Strengthening the Pillars of Cardiovascular Health: Psychological Health is a Crucial Component

The American Heart Association (AHA) recently updated its ‘Life’s Essential’ approach for maintaining cardiovascular health (CVH) in a Presidential Advisory that added sleep as an 8^th component to its previous ‘Life’s Simple 7.’¹ Equally important, the Advisory included a section devoted to the role of psychological health. In their review, the writing group affirmed that psychological health is “foundational…in achieving optimal and equitable CVH in the population.” More than 40 years of observational and experimental evidence reviewed by the group demonstrated to them the importance of psychological health factors in cardiovascular disease (CVD) risk, onset, and recurrence, along with opportunities they provide for “preserving and improving CVH.” The quality of this evidence has been formally recognized by the U.S. Preventive Services Task Force (USPSTF), and through consensus statements from professional organizations including AHA,² in which leaders in cardiovascular medicine have increasingly called for the inclusion of care related to psychological health in overall cardiovascular care. Yet, one conclusion from the Essential 8 writing group stands out:

“Psychological health is multidimensional, and at this time, it is not clear how best to combine measures of psychological health or which indicator(s) may be most important for influencing CVH.”¹

Thus, the writing group judged that while psychological health is “foundational”, pinpointing which aspect of psychological health to evaluate and on which to focus CVD risk mitigation strategies, requires further study. While we find these conclusions to be misplaced, we believe that the writing group provided a moment of reflection and recalibration for cardiovascular medicine providers and their partners from behavioral medicine whose shared concerns lie in how best to promote CVH.

Like physical health, the determination of psychological health is based on multiple factors – depression, anxiety, chronic and traumatic stress, and social integration – and each is independently associated with CVD risk and outcomes. Although dimensions of psychological health frequently overlap – for example, anxiety and social isolation often accompany depression or traumatic stress – seeking a combined measure ignores the strong evidence base concerning the CVD risk incurred by each factor alone. The approach described by Lloyd-Jones et al would be akin to using a single, combined measure of metabolic risk to represent elevated blood pressure, HbA1C, and blood lipids, which commonly co-occur. Yet, in the AHA’s ‘Life’s Simple’ and ‘Life’s Essential’ approaches, and in clinical practice, each component is measured individually, and each individual component is used to guide prevention and treatment. Indeed, the notion of a single metric that aggregates several psychological factors ‘under one roof’ would very likely overlook important factors that could also guide health and treatment recommendations for patients, providers, and policy makers.

For example, the USPSTF has recommended screening for depression and anxiety for preventive health among adults aged 19–64, because in their comprehensive review of the literature they found strong negative health consequences – including CVD and early CVD mortality – were associated with these psychological factors, individually.³ The value of this strategy – screening for, and managing both depression and anxiety – is supported by ample evidence from patients who are at an elevated risk for CVD.⁴ Moreover, the four-item Patient Health Questionnaire (PHQ-4) is an efficient tool to screen for both conditions, and this approach could be applied to both primary and secondary prevention in the service of CVH. A stepped algorithm that includes uniform screening with more comprehensive follow-up assessment and referral to counseling could be pursued as a second tier of management.⁵ This stepped approach is already used in other primary and specialty care settings, where it is shown to be feasible, acceptable, and translatable, and thus provides one avenue for inclusion now, of psychological health in the AHA’s ‘Life’s Essential’ approach.

The ‘Life’s Essential 8’ approach with – or without – inclusion of psychological health in an expansion to the ‘Life’s Crucial 9’ (Figure) for primary and secondary cardiovascular prevention, provides a way of focusing the attention of patients and providers. Yet, it does not provide an evidence-based path for delivering this type of care. We believe that doing so will require integrated care models. These care models, which in the primary care setting are shown to improve care, and reduce social inequities and healthcare costs, have yet to be developed and tested for cardiovascular patients. Since several components of the overall ‘Life’s Essential’ approach are behavioral in nature – getting adequate sleep and regular physical activity, maintaining a healthy diet, quitting tobacco – they must be informed by a proven-effective cardiovascular behavioral medicine evidence base.²

Figure. The proposed Life’s Crucial 9.

The ‘Life’s Crucial 9’ would add psychological health as another component to the American Heart Association’s ‘Life’s Essential 8.’

Thus, we believe that the focus of research should be on the development and testing of integrated cardiovascular care models that include management of psychological health. Doing so will require funding – from both government and private sectors – for implementation clinical trials that test different forms of integrated team-based care, which is matched to the various types of care systems and stages of cardiovascular prevention and intervention. We anticipate that these teams will involve specialists in cardiology, pharmacy, nursing, exercise physiology, and cardiovascular behavioral medicine, and require partnerships between clinical, institutional, patient, and community groups that mutually prioritize cardiovascular prevention, psychological health, and quality of life. As a complement to these well-designed and adequately powered trials, we also call for evidence derived from quasi-experimental research designs of policy-related interventions – e.g., capitation, pay-for-performance, or another strategy that moves us away from fee-for-service and siloed care – to complement the traditional randomized controlled trial.

Ultimately, there is no dispute in the strength of the evidence concerning psychological health and CVH, but rather how best to include ‘foundational’ psychological health within the AHA ‘Life’s Essential’ approach. While we appreciate that integrating psychological health within the overall ‘Life’s Essential’ approach presents challenges, we believe that sufficient evidence exists to meaningfully and actionably include this multi-factorial component in future clinical and implementation science efforts. As endorsed by the USPSTF, stepped screening and management of depression and anxiety should comprise a crucial 9^th dimension of cardiovascular care. Why let perfect be the enemy of good?