to their typical diet.
Understanding Cardiac Rehabilitation
To help your students understand the ramifications of surviving a heart attack, invite a
cardiac rehabilitation patient to talk to your class. About half of the people who have a heart
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attack survive, so finding a person who is following a cardiac rehabilitation program should not
be difficult. However, try to find someone who is willing to be forthright about the experience of
having a heart attack, including the negative and positive aspects. Many of those who have a heart
attack also have coronary bypass surgery, and such a patient would be a good choice.
Urge your students to ask about lifestyle changes and how difficult making those changes
proved to be. Also talk about the psychological aspects of recovery and determine if the cardiac
rehabilitation program that this patient is following includes psychologists as part of the team.
Knowing the Signs of Stroke
Stroke is the third most frequent cause of death in the US. The main treatment for
Several studies examine the factors that influence whether stroke patients seek medical care.
Students may be interested in reading some of these studies, listed below.
Citations:
Schroeder, E. B., Rosamond, W. D., Morris, D. L., Evenson, K. R., & Hinn, A. R. (2000).
Determinants of Use of Emergency Medical Services in a Population With Stroke Symptoms
The Second Delay in Accessing Stroke Healthcare (DASH II) Study. Stroke, 31(11), 2591-2596.
Kleindorfer, D., Lindsell, C. J., Moomaw, C. J., Alwell, K., Woo, D., Flaherty, M. L., …
& Kissela, B. M. (2010). Which stroke symptoms prompt a 911 call? A population-based study.
The American journal of emergency medicine, 28(5), 607-612.
Type A Behavioral Pattern
One scale to Type A behavioral pattern is Bortner’s scale (1969). Although the
instructions ask students to mark on the line, you can simply have students pick which of each
two options describes them better. The items descriptive of Type A behavioral pattern are: 1)
Citation: Bortner, R. W. (1969). A short rating scale as a potential measure of pattern A
behavior. Journal of chronic diseases, 22(2), 87- 91.
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Video Recommendations
From Fanlight Productions:
The Angry Heart (2001) examines the role of racism in heart disease, featuring a 42-year-old
African American man who has experienced heart attacks and heart surgery.
From Films for the Humanities & Sciences:
Life After Heart Attack (2006) presents the changes that occur after a person has a heart attack,
spotlighting lifestyle modifications and adherence to medications and giving the message that
rehabilitation can be successful.
Videos from the Web:
Multiple Choice Questions
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1. The circulation of blood permits
a. the transportation of oxygen to body cells.
b. the removal of carbon dioxide from cells.
c. both a and b.
d. neither a nor b.
2. Coronary arteries
a. carry blood from the heart to the remainder of the body.
b. carry blood from the body’s extremities to the heart.
c. furnish blood to the heart.
d. furnish blood to the brain.
3. The disorder that includes the formation of plaque in the arteries is
a. angina pectoris.
b. atheromatous fatigue.
c. atherosclerosis.
d. arteriosclerosis.
4. A more technical name for “hardening of the arteries” is
a. angina pectoris.
b. atherosclerosis.
c. arteriosclerosis.
d. ischemia.
5. Restriction of blood flow is called
a. arteriosclerosis.
b. ischemia.
c. arrhythmia.
d. an embolism.
6. Atherosclerosis may affect blood supply in any part of the body, but it is most dangerous
when it affects
a. veins in the extremities.
b. arteries in the extremities.
c. any veins.
d. coronary arteries.
7. Coronary artery disease differs from coronary heart disease
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a. in terms of severity—coronary artery disease is more severe than coronary heart
disease.
b. in terms of the location of the damage—coronary artery disease refers to plaque in
the arteries, whereas coronary heart disease involves damage to the myocardium.
c. in terms of the number of people affected—many more people have coronary
heart disease than coronary artery disease.
d. in no identifiable way.
8. Myocardial infarctions
a. are commonly known as heart attacks.
b. are seldom life threatening, but serve as a signal of possible heart disease.
c. result from loss of oxygen to the brain.
d. none of these.
9. What is the system that consists of the heart, arteries, and veins?
a. Musculoskeletal
b. Cardiovascular
c. Endocrine
d. Immune
10. ______ carry oxygenated blood from the heart to various parts of the body, whereas
______ moves deoxygenated blood toward the heart.
a. Veins; arteries
b. Arteries; capillaries
c. Arteries; veins
d. Veins; arterioles
11. Mike’s doctor tells him that his arteries have hardened. The more technical term for this
would be
a. atherosclerosis
b. arteriosclerosis
c. myocardium
d. cardiac attack
12. What is the term that refers to any damage to the myocardium as a result of insufficient
blood supply?
a. coronary heart disease
b. coronary artery disease
c. stroke
d. hypertension
13. Bob is experiencing dizziness, nausea, a squeezing pain in his chest, and cold sweating.
He is likely experiencing symptoms for
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a. hypertension
b. angina pectoris
c. a stroke
d. a myocardial infarction
14. Beth had difficulty breathing and a crushing pain in her chest. However, it only lasted a
few seconds. Beth likely was experiencing symptoms for
a. hypertension
b. angina pectoris
c. a stroke
d. a myocardial infarction
15. The third most frequent cause of death is _______, which is the result of oxygen
deprivation to the brain.
a. hypertension
b. angina pectoris
c. a stroke
d. a myocardial infarction
16. For blood pressure, _______ pressure represents pressure generated by the heart’s
contractions and _______, pressure represents pressure experienced between
contractions.
a. diastolic, systolic
b. diastolic, presystolic
c. systolic, diastolic
d. presystolic, diastolic
17. Millions of Americans have abnormally high blood pressure, or __________.
a. hypertension
b. angina pectoris
c. a stroke
d. a myocardial infarction
18. Approximately ________ of Americans have hypertension.
a. one-third
b. one-fourth
c. one-half
d. two-thirds
19. In younger individuals, _____ pressure is most strongly related to cardiovascular risk, but
in older individuals _______ pressure is more indicative of cardiovascular risk.
a. diastolic, systolic
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b. diastolic, presystolic
c. systolic, diastolic
d. presystolic, diastolic
20. A disorder characterized by a restriction of oxygen to the heart, a sensation of crushing
pain, and a difficulty in breathing but no loss of consciousness or damage to myocardium
is
a. stroke.
b. arrhythmia.
c. heart attack.
d. angina pectoris.
21. Stroke is the result of deprivation of oxygen to the ______, and a similar restriction to the
______ causes heart attack.
a. brain . . . myocardium
b. cerebrum . . . cerebral arteries
c. heart . . . lungs
d. central nervous system . . . peripheral nervous system
22. Darlene‘s current blood pressure is 149 over 95. This means that Darlene has
a. low blood pressure.
b. prehypertension.
c. Stage 1 hypertension.
d. Stage 2 hypertension.
23. For an adult, blood pressure of 190/130 would be
a. normal.
b. prehypertension.
c. Stage 1 hypertension.
d. Stage 2 hypertension.
24. The single best predictor for heart attack and stroke is
a. obesity.
b. hypertension.
c. high cholesterol.
d. lack of exercise.
25. Including both heart disease and stroke, a little over _____ % of deaths in the U.S. are
due to cardiovascular disease.
a. 20
b. 30
c. 70
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d. 85
26. Since 1960, death rates from cardiovascular disease have
a. increased gradually.
b. increased sharply.
c. decreased dramatically.
d. remained about the same.
27. The decline in deaths from cardiovascular disease during the last four decades of the 20th
century was due to
a. better dietary practices.
b. reduction in cigarette smoking.
c. improvements in medical care.
d. all of these.
28. Beginning in the early 1990s, death rates from cardiovascular disease
a. have been quite consistent throughout all the nations of the world.
b. dropped faster in Eastern Europe than in the United States.
c. have been higher for Russian women than for Russian men.
d. increased drastically in Russia and other former Soviet Union countries.
29. The 1964 Surgeon General’s report on the dangers of smoking was one of the studies that
led to widespread lifestyle changes and lowering of cardiovascular disease rates. The
other influential study was
a. the 1965 Surgeon General’s report.
b. the Alameda County Study.
c. the Framingham Heart Study.
d. the Chattanooga Cardiovascular Prevention Trial.
30. If a diet high in salt-cured foods is an established risk factor for hypertension, then
a. this type of diet is negatively correlated with hypertension.
b. this type of diet is a predictor of hypertension.
c. salty foods are a definitive cause of hypertension.
d. salt restriction may or may not be advised for those who are at risk for developing
hypertension.
31. Bill Clinton, whose story introduced this chapter, had some family history of heart
disease and had eaten a high-fat diet for many years of his life. Which of his risks would
be an inherent cardiovascular risk factor for the former President?
a. his high-stress job as President
b. his gender
c. his history of being overweight