Role of behavioral and psychological factors in mental stress-induced silent left ventricular dysfunction in coronary artery disease

Do men and women differ on measures of mental stress-induced ischemia?

OBJECTIVE

To consider the effects of gender on ischemia in a larger sample, with broadly defined coronary artery disease (CAD). Mental stress has been shown to cause transient myocardial ischemia in a significant percentage of people with CAD. However, little is known about the effects of mental stress on ischemic processes in women. Most studies to date either had few women or required a positive exercise stress test.

METHODS

Participants (61 women, 93 men; average age = 63 years) had documented CAD (positive stress test, abnormal catheterization even with minimal disease, or previous myocardial infarction). They underwent mental stress testing and radionuclide perfusion imaging (stress/ rest). Cardiac function data were collected and stress was compared with baseline. The data were then submitted to a series of analyses of variance.

RESULTS

A total of 50 (32%) participants exhibited reversible ischemia post psychological stress. This reflects a relative rate of 33% (n = 31 of 93) for men and 31% (n = 19 of 61) for women. No difference between men and women were observed on any measure of hemodynamic functioning (blood pressure, heart rate, or cardiac perfusion).

CONCLUSIONS

Results of this study showed no significant differences between men and women on measures of hemodynamic functioning or cardiac perfusion.

The cardiovascular toll of stress

Psychological stress elicits measurable changes in sympathetic-parasympathetic balance and the tone of the hypothalamic-pituitary-adrenal axis, which might negatively affect the cardiovascular system both acutely-by precipitating myocardial infarction, left-ventricular dysfunction, or dysrhythmia; and chronically-by accelerating the atherosclerotic process. We provide an overview of the association between stress and cardiovascular morbidity, discuss the mechanisms for this association, and address possible therapeutic implications.

Personality and risk of physical illness

Several personality characteristics have been linked in multiple well-designed prospective studies to subsequent physical health outcomes, such as longevity and the development and course of cardiovascular disease. The evidence is strongest for negative affectivity/neuroticism, anger/hostility and related traits, and optimism. Models of mechanisms underlying these associations have emphasized physiological effects of stress, exposure to stressors, and health behavior. Preliminary evidence supports the viability of some mechanisms, but formal mediational tests are lacking. In addition to addressing limitations and inconsistencies in this literature, future research should address developmental aspects of these psychosocial risk factors, contextual moderators of their health effects, and intervention applications in the prevention and management of disease. In these efforts, greater incorporation of concepts and methods in the structural, social-cognitive, and interpersonal perspectives in the field of personality are needed.

C-reactive protein and vulnerability to mental stress-induced myocardial ischemia

Myocardial ischemia provoked in the laboratory during mental stress (MSI) in patients with stable coronary artery disease (CAD) predicts subsequent clinical events. The pathophysiology of MSI differs from that of exercise ischemia, and the mechanisms tying MSI to poor prognosis are not known. C-reactive protein (CRP) is a risk marker for cardiovascular events in patients with CAD, but little is known regarding the relationship of CRP to MSI. The purpose of this study was to examine the association of CRP to risk of MSI in CAD patients. Eighty-three patients with stable CAD underwent simultaneous single-photon emission computed tomography (SPECT) imaging with technetium-99m tetrofosmin myocardial perfusion imaging (MPI) and transthoracic echocardiography (TTE), at rest and during MS induced by laboratory mental stress. Serum CRP levels were measured 24 h after MS. MSI was defined by the presence of a new perfusion defect on SPECT and/or new regional wall motion abnormality on TTE during MS. Of the 83 patients, 30 (36%) developed MSI. There was no difference in gender, sex, BMI, histories of diabetes, hypertension, smoking, lipid profile, medications used (including statins, beta-blockers, ACE inhibitors, and aspirin), or hemodynamic response during MS between those with and without MSI. In univariate logistic regression analysis, each unit (1 mg/L) increase in CRP level was associated with 20% higher risk of MSI (OR 1.2, 95% CI 1.01-1.39, P=.04). This relationship remained in multivariate models. These data suggest that levels of CRP may be a risk marker for MSI in patients with CAD.

C-reactive protein and vulnerability to mental stress-induced myocardial ischemia

Myocardial ischemia provoked in the laboratory during mental stress (MSI) in patients with stable coronary artery disease (CAD) predicts subsequent clinical events. The pathophysiology of MSI differs from that of exercise ischemia, and the mechanisms tying MSI to poor prognosis are not known. C-reactive protein (CRP) is a risk marker for cardiovascular events in patients with CAD, but little is known regarding the relationship of CRP to MSI. The purpose of this study was to examine the association of CRP to risk of MSI in CAD patients. Eighty-three patients with stable CAD underwent simultaneous single-photon emission computed tomography (SPECT) imaging with technetium-99m tetrofosmin myocardial perfusion imaging (MPI) and transthoracic echocardiography (TTE), at rest and during MS induced by laboratory mental stress. Serum CRP levels were measured 24 h after MS. MSI was defined by the presence of a new perfusion defect on SPECT and/or new regional wall motion abnormality on TTE during MS. Of the 83 patients, 30 (36%) developed MSI. There was no difference in gender, sex, BMI, histories of diabetes, hypertension, smoking, lipid profile, medications used (including statins, beta-blockers, ACE inhibitors, and aspirin), or hemodynamic response during MS between those with and without MSI. In univariate logistic regression analysis, each unit (1 mg/L) increase in CRP level was associated with 20% higher risk of MSI (OR 1.2, 95% CI 1.01-1.39, P=.04). This relationship remained in multivariate models. These data suggest that levels of CRP may be a risk marker for MSI in patients with CAD.

Anger, Hostility, and Cardiac Symptoms in Women with Suspected Coronary Artery Disease: The Women's Ischemia Syndrome Evaluation (WISE) Study

OBJECTIVE

To determine the relationship of anger and hostility to angiographic coronary artery disease (CAD), symptoms, and functional status among women with suspected CAD.

METHODS

Data were collected from 636 women with suspected CAD referred for diagnostic angiography in the Women's Ischemia Syndrome Evaluation (WISE) Study. CAD was assessed as angiographic presence/absence of disease (> or =50% stenosis in any epicardial coronary artery). Hostility/anger, angina, symptoms, and functional status were assessed by the Cook-Medley Hostility Inventory, Spielberger Anger Expression Scale, cardiovascular symptom history, and the Duke Activity Status Index.

RESULTS

Logistic regression revealed that anger-out (i.e., aggressive behavior in response to angry feelings) was independently associated with the presence/absence of angiographic CAD (OR = 1.09, CI 1.01-1.17). Anger and hostility were higher among women reporting increased cardiovascular symptoms. In women without angiographic CAD, those with nonanginal cardiac symptoms had the highest anger-out, anger expression, hostile affect, and aggressive responding scores, and those with typical angina reported the lowest functional status. Among women with CAD, functional status was lowest in women with atypical angina.

CONCLUSIONS

Among women with suspected CAD, anger-out scores were associated with the presence of angiographic CAD. Anger/hostility traits were associated with increased symptoms, particularly with nonanginal chest pain in women without angiographic CAD. Relationships among psychosocial factors, cardiac symptoms, and angiographic CAD are potentially important in the management of women with suspected CAD.

Effects of horticultural therapy on mood and heart rate in patients participating in an inpatient cardiopulmonary rehabilitation program

PURPOSE

To assess the effects of horticultural therapy (HT) on mood state and heart rate (HR) in patients participating in an inpatient cardiac rehabilitation program.

METHODS

Cardiac rehabilitation inpatients (n = 107) participated in the study. The HT group consisted of 59 subjects (34 males, 25 females). The control group, which participated in patient education classes (PECs), consisted of 48 subjects (31 males, 17 females). Both HT sessions and PEC are components of the inpatient rehabilitation program. Each group was evaluated before and after a class in their respective modality. Evaluation consisted of the completion of a Profile of Mood States (POMS) inventory, and an HR obtained by pulse oximetry.

RESULTS

Changes in the POMS total mood disturbance (TMD) score and HR between preintervention and postintervention were compared between groups. There was no presession difference in either TMD score (16 +/- 3.6 and 19.0 +/- 3.2, PEC and HT, respectively) or HR (73.5 +/- 2.5 and 79 +/- 1.8, PEC and HT, respectively). Immediately following the intervention, the HT TMD was significantly reduced (post-TMD = 1.6 +/- 3.2, P < .001), while PEC TMD was not significantly changed (TMD = 17.0 +/- 28.5). After intervention, HR fell in HT by 4 +/- 9.6 bpm (P < .001) but was unchanged in PEC.

CONCLUSION

These findings indicate that HT improves mood state, suggesting that it may be a useful tool in reducing stress. Therefore, to the extent that stress contributes to coronary heart disease, these findings support the role of HT as an effective component of cardiac rehabilitation.

Psychological distress and exertional angina in men and women undergoing thallium scintigraphy

The relation between psychological factors and angina has mostly been studied in male patients with confirmed CAD and few have evaluated this relation during actual provocation of ischemia. This study evaluated gender differences in the association between psychological distress and angina pain experience in 907 Caucasian patients (479 women, mean age = 60 years) undergoing exercise stress testing with thallium scintigraphy. Data were analyzed separately for patients with and without exercise related ischemia using a series of 2 (low/high distress) x 2 (gender) ANOVAs as well as binary logistic regressions. Among all patients, distress and gender were associated with greater risk and intensity of angina pain during testing (p < 0.05) and more angina following exertion (p < 0.05) or stress (p < 0.05) at home.

CONCLUSION

angina pain was more severe in women and individuals with high levels of distress, regardless of their ischemic status. A generalized hypersensitivity to pain/symptoms may be indicated in these patients.

Emotions in everyday life: an ambulatory monitoring study with female students

Additional heart rate as an indicator of emotional arousal was monitored throughout the day with a special ambulatory device. Fifty female students received acoustic feedback every 10-20 min. The feedback was based either on events (additional heart rate present) or was random without additional heart rate. Following the feedback the subjects were asked to disclose their emotions. The following emotions were listed on the display of the monitoring device: no emotion, happiness, anger, anxiety/fear, sadness, surprise, and disgust. The frequency and quality of the emotions were not different between event-related and random feedbacks, indicating that the subjects were not able to discriminate between events with and without additional heart rate correctly. Accordingly, the physiological profiles of the differing emotions compared to conditions with "no emotion" were equivocal. The psychological ratings of excitement and enjoyment, however, came up to expectations. The results show that cognitive schemata and personality dimensions are more important in emotion perception than physiological activation.

Psychological traits and emotion-triggering of ICD shock-terminated arrhythmias

OBJECTIVE

We have previously reported on the triggering of arrhythmia and hence, implanted cardioverter-defibrillators (ICD) shock by strong emotion. The purpose of the present study was to examine whether concordant psychological traits distinguish patients who experience emotion-triggered ICD shock.

METHODS

Two hundred forty ICD patients completed the Speilberger Trait Anxiety and Anger Inventories and Anger Expression Scale, and the abridged Cook-Medley Hostility Scale approximately 2 months after ICD implantation. Patients were also given a structured diary to record mood states retrospectively for the period 0 to 15 minutes preceding ICD shock and for a period corresponding to the same time of day 1 week later. Patients who reported emotion-triggered ICD shock were compared on concordant psychological measures to patients who did not.

RESULTS

Patients who reported at least moderate anger in the 0 to 15 minutes before ICD shock scored significantly higher on Speilberger Trait Anger (24.18 +/- 3.97 vs. 17.04 +/- 2.17, p < .0001), and Cook-Medley Aggressive Responding (5.76 +/- 0.75 vs. 3.96 +/- 1.30, p < .0001) and Hostile Affect (3.59 +/- 0.80 vs. 2.04 +/- 1.02, p < .0001), and lower on Speilberger Anger Control (7.94 +/- 1.43 vs. 10.64 +/- 1.19, p < .001) than those who did not. In multivariate analysis, only Trait Anger remained a significant predictor of anger-triggered shock (chi2 = 7.10, p < .008). Patients who reported at least moderate anxiety in the 0 to 15 minutes before ICD shock scored significantly higher on Speilberger Anxiety (22.43 +/- 1.65 vs. 19.96 +/- 1.71, p < .0001) than those who did not.

CONCLUSION

Stable psychological factors are associated with risk for ICD-shock triggered by concordant strong emotion.

Acute and chronic psychological stress in coronary disease

PURPOSE OF REVIEW

Coronary artery disease (CAD) is the leading cause of death in the United States and other developed countries. Along with a number of other factors thought to contribute to the high prevalence of CAD in developed societies (longer life expectancy, obesity, sedentary lifestyles), various psychological and social factors appear to promote the development or worsening of heart disease. It is well recognized that stress can be harmful to the cardiovascular system. The combination of the preexisting vulnerability and the major stressor are believed to result in cardiac arrhythmias and/or plaque rupture leading to death.

RECENT FINDINGS

Recently, the epidemiologic evidence of a link between stress and CAD is very convincing, yet the biopsychosocial pathway that would explain how stress can lead to disease is less clear. Different types of psychological stress have been found to be associated with increased cardiovascular events. Evidence regarding the efficacy of psychosocial interventions is also presented.

SUMMARY

It is suggested that, taken as a whole, evidence for a psychological and social impact on CAD morbidity and mortality is convincing.

What's “Unstable” in Unstable Angina?

The role of emotional distress (e.g., anger, depression, and anxiety) in anginal chest discomfort (ACD) may have been underestimated. The authors review the empirical studies in this area, which are inconsistent with the standard theory on the ischemia-angina relationship; summarize the substantial evidence indicating a strong and consistent cross-sectional/prospective epidemiological association of emotional distress and ischemia/ACD; review the distress-targeted, interventional evidence confirming a causal relationship (i.e., reduced chest discomfort and health system utilization), thus confirming clinical utility of such interventions; and explore the possible mechanisms that might account for the relationship between emotional distress and chest discomfort. Substantial clinical benefit may be achieved by aggressively detecting and treating emotional distress in ACD patients.

Biomedical and psychosocial predictors of anginal frequency in patients following angioplasty with and without coronary stenting

This study examined the contribution of biomedical and psychological variables in the report of anginal frequency at 6-week, 6- and 12-month follow-up in patients who received angioplasty with and without stent. Patients (N = 70) completed a battery of standardized questionnaries, including measures of depression, anxiety, and anger. Principal components analysis computed a single factor of negative emotion for use as a predictor in regression analyses. For the 6-week model, only baseline anginal frequency predicted anginal frequency. Negative emotion joined baseline anginal frequency in the prediction model for 6-month anginal frequency, and collectively accounted for 23% of the variance. For the 12-month model, baseline anginal frequency, female sex, and negative emotions remained in the model, accounting for 46% of the variance in anginal frequency. These results highlight the importance of biomedical and psychosocial variables in predicting anginal frequency with psychological variables sustaining predictive value over the course of recovery.

Effects of mental stress on flow-mediated brachial arterial dilation and influence of behavioral factors and hypercholesterolemia in subjects without cardiovascular disease

Mental and emotional arousal are known to trigger coronary events. The relation between hypercholesterolemia, behavioral factors, and mental stress-induced alterations in endothelial function are not well defined. Flow-mediated brachial arterial vasodilation has been established as a measure of arterial endothelial function. High-resolution ultrasound was used to measure mental stress-mediated, flow-mediated, and the combination of mental stress- and flow-mediated brachial artery dilation in 38 subjects, 20 of whom had total cholesterol levels > or =200 mg/dl. Mental stress was provoked by anger recall and mental arithmetic and trait hostility were assessed using the Cook-Medley scale. Under mental stress, participants with hypercholesterolemia showed less vasodilation than participants without hypercholesterolemia, even after adjustment for age and the magnitude of blood pressure response to mental stress. Mental stress attenuated flow-mediated brachial arterial vasodilation. There was an inverse relation between hostile affect and percent change in brachial artery diameter after mental stress combined with hyperemia (r = -0.57, p <0.001). Thus, hypercholesterolemia is associated with impaired vasodilation in response to mental stress. Mental stress inhibits flow-mediated vasodilation in normal subjects and those with hypercholesterolemia. The magnitude of this inhibition is associated with hostility.

Simultaneous assessment of myocardial perfusion and function during mental stress in patients with chronic coronary artery disease

BACKGROUND

Mental stress (MS) is an important provocateur of myocardial ischemia in many patients with chronic coronary artery disease. The majority of laboratory assessments of ischemia in response to MS have included measurements of either myocardial perfusion or function alone. We performed this study to determine the relationship between alterations in perfusion and ventricular function during MS. Methods and results Twenty-eight patients with reversible perfusion defects on exercise or pharmacologic stress myocardial perfusion imaging (MPI) underwent simultaneous technetium 99m sestamibi single photon emission computed tomography (SPECT) MPI and transthoracic echocardiography at rest and during MS according to a mental arithmetic protocol. In all cases the MS study was performed within 4 weeks of the initial exercise or pharmacologic MPI that demonstrated ischemia. SPECT studies were analyzed visually with the use of a 13-segment model and quantitatively by semiautomated circumferential profile analysis. Echocardiograms were graded on a segmental model for regional wall motion on a 4-point scale. Of 28 patients, 18 (64%) had perfusion defects and/or left ventricular dysfunction develop during MS: 9 (32%) had myocardial perfusion defects develop, 6 (21%) had regional or global left ventricular dysfunction develop, and 3 (11%) had both perfusion defects and left ventricular dysfunction develop. The overall concordance between perfusion and function criteria for ischemia during MS was only 46%. Among 9 patients with MS-induced left ventricular dysfunction, 5 had new regional wall motion abnormalities and 4 had a global decrement in function. In patients with MS-induced ischemia by SPECT, the number of reversible perfusion defects was similar during both MS and exercise/pharmacologic stress (2.8 +/- 2.0 vs 3.5 +/- 1.8, P =.41). Hemodynamic changes during MS were similar whether patients were divided on the basis of perfusion defects or left ventricular dysfunction during MS.

CONCLUSIONS

These data indicate the feasibility of simultaneous assessment of perfusion and function responses during MS. Flow and function responses to MS are frequently not concordant. These data suggest that MS-induced changes in perfusion may represent a different phenomenon than MS-induced changes in left ventricular function (either globally or regionally).

Psychosocial influences on the development and course of coronary heart disease: current status and implications for research and practice

Psychosocial characteristics predict the development and course of coronary heart disease (CHD). In this review, the authors discussed human and animal research on psychophysiological mechanisms influencing coronary artery disease and its progression to CHD. They then reviewed literature on personality and characteristics of the social environment as risk factors for CHD. Hostility confers increased risk, and a group of risk factors involving depression and anxiety may be especially important following myocardial infarction. Social isolation, interpersonal conflict, and job stress confer increased risk. Psychosocial interventions may have beneficial effects on CHD morbidity and mortality, although inconsistent results and a variety of methodological limitations preclude firm conclusions. Finally, they discussed implications for clinical care and the agenda for future research.

Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study

BACKGROUND

Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates.

METHODS AND RESULTS

To determine whether mental stress-induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5+/-0.4 years and 5.2+/-0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (P=0.04) and significantly predicted death (rate ratio=3.0; 95% CI, 1.04 to 8.36; P=0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (P=0.9) and did not predict death even after adjusting for resting ejection fraction (P=0.63), which was similar in both groups (mean, 56.4 versus 59.7; P=0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise.

CONCLUSIONS

In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stress-induced ischemia predicts subsequent death.

Changes in heart rate and heart rate variability before ambulatory ischemic events(1)

OBJECTIVES

The aim of this study was to determine the time course of autonomic nervous system activity preceding ambulatory ischemic events.

BACKGROUND

Vagal withdrawal can produce myocardial ischemia and may be involved in the genesis of ambulatory ischemic events. We analyzed trajectories of heart rate variability (HRV) 1 h before and after ischemic events, and we examined the role of exercise and mental stress in preischemic autonomic changes.

METHODS

Male patients with stable coronary artery disease (n = 19; 62.1 +/- 9.3 years) underwent 48-h ambulatory electrocardiographic monitoring. Frequency domain HRV measures were assessed for 60 min before and after each of 68 ischemic events and during nonischemic heart rate-matched control periods.

RESULTS

High-frequency HRV decreased from -60, -20 to -10 min before ischemic events (4.8 +/- 1.3; 4.6 +/- 1.3; 4.4 +/- 1.2 ln [ms(2)], respectively; p = 0.04) and further from -4, -2 min, until ischemia (4.4 +/- 1.3; 4.1 +/- 1.3; 3.7 +/- 1.2 ln [ms(2)]; p's < 0.01). Low frequency HRV decreases started at -4 min (p < 0.05). Ischemic events occurring at high mental activities were preceded by depressed high frequency HRV levels compared with events at low mental activity (p = 0.038 at -4 min, p = 0.045 at -2 min), whereas the effects of mental activities were not observed during nonischemic control periods. Heart rate variability measures remained significantly decreased for 20 min after recovery of ST-segment depression when events were triggered by high activity levels.

CONCLUSIONS

Autonomic changes consistent with vagal withdrawal can act as a precipitating factor for daily life ischemia, particularly in episodes triggered by mental activities.

Angerlike behavioral state potentiates myocardial ischemia-induced T-wave alternans in canines

OBJECTIVES

The main goal of this study was to determine whether induction of an angerlike state can result in significant levels of T-wave alternans, a marker of electrical instability, in the normal and ischemic heart.

BACKGROUND

Outbursts of anger have been implicated in the occurrence of myocardial infarction and sudden cardiac death, but the pathophysiologic mechanisms remain unknown.

METHODS

A standardized behavioral challenge of eliciting an angerlike state was conducted before and during a 3-min period of coronary artery occlusion in six canines.

RESULTS

Precordial T-wave alternans increased from 0.04 +/- 0.02 at baseline to 1.40 +/- 0.32 mV X ms (p < 0.05) during the angerlike response. When the angerlike state and myocardial ischemia were superimposed, the augmentation in T-wave alternans magnitude (to 3.27 +/- 0.61 mV X ms, p < 0.05) exceeded their additive effects, increasing by 130% over the angerlike state alone (p < 0.05) and by 390% over occlusion alone (p < 0.05). Adrenergic influences were reduced by the beta1-adrenergic receptor blocking agent metoprolol (1.5 mg/kg, intravenous), which diminished T-wave alternans magnitude (p < 0.0004 for all) during the angerlike response (from 1.40 +/- 0.32 to 0.80 +/- 0.17 mV x ms) and during the combined intervention (from 3.27 +/- 0.61 to 1.23 +/- 0.13 mV X ms). In five additional normal anesthetized canines, atrial pacing at 180 beats/min did not increase T-wave alternans magnitude monitored from lead II electrocardiogram.

CONCLUSIONS

Provocation of an angerlike state results in T-wave alternans in the normal heart and potentiates the magnitude of ischemia-induced T-wave alternans. Elevation in heart rate during arousal does not appear to be the main factor in the development of alternans in the normal heart but may be an important component during myocardial ischemia. Enhanced adrenergic activity appears to mediate the effects in both the normal and ischemic hearts. T-wave alternans may constitute a useful electrophysiologic measure for clinical use in conjunction with behavioral stress testing or ambulatory monitoring.

Day-to-day reproducibility of mental stress-induced abnormal left ventricular function response in patients with coronary artery disease and its relationship to autonomic activation

BACKGROUND

Mental stress (MS) results in left ventricular (LV) dysfunction in approximately half of the patients with symptomatic coronary artery disease (CAD) and is an adverse prognostic sign. The reproducibility of various MS tasks in inducing LV dysfunction and its relationship to autonomic activation in patients with CAD are not known. We studied the reproducibility on different days of 3 commonly used MS tasks on LV ejection fraction (LVEF), heart rate, blood pressure, and rate-pressure product and the relationship of reproducibility to autonomic activation as determined by heart rate variability in patients with chronic stable angina.

METHODS AND RESULTS

Ten patients with CAD and exercise-induced ischemia who had abnormal LVEF responses to at least one MS task from a battery of MS tasks (mental arithmetic, anger recall, and color Stroop test) while undergoing continuous ambulatory Holter and LV function monitoring underwent a second MS testing 4 to 8 weeks later, with no change in clinical status or cardiac medications in the interim. Autonomic tone was determined from indexes of heart rate variability (high frequency [HF] for parasympathetic activity and low frequency [LF] and low frequency/high frequency ratio [LF/HF] for sympathetic activity). MS tasks resulted in a small increase in heart rate (P <.0001), a modest increase in systolic blood pressure (P <.0001) and the rate-pressure product (P <.0001), and a small but statistically significant increase in LF (P <.002) and LF/HF (P <.0001), but no change in HF compared with baseline. These changes were highly reproducible over the 2 studies. With a fall in LVEF of 5% or greater considered as indicative of an MS-positive task, anger recall was the most effective and reproducible MS task in inducing LV dysfunction. MS-positive tasks were associated with a greater increase in systolic blood pressure (P =.005). Anger recall resulted in a trend toward a higher increase in systolic blood pressure (P =.08) than the other MS tasks. In MS tasks with inconsistent LVEF responses in the 2 studies (LV dysfunction present in one study but not in the other), there was significant parasympathetic withdrawal (P =.02) in MS-negative tasks but no difference in sympathetic activation. On the other hand, in MS tasks with consistent LV dysfunction on both occasions, there was no difference in parasympathetic or sympathetic activation. MS-positive tasks were not accompanied by chest pain or ST depression.

CONCLUSIONS

Of the commonly used MS tasks, anger recall produces LV dysfunction with the highest frequency and is the most reproducible task when retested 4 to 8 weeks later in patients with CAD. These data are relevant for planning studies of the effects of therapeutic interventions on MS-induced LV dysfunction.

Psychological characteristics and fatal ischaemic heart disease

OBJECTIVE

To determine the relation between psychological characteristics and subsequent fatal ischaemic heart disease (IHD) events.

DESIGN

Prospective study of participants in the Northwick Park heart study (NPHS) recruited between 1972 and 1978 and followed up for fatal events until 1997.

SETTING

Three occupational groups in north west London.

SUBJECTS

1408 white men without a history of myocardial infarction aged 40-64 years at entry who completed a Crown-Crisp experiential index form (CCEI).

MAIN OUTCOME MEASURE

Fatal IHD during follow up.

RESULTS

A one point increase in the score on the obsessionality/obsessional neurosis subscale was associated with a relative risk of fatal IHD of 1.08 (95% confidence interval (CI) 1.02 to 1.15). For the functional somatic complaint subscale the relative risk was also 1.08 (95% CI 1.02 to 1.15). In the case of the total score the relative risk of fatal IHD was 1.28 (95% CI 1.09 to 1.50) for a 10 point increase. The associations were independent of age, social class, and known cardiovascular risk factors. In the case of phobic anxiety, which had previously been found to be associated with fatal IHD in NPHS, the association was evident in the first 10 years of follow up but overall the relative risk was only 1.07 (95% CI 0.99 to 1.15) for a one point increase in the score.

CONCLUSION

Scores on two of the subscales of the CCEI and the total score are significantly associated with fatal IHD on long term follow up independently of other known risk factors.

Chest pain and the treatment of psychosocial/emotional distress in CAD patients

Treatment of psychosocial/emotional distress as a strategy for diminishing chest pain in such patients remains entirely unutilized in standard care. Sixty-three patients with known or suspected CAD were entered in an aggressive lifestyle modification program. Patients completed the Symptom Checklist 90-Revised (SCL90R) at the diagnostic interview session, at 3 and at 12 months. Statistically significant drops were observed on multiple scales of the SCL90R at both 3 and 12 months. An item from the SCL90R was used as a proxy for angina. Multiple measures of emotional distress at baseline were found to correlate with chest pain at baseline, but not a number of traditional cardiovascular risk factors. The chest pain item displayed improvement at both 3 and 12 months. Improvement on all scales of the SCL90R correlated with improvement in chest pain. It may be possible to control chest pain in some CAD patients with psychosocial interventions.

ECG Changes, Emotional Arousal, and Subjective State

Abstract Laboratory studies with CHD patients suggest an adverse influence of emotional/mental arousal on myocardial ischaemia or ventricular premature contractions (VPCs). However, it is controversial whether such studies can be generalized to everyday life. In addition, existing ambulatory monitoring studies have shortcomings because emotional arousal is entirely based on subjective reports. The hypothesis of the present study is that during ischaemic episodes or VPCs “objective emotional/mental arousal” will be more pronounced than during comparable episodes without these events. Objective emotional/mental arousal was indicated by a special ambulatory monitoring method which was based on the online analysis of heart rate and physical activity, resulting in the so-called emotional or non-metabolic heart rate. Moreover, the method allowed for ratings of anginal pain. In 223 CHD patients the associations between ischaemia, VPCs, objective emotional/mental arousal, and anginal pain were investigated. Forty-nine patients revealed ischaemic episodes and 115 patients VPCs. Emotional/mental arousal was higher during ischaemic episodes as compared to control minutes whereas minutes with VPCs showed no difference. No differences between ischaemic episodes or VPCs and the respective control minutes were observed for anginal pain. Objective emotional/mental arousal was associated in this study with ischaemia but not with arrhythmia, thus partly confirming the hypothesis stated. Because anginal pain was not related to objective cardiac events, detection of CHD has to rely on medical examinations.

Destabilizing effects of mental stress on ventricular arrhythmias in patients with implantable cardioverter-defibrillators

BACKGROUND

The incidence of sudden cardiac death increases in populations who experience disasters such as earthquakes. The physiological link between psychological stress and sudden death is unknown; one mechanism may be the direct effects of sympathetic arousal on arrhythmias. To determine whether mental stress alters the induction, rate, or termination of ventricular arrhythmias, we performed noninvasive programmed stimulation (NIPS) in patients with defibrillators and ventricular tachycardia (VT), which is known to be inducible and terminated by antitachycardia pacing, at rest and during varying states of mental arousal.

METHODS AND RESULTS

Eighteen patients underwent NIPS in the resting-awake state (nonsedated). Ten underwent repeat testing during mental stress (mental arithmetic and anger recall). Induced VT was faster in 5 patients (P=0.03). VT became more difficult to terminate in 5 patients during mental stress; 4 required a shock (P=0.03). There was no change in ease of induction with mental stress. There was no evidence of ischemia on ECG or continuous ejection fraction monitoring. Eight patients received a shock in the resting-awake state and did not perform mental stress. Four underwent repeat NIPS after sedation; 3 then had induced VT terminated with antitachycardia pacing. All patients with an increase in norepinephrine of >50% had alterations in VT that required shock for termination (P<0.01).

CONCLUSIONS

Mental stress alters VT cycle length and termination without evidence of ischemia. This suggests that mental stress may lead to sudden death through the facilitation of lethal ventricular arrhythmias.

Plasma homocysteine levels increase in women during psychological stress

Homocysteine is an amino acid that has been strongly associated with vascular disease. Plasma homocysteine concentrations are known to vary with dietary patterns and to decrease with exogenous estrogen use, but no other behavioral factors have been examined as potential modifiers of this risk factor. Because psychological stress has also been implicated in the development of cardiovascular disease, the purpose of this study was to test the hypothesis that acute psychological stress induces elevations in plasma homocysteine concentrations. A secondary aim was to test potential differences in response between premenopausal and postmenopausal women. Thirty-four healthy women, one-half of whom were naturally postmenopausal with no hormone replacement, participated in this study. The psychological stressors included standard mental arithmetic and speech stressors. Blood samples were taken prior to, during, and after the stressors, and heart rate and blood pressure were also monitored. Results indicated significant elevations in plasma homocysteine during acute psychological stress, with a return to baseline concentrations during recovery. The pattern of findings for blood pressure and heart rate was similar, suggesting that the rise in homocysteine concentrations may have been sympathetically-mediated. No effects of menopausal status or endogenous estrogens were found. The findings provide preliminary evidence that plasma homocysteine may be an important factor in the relationship between psychological stress and risk for heart disease.

Effects of therapy with nifedipine GITS or atenolol on mental stress-induced ischemic left ventricular dysfunction

OBJECTIVES

We sought to determine the effect of nifedipine gastrointestinal therapeutic system (GITS) or atenolol on ischemic left ventricular dysfunction induced by mental stress.

BACKGROUND

The efficacy of conventional antianginal therapy in preventing myocardial ischemia induced by mental stress is unknown.

METHODS

Nifedipine GITS, atenolol and placebo were administered to 15 subjects with stable angina in a double-blind crossover trial. Subjects underwent a series of mental stressors at the end of each treatment. Radionuclide ventriculography was performed at baseline and at peak mental stress. Other measured variables included time to ischemia on exercise treadmill testing, ischemia on 48-h ambulatory electrocardiogram (ECG) monitoring, and resting and mental stress-induced levels of plasma catecholamines, tissue plasminogen activator antigen, plasminogen activator inhibitor-1 and platelet aggregability.

RESULTS

Mental stress resulted in a significant increase in plasma epinephrine and norepinephrine levels during each treatment phase. Atenolol therapy was associated with lower baseline and postmental stress rate-pressure product compared with nifedipine or placebo. Therapy with either nifedipine GITS or atenolol prevented the development of wall-motion abnormalities and the decline in regional ejection fraction (EF) in the segment with the largest deterioration in wall motion during placebo therapy. Both medications prevented the decrease in global EF in subjects who demonstrated at least a 5% fall in global EF on placebo therapy. No therapy exerted a statistically significant benefit on exercise performance or frequency of ischemia during ambulatory ECG monitoring.

CONCLUSIONS

Both nifedipine GITS and atenolol are effective at preventing mental stress-induced wall-motion abnormalities, although the mechanisms may be different.

Triggers of daily life ischaemia

OBJECTIVE

To determine the usual triggers of silent and symptomatic ischaemia.

DESIGN

Patients wore an ambulatory recorder for 48 hours. The device emitted a tone on detection of ischaemia and patients noted activities, feelings, and symptoms so that ischaemia could be attributed to one of four triggers: physical stress, mental stress, combined physical/mental stress, or no stressor.

SETTING

Home environment.

PATIENTS

Patients (n = 38) with stable coronary disease, positive exercise electrocardiography, and ischaemic episodes on ambulatory electrocardiography.

MAIN OUTCOME MEASURE

Matching ischaemic episodes with perceived triggers.

RESULTS

Altogether 257 ischaemic episodes (53% silent) were documented. Triggers were: physical stress, 56%; mental stress, 5%; combined physical/mental stress, 8%; no identifiable trigger, 31%. Episodes associated with mental or no stress were more often silent (69% and 75%, respectively) than those associated with physical stress (45%, p < 0.01), while combined physical/mental stress episodes were usually symptomatic (10% silent, p < 0.01 v other stressors). Although physical stress was less commonly a trigger of silent ischaemia than angina (47% v 65%, p < 0.01), it was still the predominant trigger of silent ischaemia. There was no identifiable trigger in 45% of silent and only 17% of anginal episodes (p < 0.01). Only nine silent episodes involved mental stress alone as a trigger.

CONCLUSIONS

Daily life ischaemia is usually triggered by physical activity. Mental stress alone is an uncommon trigger of either silent or symptomatic ischaemia, while combined physical/mental stress is a significant but minor trigger of angina. Patients can identify a trigger in 83% of anginal episodes, compared with only half of silent ischaemic episodes.

Dimensions of anger and CHD in men and women: self-ratings versus spouse ratings

One hundred one males and 95 females referred for thallium stress testing were administered Spielberger's State-Trait Anger Expression Inventory (STAXI), the Ho scale cynicism items, the Cynical Beliefs Scale, and Bendig's Manifest Anxiety Scale. A subset of 53 males and 43 females was rated by their spouses by means of STAXI. Based on the thallium findings and their medical history, patients were classified either as healthy, or as having documented CHD, or as questionable. Patients' STAXI and cynicism measures were submitted to a principal-components analysis which yielded three factors: Impulsive Anger-out. Inwardly experienced anger, and Cynicism. The relationships between factor scores and documented CHD was determined by means of logistic regression analyses. Only Impulsive Anger-out correlated (positively) with CHD, but only when based on spouses' ratings and only in males (p < .01, RR = 3.13). Covarying traditional risk factors and cynicism did not attenuate this relationship. However, a significant relationship between Ho scale cynicism and CHD did not survive adjustment for traditional risk factors. Anxiety was not a risk factor for CHD.

Cerebral cortical hyperactivation in response to mental stress in patients with coronary artery disease

The central nervous system (CNS) effects of mental stress in patients with coronary artery disease (CAD) are unexplored. The present study used positron emission tomography (PET) to measure brain correlates of mental stress induced by an arithmetic serial subtraction task in CAD and healthy subjects. Mental stress resulted in hyperactivation in CAD patients compared with healthy subjects in several brain areas including the left parietal cortex [angular gyrus/parallel sulcus (area 39)], left anterior cingulate (area 32), right visual association cortex (area 18), left fusiform gyrus, and cerebellum. These same regions were activated within the CAD patient group during mental stress versus control conditions. In the group of healthy subjects, activation was significant only in the left inferior frontal gyrus during mental stress compared with counting control. Decreases in blood flow also were produced by mental stress in CAD versus healthy subjects in right thalamus (lateral dorsal, lateral posterior), right superior frontal gyrus (areas 32, 24, and 10), and right middle temporal gyrus (area 21) (in the region of the auditory association cortex). Of particular interest, a subgroup of CAD patients that developed painless myocardial ischemia during mental stress had hyperactivation in the left hippocampus and inferior parietal lobule (area 40), left middle (area 10) and superior frontal gyrus (area 8), temporal pole, and visual association cortex (area 18), and a concomitant decrease in activation observed in the anterior cingulate bilaterally, right middle and superior frontal gyri, and right visual association cortex (area 18) compared with CAD patients without myocardial ischemia. These findings demonstrate an exaggerated cerebral cortical response and exaggerated asymmetry to mental stress in individuals with CAD.

Effects of mental stress on left ventricular and peripheral vascular performance in patients with coronary artery disease

OBJECTIVES

We sought to investigate the mechanism of a mental stress-induced fall in left ventricular ejection fraction (LVEF) in patients with coronary artery disease.

BACKGROUND

Mental stress induces a fall in LVEF in a significant proportion of patients with coronary artery disease. This is accompanied by an increase in heart rate, blood pressure and rate-pressure product. Whether the mental stress-induced fall in LVEF is due to myocardial ischemia, altered loading conditions or a combination of both is not clear.

METHODS

Left ventricular (LV) function was studied noninvasively by serial equilibrium radionuclide angiocardiography and simultaneous measurement of peak power, a relatively afterload-independent index of LV contractility, in 21 patients with coronary artery disease (17 men, 4 women) and 9 normal subjects (6 men, 3 women) at baseline, during mental stress and during exercise. Peripheral vascular resistance (PVR), cardiac output (CO), arterial and end-systolic ventricular elastance (Ea, Ees,) and ventriculoarterial coupling (V/AC) were also calculated. Patients underwent two types of mental stress-mental arithmetic and anger recall-as well as symptom-limited semisupine bicycle exercise.

RESULTS

Nine patients (43%) had an absolute fall in LVEF of > or = 5% (Group I) in response to at least one of the mental stressors, whereas the remaining patients did not (Group II). Group I and Group II patients were similar in terms of baseline characteristics. Both groups showed a significant but comparable increase in systolic blood pressure (15+/-7 vs. 9+/-10 mm Hg, p=0.12) and a slight increase in heart rate (7+/-4 vs. 8+/-7 beats/min, p=0.6) and a comparable increase in rate-pressure product (2.2+/-0.9 vs. 1.9+/-1.2 beats/min x mm Hg, p=0.6) with mental stress. However, PVR increased in Group I and decreased in Group II (252+/-205 vs. -42+/-230 dynes x s x cm(-5), p=0.006), and CO decreased in Group I and increased in Group II (-0.2+/-0.4 vs. 0.6+/-0.7 liters/min, p=0.02) with mental stress. There was no difference in the change in peak power (p=0.4) with mental stress. With exercise, an increase in systolic blood pressure, heart rate, rate-pressure product and CO and a fall in PVR were similar in both groups. Of the two mental stressors, anger recall resulted in a greater fall in LVEF and a greater increase in diastolic blood pressure. Exercise resulted in a fall in LVEF in 7 patients (33%). However, exercise-induced changes in LVEF and hemodynamic variables were not predictive of mental stress-induced changes in LVEF and hemodynamic variables. Conclusions. Abnormal PVR and Ea responses to mental stress and exercise are observed in patients with a mental stress-induced fall in LVEF. Peripheral vasoconstrictive responses to mental stress contribute significantly toward a mental stress-induced fall in LVEF.

The Psychophysiological Investigations of Myocardial Ischemia (PIMI) study: objective, methods, and variability of measures

OBJECTIVE

This study evaluated physiological, neuroendocrine, and psychological status and functioning of patients with coronary artery disease in order to clarify their role in the expression of symptoms during myocardial ischemia (MI), and to establish repeatability of responses to mental stress. Design and methods of the study are presented.

METHODS

One hundred ninety-six coronary artery disease patients were examined during physical and mental stress tests in four hospitals. Eligibility criteria included narrowing of at least 50% in the diameter of at least one major coronary artery or verified history of myocardial infarction, and evidence of ischemia on an exercise treadmill test. Psychological, biochemical, and autonomic function data were obtained before, during, and after exposure to mental and exercise stressors during 2 or 3 half-days of testing. Ventricular function was assessed by radionuclide ventriculography, and daily ischemia by ambulatory electrocardiography. Sixty patients returned for a short-term mental stress repeatability study. Twenty-nine individuals presumed to be free of coronary disease were also examined to establish reference values for cardiac responses to mental stress.

RESULTS

Study participants were 41 to 80 years of age; 83 (42%) had a history of MI, 6 (3%) of congestive heart failure, and 163 (83%) of chest pain; 170 (87%) were men; and 90 (46%) had ischemia accompanied by angina during exercise treadmill testing. Ischemia during ambulatory monitoring was found in 35 of 90 (39%) patients with and 48 of 106 (45%) patients without angina during exercise-provoked ischemia. Intraobserver variability of ejection fraction changes during bicycle exercise and two mental stress tests (Speech and Stroop) was good (kappa = 1.0, .90, and .76, respectively; percent agreement = 100, 97.5, and 93.8%, respectively). Variability of assessed wall motion abnormalities during bicycle exercise was better (kappa, agreement = 85%) than during Speech or Stroop kappa and .57, percent agreement = 70% and 82.5%, respectively).

CONCLUSIONS

Study design, quality control data, and baseline characteristics of patients enrolled for a clinical study of symptomatic and asymptomatic myocardial ischemia are described. Lower repeatability of reading wall motion abnormalities during mental stress than during exercise may be due to smaller effects on wall motion and lack of an indicator for peak mental stress.

Hostility, aggression and the risk of nonfatal myocardial infarction in postmenopausal women

Hostility can predict coronary heart disease (CHD) and total mortality in men. However, in women this association has not been as thoroughly explored. This study examines whether hostile and aggressive attitudes are associated with myocardial infarction (MI) in postmenopausal women. Cases included 277 women who presented with an incident MI. Controls included a random sample of 988 female health maintenance organization enrollees. Women were asked the Hostile-Affect and the Aggressive-Responding factors of the Cook-Medley Hostility Scale. The Hostile-Affect score was linearly associated with increased risk for MI (odds ratio [OR] per point = 1.22; 95% confidence interval [CI95%] = 1.07-1.38), whereas the Aggressive-Responding score had a modest protective effect (OR = 0.92 per point; CI95% = 0.84-1.02); p = 0.009. Adjustment for sociodemographic and MI risk factors altered these results only slightly. These hostility measures are easily administered, and could help to identify women who are at high risk for CHD and who may benefit from preventive measures.

Acute and chronic psychological risk factors for coronary syndromes: moderating effects of coronary artery disease severity

This article provides a selective review of the effects of psychosocial factors and responses to acute mental stress on the onset of acute coronary syndromes. The literature suggests that the relationship between the anatomical severity of coronary artery disease (CAD) and likelihood of subsequent cardiac events, such as myocardial infarction, is not linear. Furthermore, evidence will be provided that the age-dependent associations between psychosocial factors and risk of cardiac events is at least in part mediated through the severity of underlying CAD. Finally, research will be summarized that supports the importance of both chronic psychosocial factors (e.g., low socioeconomic status and/or high hostility) and episodic psychological distress syndromes, such as vital exhaustion and depression. In reviewing this literature, two perspectives will be focused on: (1) the relationship between psychosocial factors and progressive CAD; and (2) the evidence concerning underlying pathophysiological mechanisms.

Cardiovascular function during cognitive stress in men before and after coronary artery bypass grafts

Cardiovascular function during cognitive stress using the Stroop Color Test (SCWT) was documented in 25 men with ischemic heart disease (IHD) before and after coronary artery bypass grafting (CABG). Impedance cardiography was used to measure changes from resting baseline in heart rate (HR), stroke volume (SV), cardiac output (CO), myocardial contractility, and total peripheral resistance (TPR). Cognitive stress was associated with significant increases in HR, blood pressure, SV, CO, and myocardial contractility. TPR did not change from resting baseline during cognitive stress before CABG. However, TPR decreased significantly from resting baseline during cognitive stress after CABG. These findings support the theory that cognitive stress is associated with a significant increase in myocardial oxygen demand.

[Psychopathological disorders and coronary diseases]

The role of psychological factors in the genesis of coronary diseases has been considered for a long time. Friedman took it upon himself to describe a personality profile (pattern A) constituting a risk factor for coronary heart disease of which, however, the practical interest seems limited. The association of psychopathological conditions and coronary heart disease has on the other hand not been extensively studied. Recent epidemiological data show that anxiety and depressive states represent a high comorbidity with coronary heart diseases. Panic attacks remain underestimated; they seem to participate in a complex physiopathological mechanism along with ischemic coronary heart diseases. Recent studies have shown that the existence of a depressive illness during coronary heart disease and particularly in the time period following a myocardial infarction, constitutes an independent risk factor, thus increasing the mortality rate. The evolution of coronary heart disease seems greatly influenced by the existence of anxious or depressive states, the diagnosis and the treatment of these states represent a major interest towards a better management of coronary patients.

Prenatal psychosocial factors and the neuroendocrine axis in human pregnancy

OBJECTIVE

Physiological processes including neuroendocrine function have been proposed as mediators of the relationship between prenatal psychological state and pregnancy outcome; however, there are virtually no human studies that have systematically assessed such mechanisms. Neuroendocrine processes are significantly altered during pregnancy, and are characterized by the evolution of a transient neuroendocrine system, the placenta, and modifications in endocrine control mechanisms. Because these alterations have implications for neuroendocrine responsivity to exogenous conditions, the aim of the present study was to examine the cross-sectional association between prenatal psychosocial factors and stress-related neuroendocrine parameters during human pregnancy.

METHOD

Fifty-four adult women with a singleton, intrauterine pregnancy were recruited before 28 weeks of gestation. Maternal antecubital venous blood samples were withdrawn at 28 weeks of gestation for bioassays of adrenocorticotropin hormone (ACTH), beta-endorphin (beta E), and cortisol. Measures of prenatal stress, social support, and personality were collected using a two-part, self-report questionnaire administered at 28 and 30 weeks of gestation. Biomedical data were obtained from the medical record. Factors known to influence neuropeptide and hormone levels during pregnancy were controlled, including gestational age, circadian variation, and obstetric risk.

RESULTS

In the present sample, prenatal psychosocial stress, social support, and personality variables were associated with neuroendocrine parameters in two primary ways. First, certain psychosocial factors were significantly associated with plasma levels of ACTH, beta E, and cortisol, and second, psychosocial factors were associated with a measure of disregulation of the normal relationship between two pro-opiomelanocortin (POMC) derivatives, ACTH and beta E. Furthermore, a combination of the maternal psychosocial and sociodemographic factors during pregnancy accounted for 36% of the variance in ACTH, 22% of the variance in the ACTH-beta E disregulation index, 13% of the variance in cortisol, and 3% of the variance in beta E.

CONCLUSIONS

The present findings are consistent with the premise that maternal-placental-fetal neuroendocrine parameters are significantly associated, both in magnitude and specificity, with features of maternal psychosocial functioning in pregnancy despite the systemic alterations associated with the endocrinology of pregnancy. These findings provide a basis for further investigations of the role of the neuroendocrine system as a putative mediating pathway between prenatal psychosocial factors and birth outcome, and possibly also as a mechanism linking features of the maternal psychosocial environment to fetal/infant brain development.

Circadian variation of ambulatory myocardial ischemia. Triggering by daily activities and evidence for an endogenous circadian component

BACKGROUND

The morning peak in myocardial ischemia has been related to diurnal variations in physical and mental activities and to postural changes upon awakening. This study assesses (1) the effects of exogenous activity triggers at different times of the day and (2) the contribution of an endogenous (ie, activity- and posture-independent) circadian vulnerability for ambulatory ischemia.

METHODS AND RESULTS

Sixty-three stable coronary artery disease patients underwent ambulatory ECG monitoring and completed a structured diary assessing physical and mental activities. During 2519 hours of observation, a morning increase in ischemia coincided with increases in physical and mental activities, and an evening decrease in ischemia coincided with a decline in activities. During the morning, ischemic versus ischemia-free periods were more likely to occur with high levels of physical activity (P < .001). High physical activity triggered ischemia to a lesser but still significant extent (P < .05) in the afternoon but not in the evening (P = NS). High levels of mental activity triggered ischemia significantly during the morning (P < .04) and evening (P < .04) but not in the afternoon. When a residualized score procedure was used to correct ischemic time for each patient's simultaneously measured activities, for hourly heart rates, or for activity-related heart rate fluctuations, the circadian variation in ischemia was still observed (P < .001), with a peak at 6 AM. A significant increase in ischemia occurred immediately after awakening (P < .05), but activity-adjusted increases in morning ischemia persisted (P < .05) for 2 hours after awakening.

CONCLUSIONS

Exogenous factors (physical and mental activities) are most potent as triggers of ischemia during the morning hours, and the postural change after awakening contributes to the morning increase in ischemia. There is also evidence for an endogenous, activity-independent circadian influence on ischemic susceptibility that is independent of exogenous factors and that sustains the increase in ischemia upon awakening.

Triggers of myocardial ischemia during daily life in patients with coronary artery disease: physical and mental activities, anger and smoking

OBJECTIVES

This study assessed the potency of physical and mental activities and emotions (anger and anxiety) and smoking and other substance use as proximate triggers of ischemia in patients with coronary artery disease during daily life.

BACKGROUND

Myocardial ischemia occurs during a wide variety of activities in patients with coronary artery disease, but frequency and relative potency of physical and mental activities, smoking and use of caffeine and alcohol as triggers of ischemia during daily life have not been established.

METHODS

Patients (n = 63) with coronary artery disease and evidence of out-of-hospital ischemia kept a validated structured diary of physical and mental activities and psychologic states while undergoing ambulatory electrocardiographic monitoring for 24 to 48 h.

RESULTS

Ischemia occurred most frequently during moderately intense physical and mental activities. Patients spent the largest proportion of time engaged in low intensity physical and mental activities (p < 0.05), but the likelihood of ischemia was greatest during intense physical (p < 0.0001) and stressful mental activities (p < 0.03). The percentage of time in ischemia was elevated and approximately equivalent for high intensity physical and high intensity mental activities (5%) compared with 0.2% when patients were engaged in low intensity activities. Strenuous physical activity (e.g., effortful walking, p < 0.05) and the experience of intense anger were potent ischemic triggers, and heart rates at onset of ischemia increased with the intensity of physical and mental activity and with anger. Among smokers, ischemia was more than five times as likely when patients smoked than when they did not (during 24% vs. 5% of diary entries, p < 0.0001). Coffee and alcohol consumption were also related to ischemia (p < 0.05), but this association disappeared after controlling for concurrent cigarette smoking.

CONCLUSIONS

Triggers of ischemia in patients with coronary artery disease during daily life include not only strenuous exercise, but also activities involving low levels of exertion, such as anger and smoking. Mental activities appear to be as potent as physical activities in triggering daily life ischemia. Coffee and alcohol consumption are related to ischemia only by virtue of their associations with smoking.

Psychological determinants of anginal pain perception during exercise testing of stable patients after recovery from acute myocardial infarction or unstable angina pectoris

The objective of this study was to test the hypothesis that psychological factors are determinants of anginal symptoms during positive exercise tests. The sample consisted of clinically stable patients who were enrolled in the Multicenter Study of Myocardial Ischemia 1 to 6 months after admission to a coronary care unit. Among 186 post-myocardial infarction patients, 151 developed ischemia (i.e., a stress-induced myocardial perfusion defect) without symptoms (silent ischemia) and 35 developed angina with ischemia (symptomatic ischemia) during a thallium exercise test; among 39 patients who had been hospitalized for unstable angina, 24 developed silent ischemia and 15 developed symptomatic ischemia. Two sets of psychometric tests were administered: set 1, factors that influence awareness of physical symptoms, and set 2, factors associated with biases toward or against reporting perceived symptoms. Two hundred eleven patients produced complete data in each set. Analysis of set 1 factor scores revealed significant effects of symptom status (p = 0.006) and index event (p = 0.02), but no interaction. No effects were found in set 2. Patients who are clinically stable after recovery from an acute coronary event and who experience angina during exercise testing are more aware of physical symptoms in general than are comparable patients with silent ischemia. Psychological biases toward or against reporting perceived symptoms do not differentiate these groups. Thus, it appears that silent ischemia is probably "silent" in the sense of being truly asymptomatic rather than of stoic endurance or denial of perceived symptoms.

Mental stress-induced ischemia in the laboratory and ambulatory ischemia during daily life. Association and hemodynamic features

BACKGROUND

The purpose of this study was to determine the correspondence of mental stress-induced ischemia in the laboratory with ambulatory ischemia and to assess the relationship between hemodynamic responses to mental stress and the occurrence of ischemia. Although exercise testing is usually used to elicit myocardial ischemia, ischemia during daily life usually occurs at relatively low heart rates and in the absence of strenuous physical exercise. Mental stress has been shown to trigger ischemic events in the laboratory at lower heart rates but at blood pressures comparable to exercise. We therefore compared the extent to which mental stress and exercise testing identify patients who develop ischemia out of hospital.

METHODS AND RESULTS

One hundred thirty-two patients with documented coronary disease and recent evidence of exercise-induced myocardial ischemia underwent 48-hour ambulatory monitoring and radionuclide ventriculography during exercise and mental stress testing. Patients who displayed mental stress-induced ischemia in the laboratory were more likely to exhibit ischemia during daily life (P < .021). Furthermore, patients who exhibited ischemia during ambulatory monitoring displayed larger diastolic blood pressure (P < .006), heart rate (P < .039), and rate-pressure product responses (P < .018) during mental stress.

CONCLUSIONS

Among patients with prior positive exercise stress tests, mental stress-induced ischemia, defined by new wall motion abnormalities, predicts daily ischemia independent of exercise-induced ischemia. Exaggerated hemodynamic responses during mental stress testing also identify individuals who are more likely to exhibit myocardial ischemia during daily life and mental stress.

Sympathetically mediated effects of mental stress on the cardiac microcirculation of patients with coronary artery disease

Mental stress often causes myocardial ischemia in patients with coronary artery disease (CAD). There is increasing evidence that the coronary microcirculation of patients with atherosclerosis may be dysfunctional, with the potential of contributing to myocardial ischemia. This study investigated sympathetically mediated coronary microcirculatory and regional noradrenergic effects of mental stress. We measured left anterior descending coronary artery blood flow and norepinephrine kinetics at rest and during a 10-minute video game in 10 CAD patients with nonsignificant atherosclerosis of this artery and in 5 patients with normal coronary angiograms (NCA). The 2 groups did not differ in their responses of systemic and cardiac norepinephrine spillovers, heart rate, and blood pressure during mental stress. Patients with NCA had microvascular dilation during mental stress (26 +/- 9% [mean +/- SD] decline in coronary vascular resistance from baseline, p < 0.01), whereas patients with CAD did not (9 +/- 20% decline, p = 0.11). Six patients with CAD then received intracoronary phentolamine (1.7 micrograms/kg/min for 5 minutes, followed by 0.17 micrograms/kg/min) and played the video game again. In contrast to nonsignificant changes in coronary resistance during the initial video game (6 +/- 15% decline, p = 0.20), coronary vascular resistance decreased significantly during the repeat video game (25 +/- 19% decline, p = 0.02). Vasomotor responses of epicardial coronary artery segments did not differ between the 2 video game studies. Five other patients (4 with CAD, 1 with NCA) repeated the video game during intracoronary administration of 5% dextrose, with systemic and coronary hemodynamic and noradrenergic responses unchanged from those during the initial video game.(ABSTRACT TRUNCATED AT 250 WORDS)