Fig. 1. Pathophysiological model of the relationships between chronic, episodic, and acute psychological risk factors for coronary syndromes. Acute psychological factors result in physiological responses, leading to cardiac effects (ie, electrical instability, increased cardiac demand, and decreased coronary supply). In vulnerable patients, these cardiac effects may have pathophysiological results, including arrhythmias, myocardial ischemia, thrombus formation, and plaque rupture. Episodic psychological factors have physiological correlates that are involved in the progression of severe coronary disease to acute coronary syndromes. Chronic psychological factors promote the onset of early atherosclerosis, especially in the setting of genetic vulnerability, adverse health behaviors, and other environmental risk factors. In addition, chronic psychological factors are related to increased frequency and response magnitude of acute psychological factors and promote the risk of developing episodic factors. BP = blood pressure; HR = heart rate. Modified from Krantz et al. (1).