I recall a moment in 1984 when my MD supervisor, the late Professor Robert Cawley, questioned my interest in type A behaviour, which was considered at the time to be a key psychosocial risk factor for coronary heart disease. ‘I do not think that will lead anywhere, my boy’, he opined, and his prescient remarks were borne out later that decade when the type A bubble burst. Looking back on the type A phenomenon, it is clear that the obsession with identifying single psychosocial risk factors for coronary heart disease was simplistic and doomed to fail. This book tells you why.
The contributors explore the evidence that psychosocial factors can contribute to coronary heart disease and whether interventions have a role in its prevention. In their introductory chapter, the editors apologise for retaining the word ‘stress’ for its value in orienting the potential reader. This is commendable, but although it may improve sales to the ‘trade’ market it may also have the undesirable effect of alienating cardiologists, who traditionally have displayed little enthusiasm for exploring the psychosocial aspects of their patients' lives.
Both editors (and some of the other contributors) are veterans of the Whitehall II study of British civil servants. This cohort study was established with the explicit aim of determining the role of psychosocial factors in generating social gradients in physical and mental health. The Whitehall studies have made crucial contributions to the understanding of the role of the workplace as a potential risk factor for coronary heart disease and a range of potentially toxic occupational environments are described here. Redford Williams explains why the type A story itself ended in a culde-sac, but led to the discovery of hostility as a risk factor for not only coronary heart disease but also virtually any physical illness.
The chapter I enjoyed most addressed ‘life course’ approaches, which recognise that factors acting in early life accumulate and interact with factors acting in later life in the production of disease in adulthood. In essence, this approach reinforces the need for studies with valid and detailed data collected at all stages of the life course, not merely at one point in time. The search for independent risk factors is atemporal and ignores the fact that what we observe at any one time as an array of adult risk factors is the result of interlacing chains of biological and social exposures that have coevolved over time.
Other chapters address the role of smoking, exercise, diet and depression in coronary heart disease, as well as pathophysiological mechanisms and treatment. The text is replete with alarming facts which are likely to increase your heart rate: for example, episodes of intense anger are responsible for triggering 36 000 acute myocardial infarctions in the USA every year, and 72% of a series of patients with exercise-induced ischaemia showed abnormalities of left ventricular wall motion during tasks such as simulated public speaking. These reassuring facts should provide some comfort next time you are giving a talk!
This excellent book provides a comprehensive and evidence-based approach to a very complex subject and should be read by all interested and involved in the management of patients with heart disease.