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      Inter-ethnic marriages and severity of coronary artery disease: A multicenter study of Arabian Gulf States

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          Abstract

          AIM

          To assess the association of inter-ethnic vs intra-ethnic marriage with severity of coronary artery disease (CAD) in men undergoing angiography.

          METHODS

          We conducted a prospective multicenter, multi-ethnic, cross sectional observational study at five hospitals in Saudi Arabia and the United Arab Emirates, in which we used logistic regression analysis with and without adjustment for baseline differences.

          RESULTS

          Data were collected for 1068 enrolled patients undergoing coronary angiography for clinical indications during the period of April 1 st, 2013 to March 30 th, 2014. Ethnicities of spouses were available only for male patients. Of those enrolled, 687 were married men and constituted the cohort for the present analysis. Intra-ethnic marriages were reported in 70% and inter-ethnic marriages in 30%. After adjusting for baseline differences, inter-ethnic marriage was associated with lower odds of having significant CAD [adjusted odds ratio 0.52 (95%CI: 0.33, 0.81)] or multi-vessel disease (MVD) [adjusted odds ratio 0.57 (95%CI: 0.37, 0.86)]. The adjusted association with left main disease showed a similar trend, but was not statistically significant [adjusted odds ratio 0.74 (95%CI: 0.41, 1.32)]. The association between inter-ethnic marriage and the presence of significant CAD and MVD was not modified by number of concurrent wives ( P interaction > 0.05 for both).

          CONCLUSION

          Among married men undergoing coronary angiography, inter-ethnic, as compared to intra-ethnic, marriage is associated with lower odds of significant CAD and MVD.

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          Most cited references30

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          Impact of Psychological Factors on the Pathogenesis of Cardiovascular Disease and Implications for Therapy

          Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.
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            Psychological stress and cardiovascular disease.

            There is an enormous amount of literature on psychological stress and cardiovascular disease. This report reviews conceptual issues in defining stress and then explores the ramifications of stress in terms of the effects of acute versus long-term stressors on cardiac functioning. Examples of acute stressor studies are discussed in terms of disasters (earthquakes) and in the context of experimental stress physiology studies, which offer a more detailed perspective on underlying physiology. Studies of chronic stressors are discussed in terms of job stress, marital unhappiness, and burden of caregiving. From all of these studies there are extensive data concerning stressors' contributions to diverse pathophysiological changes including sudden death, myocardial infarction, myocardial ischemia, and wall motion abnormalities, as well as to alterations in cardiac regulation as indexed by changes in sympathetic nervous system activity and hemostasis. Although stressors trigger events, it is less clear that stress "causes" the events. There is nonetheless overwhelming evidence both for the deleterious effects of stress on the heart and for the fact that vulnerability and resilience factors play a role in amplifying or dampening those effects. Numerous approaches are available for stress management that can decrease patients' suffering and enhance their quality of life.
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              The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology.

              Observational studies indicate that psychologic factors strongly influence the course of coronary artery disease (CAD). In this review, we examine new epidemiologic evidence for the association between psychosocial risk factors and CAD, identify pathologic mechanisms that may be responsible for this association, and describe a paradigm for studying positive psychologic factors that may act as a buffer. Because psychosocial risk factors are highly prevalent and are associated with unhealthy lifestyles, we describe the potential role of cardiologists in managing such factors. Management approaches include routinely screening for psychosocial risk factors, referring patients with severe psychologic distress to behavioral specialists, and directly treating patients with milder forms of psychologic distress with brief targeted interventions. A number of behavioral interventions have been evaluated for their ability to reduce adverse cardiac events among patients presenting with psychosocial risk factors. Although the efficacy of stand-alone psychosocial interventions remains unclear, both exercise and multifactorial cardiac rehabilitation with psychosocial interventions have demonstrated a reduction in cardiac events. Furthermore, recent data suggest that psychopharmacologic interventions may also be effective. Despite these promising findings, clinical practice guidelines for managing psychosocial risk factors in cardiac practice are lacking. Thus, we review new approaches to improve the delivery of behavioral services and patient adherence to behavioral recommendations. These efforts are part of an emerging field of behavioral cardiology, which is based on the understanding that psychosocial and behavioral risk factors for CAD are not only highly interrelated, but also require a sophisticated health care delivery system to optimize their effectiveness.
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                Author and article information

                Journal
                World J Cardiol
                WJC
                World Journal of Cardiology
                Baishideng Publishing Group Inc
                1949-8462
                26 April 2017
                26 April 2017
                : 9
                : 4
                : 371-377
                Affiliations
                Amin Daoulah, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah 21499, Kingdom of Saudi Arabia
                Salem Al-kaabi, Cardiology Department, Zayed Military Hospital, Abu Dhabi 3740, United Arab Emirates
                Amir Lotfi, Division of Cardiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA 01199, United States
                Mushabab Al-Murayeh, Cardiovascular Department, Armed Forces Hospital Southern Region, Khamis Mushayt 61961, Kingdom of Saudi Arabia
                S Ali Nasseri, Politecnico di Torino, 10126 Torino, Italy
                Waleed Ahmed, Mohamed Hamzi, Mohammed Abufayyah, Internal Medicine Department, King Faisal Specialist Hospital and Research Center, Jeddah 21499, Kingdom of Saudi Arabia
                Salah N Al-Otaibi, Cardiac Anesthesiology, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Kingdom of Saudi Arabia
                Mohamed N Alama, Cardiology Department, King Abdul Aziz University Hospital, Jeddah 21589, Kingdom of Saudi Arabia
                Osama E Elkhateeb, Cardiology Department, King Abdullah Medical City in Holy Capital, Makkah 24241, Kingdom of Saud Arabia
                Amy J Plotkin, Department of Pathology, Johns Hopkins University, Baltimore, MD 21287, United States
                Majed M Malak, Khalid Alshali, Internal Medicine Department, King Abdul Aziz University Hospital, Jeddah 21589, Kingdom of Saudi Arabia
                Saleh Al Khunein, Anesthesia Department, Prince Sultan Military Medical City, Riyadh 11159, Kingdom of Saudi Arabia
                Alawi A Alsheikh-Ali, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai 505055, United Arab Emirates
                Alawi A Alsheikh-Ali, Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi 51900, United Arab Emirates
                Author notes

                Author contributions: Daoulah A participated in study design; acquisition, interpretation of the data, and drafted the initial manuscript; Alsheikh-Ali AA participated in analysis and interpretation of the data; all other authors participated equally in data collection, and reviewing the article critically for important intellectual content.

                Correspondence to: Amin Daoulah, MD, FRCPC, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah 21499, Kingdom of Saudi Arabia. amindaoulah@ 123456yahoo.com

                Telephone: +966-505-795656 Fax: +966-266-77777-65822

                Article
                jWJC.v9.i4.pg371
                10.4330/wjc.v9.i4.371
                5411972
                687d8fa1-4518-42bf-abbf-d224a447787d
                ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.

                Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 6 January 2017
                : 28 February 2017
                : 12 March 2017
                Categories
                Observational Study

                arabian gulf,inter-ethnic marriage,coronary artery disease,cardiac epidemiology,coronary angiography

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