As a cardiologist practicing holistic integrative medicine, I am acutely aware of the mind-body issues that can contribute to cardiovascular disease. What is the role of stress, and of perceived stress? How does stress make us sick and how do positive thoughts keep us well? Why do emotions such as cynicism and hostility affect our health, and how can we use optimism, happiness, and joy to balance them? My charge is ultimately to increase the awareness that healing the heart is about not only the physical body, but also the emotional, mental, and spiritual body.

The Heart As the Little Brain
The field of neurocardiology is the study of the heart-brain connection. We now know that the heart has neurons just as the brain has neurons, and the heart and the brain are both connected to major nerves, the most notable being the vagus nerve. Leading-edge research has shown that it is the heart that processes our initial reactions to stress. The Cleveland Clinic has the first heart-brain institute dedicated to gaining an understanding of this relationship.

HeartMath research has shown that the heart responds to stress first, and sends that information to the brain with a judgment attached before mental cognition ever occurs. If the heart perceives a situation as a threat, the brain than sets off the alarm signals to produce stress hormones, which initiate the inflammatory cascade. The body starts pouring out adrenalin and noradrenaline, causing the blood vessels to constrict, making platelets sticky, raising heart rate, and elevating blood pressure.

This increases the risk of a cardiovascular event and can damage the lining of the blood vessels. Under chronic stress, cortisol is elevated; and as cortisol increases, GABA (the happy hormone) becomes suppressed, resulting in even higher levels of cortisol. During the stress response, the body considers immune function a luxury, so the immune response is essentially toggled off, which reduces the body's ability to fight infection and cancer.

Lifestyle Medicine
As a cardiologist, I see the need for multifaceted programs that incorporate functional medicine with an in-depth approach to lifestyle and mind-body medicine. In response to this need, I have developed a center that offers comprehensive life-enhancement programs, the Scripps Center for Integrative Medicine. We have a vegetarian cooking school, a number of yoga and meditation classes, mindfulness-based stress-reduction classes, and various support groups. We also have a full fitness center with all the equipment that patients need, whether they are in physical therapy or simply want a healthful workout. The facility offers the best of conventional Western medicine with access to all the latest technology for the heart, as well as support for lifestyle change. This provides a great many tools for my toolbox that go beyond simply using medication.

The intake – In our initial intake, we take a careful look at patients' lifestyle. We may evaluate the quality of the water that they drink for potential toxins, but we also want to know whether they have toxic emotions. How do they respond to stressful situations? Are they physically active enough to work off stress? What is their emotional resiliency? Are they connected to their community?

In every individual, these lifestyle factors and behaviors interact with genetics to determine whether they become sick or remain healthy, which is defined as genetic expression. How they live their lives and who they live with, as well as their lifestyle and environment, account for 70% to 90% of all chronic disease today. We also translate the insights of mind-body medicine into practical clinical strategies that patients can apply in their own lives.

The interview – Everyone who sees me for a new appointment spends an hour with me and an hour with a nutritionist. To understand how patients are functioning in all major facets of their lives, we do a full work-up and patient history including:

• an in-depth physical examination and interview
• blood work
• notes from the intake interview regarding their concerns

However, before I do the intake, I have my patients fill out a series of questionnaires. As clinicians, we need to ask the question, "What is going on in your life?" Not just, "What are you are eating?" We need to look at who this individual is, beyond their blood test and their biomarkers.

Questionnaires – The forms that they fill out for the initial intake provide me with a baseline, indicating where they are, the goals we are going to create, and how we are going to get there. We have to determine what they have done that has been most effective and what they still need. Since our program includes lifestyle medicine, we establish a baseline in these areas through:

• a three-day food diary covering two weekdays and one weekend day
• an exercise diary

We also capture information through a series of psychosocial questionnaires. Our choice of assessment depends on the individual and may include any of the following:

• Beck Depression Inventory
• SF-36 to capture a snapshot of their physical and mental functioning
• Cook-Medley Hostility Scale
• scale for loneliness and isolation
• spirituality questionnaire

By the time I see patients in the office, I have information on their nutrition and their status psychologically and emotionally. At that point, we do biomarker testing. Initially we are looking at the obvious things: Are they prediabetic or diabetic, do they have a vitamin D deficiency, is their thyroid working properly, and what are their cholesterol levels? We are also looking at a host of unique biomarkers, and of course, we are meeting with individual patients and hearing their concerns.

Impetus for change – It is important to ask patients, "What are your concerns, and what are your goals?" I also make it a point to ask, "What do you consider to be optimal health and what would you like to achieve?" We support change by exploring what our patients want, which may be different than what we perceive. What is their purpose in life, are they actually ready to start making changes, and what are they willing to change?

Defining goals and incentives – When I ask, "What is your motivation for wanting to get healthy?" what often emerges from these conversations is amazing. I get responses such as, "I want to be healthy because my wife has cancer and I want to be there for her," or "I'm willing to change because I want to see my grandchildren graduate from high school." We use a holistic approach, which takes into account the whole person – mind, emotions, and spirit – as well as the body. Drawing on a deeper understanding of our client's motivation, we can put a plan into place to reverse some of the challenges that a person might be experiencing.

Physician extenders – It is important to have staff that serve as extenders to the primary care provider, in order to achieve good follow-up and compliance. The question of how to amplify the physicians' efforts is an important one. For example, I may have my nurse practitioner see someone every month, and I may see them every two months. In addition, patients may be in a program where they are coming to the Center three times a week. This enables us to provide close follow-up to support healthful lifestyle behaviors. We partner with our patients and coach them along the way.

Follow-up – What else do we do to achieve good compliance?In terms of follow-up, that almost always involves an ongoing conversation. We often have people keep a food journal. There are also apps that can be used to document what they are eating and how much they are exercising. When people track their behaviors, that often makes a huge difference because they can begin to see the patterns. I hear things like, "I didn't realize I was consuming that many calories." or "I had no idea I was eating so much sugar!"

A team approach – If they need to increase their level of exercise, I may recommend a formal lifestyle-change approach such as our three-month program called Healing Hearts. Patients exercise in a group, they go to yoga in a group, and have access to support groups. If I need to refer them to a psychologist or a psychiatrist to help them deal with stress, I can refer patients out, but that is unusual if they are in one of these programs.

The Role of Stress in Illness
Stress is now considered an underlying factor in 70% of heart disease, which continues to be the number one killer in the US. Show me someone who has a cardiac event, and I'll show you someone who has been under an enormous amount of stress within the last six weeks, six months, or year. Research has shown that one single episode of anger typically increases the risk of a heart attack by 230%.

Many forms of stress – When you think of mind-body issues, such as anger or depression, these negative emotions are much more likely to support an unhealthy lifestyle. Emotional factors such as anxiety, stress, or grief have an enormous effect in our health. Show me a couple where the wife has died, and the data indicate that within six months the husband is likely to be dead.

Beyond cholesterol – We know that in 50% of heart attacks, cholesterol is not even a factor. Although everyone is focused on cholesterol due to the emphasis on pharmaceutical treatment, the reality is different than we have assumed. Primary lifestyle factors that are actually causing cardiovascular events include poor nutrition, stress, and weight gain, which all trigger systemic inflammation. The issues involve much more than just someone's cholesterol level.

Metabolic syndrome – Almost 75% of our population is struggling with weight gain or obesity.Stress is driving much of the behavior that is causing that weight gain. If people are stressed, they are likely to be drinking more and they're less likely to be eating appropriately. Elevated stress hormones are another factor that is causing people to put weight on in the midline.

Adverse childhood events – We always think of a toxic environment as one that contains lead, mercury, or some other type of environmental toxin. But research shows us that someone who lived with parents that were angry, fighting, or in constant crisis is much more likely to develop disease in midlife. That is the Harvard Mastery study. Then there is Vince Felitti's work out of the Kaiser System showing the link between cumulative childhood stress and poor health, in conditions ranging from lung cancer and autoimmune disorders to chronic headaches. "Adverse childhood events" are also associated with premature mortality.

Healing psychological trauma – How do we reverse a history of significant childhood abuse? We cannot change the fact that this has occurred, but we can help our patients heal. We work with them to look at what happened, embrace it, accept it, and move on. We help people do forgiveness work, learning to cope differently, to cope without anger, to communicate better, to get their needs met without being frustrated, and to improve their self-esteem.

The effects of grief – A study just came out in Circulation looking at people experiencing extreme grief, and found that they have a higher risk of cardiovascular events. That simply confirms what we've known all along, referred to as "broken heart syndrome." In fact, the term "broken heart syndrome" is used to describe a weakened heart muscle following a stressful event. So we are starting to look at the heart in a different way.

Mind-Body Interventions
A physician who practices integrative medicine may see stress primarily as a biochemical phenomenon, as physiology, rather than a function of the heart and emotions. Although it is useful to address the body's chemistry, a supplement is just that – a supplement to eating right, exercising right, increasing emotional resiliency, and improving how well we respond to stress and tension.

How can we integrate a mind-body approach to help our patients rebuild their emotional lives, and reduce the risk of heart attack and strokes? At the Scripps Center, our approach to the health of mind, body, and spirit includes yoga, meditation, and mindfulness-based stress reduction.

Breathing techniques – I teach my patients to breathe. The easiest thing I can do in the office is to give them simple breathing techniques they can use when they are in a stressful situation.

Meditation – There is a wonderful program in transcendental meditation (TM) here in San Diego to which I refer my patients. I encourage them to set aside quiet time and meditate for 20 minutes twice a day. Anyone can do this, it does not take much time, and TM is an example of an easy way to learn meditation.

Mindfulness-Based Stress Reduction – Both the research on TM and on mindfulness show reduction in cigarette use and in alcohol consumption with these meditative practices. My own belief is that when people do not have peace inside, they have many more addictive behaviors.

Mantra – Every spiritual tradition uses repetitive prayers to settle the mind, whether it involves use of the Catholic rosary, the Buddhist mala, or chanting in Hindu practices or Judaism. Mantra can be very effective in interrupting restless thoughts – the "monkey mind," which can be compared to a monkey jumping from branch to branch.

HeartMath – To be healthy, there needs to be variation in one's heart rate. People who have low heart rate variability are at an increased risk for cardiovascular events and sudden death. The research using HeartMath software shows that use of a mantra or a repetitive prayer moves us out of the stress response.

The Future of Mind-Body Medicine
A consortium of medical centers is developing new models of clinical care that will put these tools in clinicians' hands. In March, we will have begun researching the models in centers on the both the East and West Coasts. The new clinical models are anticipated to be ready for prime time about a year from now and will be incorporated into live training and in distance-learning programs.

We need a more comprehensive model of care. Our patients can have a perfect diet, but if they are eating healthful food with anger in their hearts, it is not going to help them. We want to look at all of the pieces of the puzzle, because human beings are complex. True healing occurs when all aspects of health and lifestyle come together in the healing process. The goal is to design the patient encounter in a way that connects the clinician and the patient, so that when patients go home they do not feel so disconnected, and they have the support that they need to heal.

Upcoming Workshop
Institute for Functional Medicine International Conference: A New Era in Preventing, Managing, and Reversing Cardiovascular and Metabolic Dysfunction; May 31–June 3, 2012, Scottsdale, Arizona. For more information, see FunctionalMedicine.org/AIC.

Nancy Faass is a writer and editor in San Francisco who has worked on more than 40 books for publishers that include Elsevier, Harper, McGraw-Hill, Mosby, New Harbinger, New World Library, North Atlantic, and others. Director of The Writers' Group, her work includes writing for the Web, and work on articles and white papers. For more information, see www.HealthWritersGroup.com.

Mimi Guarneri, MD, FACC, is board-certified in cardiology, internal medicine, nuclear medicine, and holistic medicine, and is the founder and medical director of the Scripps Center for Integrative Medicine. Her training includes a medical degree from SUNY, internship and residency at Cornell Medical Center (where she later became chief medical resident), and cardiology fellowships at both New York University Medical Center and Scripps Clinic. Dr. Guarneri is president of the American Board of Integrative and Holistic Medicine, in 2009 was recognized as ARCS scientist of the year, and in 2011 received the Bravewell Physician Leadership award.