Vital interconnections between heart and mind

With its growth as a medical journal, Heart and Mind is uniquely positioned to promote topics at the core of health-care's mission to reduce suffering that are both cutting-edge and under-researched. Here, I outline interrelated areas of heart–mind convergence that the Journal seeks to affirm and support. Reinforced by my long-standing observations as patient, researcher, and clinician, these topics emerge from an evolving and increasingly multidisciplinary scientific literature. By defining an expanded range of topics, this article encourages all cardiac health-care stakeholders to prioritize these key domains in clinical practice, research, medical education, and health policy. This is a time of crisis in health-care systems, particularly in cardiac care, which has largely focused on physical health while neglecting the critical role that the mind plays in human function.[1] The typical incomplete framework for heart disease often neglects this mind and body connection. It gives priority to expensive and reductive approaches. Likewise, it inclines toward late-stage interventions that both disempower and alienate patients, often adding a layer of unnecessary distress on top of the experience of illness. Modern medicine works against a whole-person approach that aspires to have individuals thrive with or without heart disease. Heart and Mind is poised to expand and redefine heart disease and cardiac care by firmly articulating that true heart health inexorably connects with our subjective, cognitive, social, and emotional lives. As the Journal moves into its 6th year, cardiac researchers, clinicians, and patients desperately need a journal that emphasizes the synergy of heart and mind, including the five key priorities described here. PSYCHOCARDIOLOGY The development of research covering the overlap of heart disease and mental health has been painfully slow despite the obvious experiential interconnections between heart and mind. We have long known that cardiac and psychological functions are correlated in a manner indicating bidirectional causality.[2] The presence of mental health conditions predisposes individuals to the development of various forms of heart disease.[2] Conversely, the presence of symptomatic heart disease predisposes individuals to mental health disorders.[3] This complex, bidirectional co-occurrence, the focus of the emerging field of psychocardiology,[4] is mediated by several, often interrelated mechanisms, including behavioral and psychosocial issues, systemic inflammation, autonomic nervous system imbalance, and stress hormone excess.[5,6,7,8] This array of connections occurs across a wide spectrum of psychological and psychiatric issues and the full complement of heart conditions, including atherosclerosis, heart failure, valvular heart disease, and heart rhythm disorders. PATIENT-CENTERED CARE AND OUTCOMES Second, a focus on patient-centered care and outcomes follows from the need to support cardiac patients in both heart and mind. Clinical research should be oriented to finding solutions and interventions that optimize the outcomes that patients, rather than physicians and researchers, identify as most salient.[9] While it might seem obvious that patients' subjective experience is of foremost importance, current systems of research and clinical care implicitly (and sometimes explicitly) undermine this primacy. While traditional epidemiological outcomes (e.g., ejection fraction, hospitalization, initial cardiac diagnosis, and cardiac events like myocardial infarction) are measurable, objective, and compelling, patients are most directly concerned with their subjective and long-term experience of heart disease, including its impact on quality of life, functional capabilities, and symptom burden.[10,11] While there can be considerable overlap between the two, patient-centered outcomes more fully capture whole-person needs and can sometimes pinpoint the failures of our current health-care system. This may be particularly true for low-income and minority patients, and indicates the relevance of patient-centered care to issues of health equity. ALTERNATIVE HEALTH-CARE APPROACHES The relative neglect of the mind component of human existence by Western medicine suggests the value of other models of health shaped by broader, often historically traditional perspectives. Where appropriate, for example, it may be useful to integrate aspects of other traditions within Western medical practice.[12] Such mind–body approaches as mindfulness, meditation, yoga, biofeedback, music therapy, traditional Chinese medicine, and Ayurvedic medicine can fill gaps neglected in typical cardiac care and open up new interventional strategies.[13,14] Many people gravitate toward these alternative approaches after becoming disillusioned with Western medicine. Some of the attraction may be that these traditions include a fundamental form of personalized or precision medicine, the tailoring of therapies for specific signs or symptoms to patient-specific characteristics, or body constitutions. Evidence that yoga[15] and mindfulness practices[16] reduce the fraction of time spent in atrial fibrillation indicates the potential power of an integrated health-care approach. In addition, standard methods for clinical evaluation and research must be augmented by new strategies that accommodate patient-centered outcomes, alternative health-care models, and tailored treatment strategies. PATIENT SELF-MANAGEMENT AND HEALTH BEHAVIOR CHANGE AS TREATMENT The value of patient self-management,[17] lifestyle modification for prevention and treatment, and patient–physician shared decision-making are all extensions of a mind–body perspective. Expanded involvement of patients in their own medical care not only leads to better outcomes but also helps protect those with heart disease from an alienating sense that illness has subverted their lives and agency. This includes the role of patient health behaviors as part of comprehensive treatment strategies. Some current features of care, such as cardiac rehabilitation,[5] are congruent with improving long-term outcomes, patient self-management, and a whole-person approach but are drastically underused. While cardiac care is often complex and technical, new digital approaches and communication tools[18,19] can help patients engage in shared decision-making and day-to-day self-management. Providing patients with true control over crucial components of their medical care can reduce distress and alienation as well as humanize care. NARRATIVE MEDICINE Finally, the use of a narrative medicine approach and the empathy it engenders[20] is an effective tool for clinicians and their patients. This process encourages patients and providers to reflect on their experiences by telling or writing their stories. The aspiration to improve cardiac care is served by communicating the narrative experience that patients, caretakers, and providers have with heart disease and its treatment. Many narrative elements of experience also may be gathered through qualitative research methods.[21] Just as much as statistics, stories can communicate vital information and help foster a sense of shared community. Narratives expressing the successes and failures of cardiac care readily tap into the emotional components of heart disease so important to patients. In this and other ways, patients with heart disease should have an active voice within Heart and Mind. CONCLUSIONS To define and broaden the scope of Heart and Mind's important mission, I describe five interrelated areas of heart–mind connection, including psychocardiology, patient-centered outcomes and care, alternative medicine approaches, patient self-management and health behaviors, and narrative medicine. All cardiac health-care stakeholders should give priority to these key areas, not only in research and publication but also in clinical practice, medical education, and health policy. Growing discontent about the status quo among patients and physicians and the disarray of many health systems provides a critical opportunity to shift the mindset of medicine firmly back to relieving suffering and supporting well-being. Financial support and sponsorship This work was conducted at the Joe and Linda Chlapaty Stanford DECIDE Center of the Atrial Fibrillation Strategically Focused Research Network Award from the American Heart Association: 18SFRN34120036.