1 stress, health and performance: the heart of the matter csahu symposium 2009 bruce c. wilson, md...
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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
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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
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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
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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
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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)
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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)
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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
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)
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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
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
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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%
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The Real CostsThe Real Costs
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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.
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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
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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?
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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.
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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
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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)
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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%
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• 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
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$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
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Questions?