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From the Departments of Psychiatry (P.J.M., J.E.D.) and Medicine (C.F.), University of California, San Diego, California and the Division of Psychosocial Medicine (R.v.K.), University Hospital, Zurich, Switzerland.
Address reprint requests to: Joel E. Dimsdale, MD, Department of Psychiatry, UCSD, 9500 Gilman Drive, La Jolla, CA 92093-0804. Email: jdimsdale{at}ucsd.edu
OBJECTIVE: A hypercoagulable state before overt thrombosis resulting from an imbalance between the coagulation and fibrinolysis systems is related to cardiovascular disease progression and acute coronary syndromes. Psychological stressors and depressive and anxiety disorders also are associated with coronary artery disease. This review explores whether changes in blood coagulation, anticoagulant, and fibrinolytic activity may constitute psychobiological pathways that link psychological factors with coronary syndromes.
METHODS: Literature on coagulation, anticoagulation, and fibrinolysis measures in conjunction with psychological factors (mental stress, psychosocial strain, and psychiatric disorders) was identified by MEDLINE search back to 1966 and through checking the bibliographies of these sources. Sixty-eight articles were critically reviewed.
RESULTS: In healthy subjects, acute mental stress simultaneously activates coagulation (ie, fibrinogen or von Willebrand factor) and fibrinolysis (ie, tissue-type plasminogen activator) within a physiological range. In patients with atherosclerosis and impaired endothelial anticoagulant function, however, procoagulant responses to acute stressors may outweigh anticoagulant mechanisms and thereby promote a hypercoagulable state. Chronic psychosocial stressors (job strain or low socioeconomic status) are related to a hypercoagulable state reflected by increased procoagulant molecules (ie, fibrinogen or coagulation factor VII) and by reduced fibrinolytic capacity. There is also some evidence that points to hypercoagulability in depression.
CONCLUSIONS: Different categories of psychological measures to varying extent are associated with characteristic patterns of coagulation and fibrinolysis activity. Associations between psychological factors and several coagulation and fibrinolysis variables related to atherosclerosis provide a plausible biobehavioral link to coronary artery disease.
Key Words: Psychological stress • personality • depressive disorder • blood coagulation • fibrinolysis • hemostasis
Abbreviations: CAD = coronary artery disease; FVII = clotting factor FVII; PAI-1 = type 1 plasminogen activator inhibitor; QS = quality score; t-PA = tissue-type plasminogen activator; vWF = von Willebrand factor.
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