A cortical potential reflecting cardiac function

A bihemispheric autonomic model for traumatic stress effects on health and behavior

A bihemispheric autonomic model (BHAM) may support advanced understanding of traumatic stress effects on physiology and behavior. The model builds on established data showing hemispheric lateralization in management of the autonomic nervous system, and proposes that traumatic stress can produce dominant asymmetry in activity of bilateral homologous brain regions responsible for autonomic management. Rightward and leftward dominant asymmetries are associated with sympathetic high arousal or parasympathetic freeze tendencies, respectively, and return to relative symmetry is associated with improved autonomic regulation. Autonomic auto-calibration for recovery (inverse of Jacksonian dissolution proposed by polyvagal theory) has implications for risk behaviors associated with traumatic life stress. Trauma-induced high arousal may be associated with risk for maladaptive behaviors to attenuate arousal (including abuse of alcohol or sedative-hypnotics). Trauma-induced freeze mode (including callous-unemotional trait) may be associated with low resting heart rate and risk for conduct disorders. The model may explain higher prevalence of leftward hemispheric abnormalities reported in studies of violence. Implications of the BHAM are illustrated through case examples of a military special operations officer with history of traumatic brain injury and post-traumatic stress disorder, and a university student with persisting post-concussion symptoms. Both undertook use of a noninvasive closed-loop neurotechnology - high-resolution, relational, resonance-based, electroencephalic mirroring - with ensuing decrease in hemispheric asymmetry, improvement in heart rate variability, and symptom reduction. Finally, the BHAM aligns with calls for researchers to use brain-behavioral constructs (research domain criteria or RDoC, proposed by the National Institutes of Mental Health) as building blocks for assessment and intervention in mental health science.

Heart rate variability biofeedback: how and why does it work?

In recent years there has been substantial support for heart rate variability biofeedback (HRVB) as a treatment for a variety of disorders and for performance enhancement (Gevirtz, 2013). Since conditions as widely varied as asthma and depression seem to respond to this form of cardiorespiratory feedback training, the issue of possible mechanisms becomes more salient. The most supported possible mechanism is the strengthening of homeostasis in the baroreceptor (Vaschillo et al., 2002; Lehrer et al., 2003). Recently, the effect on the vagal afferent pathway to the frontal cortical areas has been proposed. In this article, we review these and other possible mechanisms that might explain the positive effects of HRVB.

Fear from the heart: sensitivity to fear stimuli depends on individual heartbeats

Cognitions and emotions can be influenced by bodily physiology. Here, we investigated whether the processing of brief fear stimuli is selectively gated by their timing in relation to individual heartbeats. Emotional and neutral faces were presented to human volunteers at cardiac systole, when ejection of blood from the heart causes arterial baroreceptors to signal centrally the strength and timing of each heartbeat, and at diastole, the period between heartbeats when baroreceptors are quiescent. Participants performed behavioral and neuroimaging tasks to determine whether these interoceptive signals influence the detection of emotional stimuli at the threshold of conscious awareness and alter judgments of emotionality of fearful and neutral faces. Our results show that fearful faces were detected more easily and were rated as more intense at systole than at diastole. Correspondingly, amygdala responses were greater to fearful faces presented at systole relative to diastole. These novel findings highlight a major channel by which short-term interoceptive fluctuations enhance perceptual and evaluative processes specifically related to the processing of fear and threat and counter the view that baroreceptor afferent signaling is always inhibitory to sensory perception.

The neural subjective frame: from bodily signals to perceptual consciousness

The report 'I saw the stimulus' operationally defines visual consciousness, but where does the 'I' come from? To account for the subjective dimension of perceptual experience, we introduce the concept of the neural subjective frame. The neural subjective frame would be based on the constantly updated neural maps of the internal state of the body and constitute a neural referential from which first person experience can be created. We propose to root the neural subjective frame in the neural representation of visceral information which is transmitted through multiple anatomical pathways to a number of target sites, including posterior insula, ventral anterior cingulate cortex, amygdala and somatosensory cortex. We review existing experimental evidence showing that the processing of external stimuli can interact with visceral function. The neural subjective frame is a low-level building block of subjective experience which is not explicitly experienced by itself which is necessary but not sufficient for perceptual experience. It could also underlie other types of subjective experiences such as self-consciousness and emotional feelings. Because the neural subjective frame is tightly linked to homeostatic regulations involved in vigilance, it could also make a link between state and content consciousness.

Volitional control of heartbeat and its dependence on pallium

It is believed that we cannot change our heart rhythm by will because the heartbeat is mainly controlled by the autonomic nervous system (ANS), which cannot be affected directly by subjective will. An experiment was designed to determine whether the heartbeat and ANS could be controlled by volition, and, if it is true, how they were controlled. It was demonstrated that the ANS could be partly controlled by volition. The volition, which tended to slow down the heartbeat, initiated synchronized activity in the medial prefrontal cortex, inhibited the sympathetic system, and then decreased the heartbeat. On the other hand, another kind of volition, which sped up the heartbeat, initiated desynchronized activity at the precentral, central, parietal, and occipital regions, inhibited the parasympathetic system and excited the sympathetic system, and then increased the heartbeat. Moreover, information flow from posterior cortex to anterior cortex was observed during the experiment. The parietal area played an important role in triggering the sensorimotor cortex and integrating the information, and the information flow from the central and precentral cortex to heart was dominant. All that demonstrated that volition can partly control the heartbeat, but the behavior was different from the motor nervous system.

Suppression of the auditory N1-component for heartbeat-related sounds reflects interoceptive predictive coding

Although many studies have elucidated the neurocognitive mechanisms supporting the processing of externally generated sensory signals, less is known about the processing of interoceptive signals related to the viscera. Drawing a parallel with research on agency and the perception of self-generated action effects, in the present EEG study we report a reduced auditory N1 component when participants listened to heartbeat-related sounds compared to externally generated sounds. The auditory suppression for heartbeat sounds was robust and persisted after controlling for ECG-related artifacts, the number of trials involved and the phase of the cardiac cycle. In addition, the auditory N1 suppression for heartbeat-related sounds had a comparable scalp distribution as the N1 suppression observed for actively generated sounds. This finding indicates that the brain automatically differentiates between heartbeat-related and externally generated sounds through a process of sensory suppression, suggesting that a comparable predictive mechanism may underlie the processing of heartbeat and action-related information. Extending recent behavioral data about cardio-visual integration, the present cardio-auditory EEG data reveal that the processing of sounds in auditory cortex is systematically modulated by an interoceptive cardiac signal. The findings are discussed with respect to theories of interoceptive awareness, emotion, predictive coding, and their relevance to bodily self-consciousness.

Spontaneous fluctuations in neural responses to heartbeats predict visual detection

Spontaneous fluctuations of ongoing neural activity substantially affect sensory and cognitive performance. Because bodily signals are constantly relayed up to the neocortex, neural responses to bodily signals are likely to shape ongoing activity. Here, using magnetoencephalography, we show that in humans, neural events locked to heartbeats before stimulus onset predict the detection of a faint visual grating in the posterior right inferior parietal lobule and the ventral anterior cingulate cortex, two regions that have multiple functional correlates and that belong to the same resting-state network. Neither fluctuations in measured bodily parameters nor overall cortical excitability could account for this finding. Neural events locked to heartbeats therefore shape visual conscious experience, potentially by contributing to the neural maps of the organism that might underlie subjectivity. Beyond conscious vision, our results show that neural events locked to a basic physiological input such as heartbeats underlie behaviorally relevant differential activation in multifunctional cortical areas.

Synergistic application of cardiac sympathetic decentralization and comprehensive psychiatric treatment in the management of anxiety and electrical storm

We report here, for the first time, two cases demonstrating a synergistic application of bilateral cardiac sympathetic decentralization and multimodal psychiatric treatment for the assessment and management of anxiety following recurrent Implantable Cardioverter Defibrillator (ICD) shocks. In a first case the combination of bilateral cardiac sympathetic decentralization (BCSD), cognitive behavioral psychotherapy and anxiolytic medication was sufficient to attenuate the patient's symptoms and maladaptive behaviors, with a maintained benefit at 1 year. Among the more prominent subjective changes in the post-lesion state we observed a decrease in aversive interoceptive sensations, particularly of the heartbeat. The patient continued to experience cognitive threat appraisals on a frequent basis, although these were no longer incapacitating. In a second case, we report the effect of BCSD on autonomic tone and subjective state. In the post-lesion state we observed attenuated sympathetic responses to the valsalva maneuver, isometric handgrip and mental arithmetic stressor, including decreased systolic and diastolic blood pressure and, decreased skin conductance. Collectively, these preliminary findings suggest that an integrative, multidisciplinary approach to treating anxiety disorders in the setting of ventricular arrhythmias and recurrent ICD shocks can result in sustained improvements in physical, psychological, and functional status. These findings raise the possibility of a potential role for the stellate ganglion in the modulation of emotional experience and afferent transmission of interoceptive information to the central nervous system.

Cortisol rapidly affects amplitudes of heartbeat-evoked brain potentials--implications for the contribution of stress to an altered perception of physical sensations?

Little is known about the impact of stress and stress hormones on the processing of visceral-afferent signals. Clinical data suggest that cortisol may lower the threshold for interoceptive stimuli, while a pharmacological administration of cortisol decreases the sensitivity for physical symptoms. To clarify the role of cortisol for the processing of interoceptive signals, we investigated 16 healthy men on two occasions, once during the infusion of 4 mg of cortisol and once during the infusion of a placebo substance. Heartbeat-evoked potentials (HEP; derived from resting EEG and ECG, during open and closed eyes), which are psychophysiological indicators for the cortical processing of cardioceptive signals, were measured over 6-min periods once before, and four times after the infusion (1-7, 11-17, 21-27 and 31-37 min). We found that HEP amplitudes were higher during open than during closed eyes between 1 and 17 min after cortisol infusion. There was no effect of cortisol on heart rate. We conclude that cortisol may rapidly modulate the cortical processing of cardioceptive neural signals. These results may have relevance for the effects of stress on the development and maintenance of psychosomatic symptoms.

The man who feels two hearts: the different pathways of interoception

Recent advances in neuroscience have provided new insights into the understanding of heart-brain interaction and communication. Cardiac information to the brain relies on two pathways, terminating in the insular cortex (IC) and anterior cingulate cortex (ACC), along with the somatosensory cortex (S1-S2). Interoception relying on these neuroanatomical pathways has been shown to modulate social cognition. We report the case study of C.S., a patient with an 'external heart' (an extracorporeal left-univentricular cardiac assist device, LVAD). The patient was assessed with neural/behavioral measures of cardiac interoception complemented by neuropsychological and social cognition measures. The patient's performance on the interoception task (heartbeat detection) seemed to be guided by signals from the artificial LVAD, which provides a somatosensory beat rather than by his endogenous heart. Cortical activity (HEP, heartbeat-evoked potential) was found decreased in comparison with normal volunteers, particularly during interoceptive states. The patient accurately performed several cognitive tasks, except for interoception-related social cognition domains (empathy, theory of mind and decision making). This evidence suggests an imbalance in the patient's cardiac interoceptive pathways that enhances sensation driven by the artificial pump over that from the cardiac vagal-IC/ACC pathway. A patient with two hearts, one endogenous and one artificial, presents a unique opportunity to explore models of interoception and heart-brain interaction.

Neural traces of stress: cortisol related sustained enhancement of amygdala-hippocampal functional connectivity

Stressful experiences modulate neuro-circuitry function, and the temporal trajectory of these alterations, elapsing from early disturbances to late recovery, heavily influences resilience and vulnerability to stress. Such effects of stress may depend on processes that are engaged during resting-state, through active recollection of past experiences and anticipation of future events, all known to involve the default mode network (DMN). By inducing social stress and acquiring resting-state functional magnetic resonance imaging (fMRI) before stress, immediately following it, and 2 h later, we expanded the time-window for examining the trajectory of the stress response. Throughout the study repeated cortisol samplings and self-reports of stress levels were obtained from 51 healthy young males. Post-stress alterations were investigated by whole brain resting-state functional connectivity (rsFC) of two central hubs of the DMN: the posterior cingulate cortex (PCC) and hippocampus. Results indicate a ’recovery’ pattern of DMN connectivity, in which all alterations, ascribed to the intervening stress, returned to pre-stress levels. The only exception to this pattern was a stress-induced rise in amygdala-hippocampal connectivity, which was sustained for as long as 2 h following stress induction. Furthermore, this sustained enhancement of limbic connectivity was inversely correlated to individual stress-induced cortisol responsiveness (AUCi) and characterized only the group lacking such increased cortisol (i.e., non-responders). Our observations provide evidence of a prolonged post-stress response profile, characterized by both the comprehensive balance of most DMN functional connections and the distinct time and cortisol dependent ascent of intra-limbic connectivity. These novel insights into neuro-endocrine relations are another milestone in the ongoing search for individual markers in stress-related psychopathologies.

Volitional control of the heart rate

The heart rate is largely under control of the autonomic nervous system. The aim of the present study is to investigate the interactions between the brain and heart underlying volitional control of the heart and to explore the effectiveness of volition as a strategy to control the heart rate without biofeedback. Twenty seven healthy male subjects voluntarily participated in the study and were instructed to decrease and increase their heart beats according to rhythmic, computer generated sound either 10% faster or slower than the subjects' measured heart rate. Sympathetic and parasympathetic activities were estimated with the heart rate variability (HRV) obtained by power spectral analysis of RR intervals. Functional coupling patterns of cerebral cortex with the heart were determined by Partial directed coherence (PDC). In HR(slow) task; HR and sympathetic activity significantly decreased. However parasympathetic activity and power spectral density of EEG in low Alpha (8-10.5 Hz) band significantly increased. Moreover information flow from parietal area (P3 and P4) to RR interval significantly increased. During HR(quick) task; HR, sympathetic activity and power spectral density of EEG in low Beta (14-24 Hz) band significantly increased. Parasympathetic activity significantly decreased. Information flow from FT8, CZ and T8 electrodes to RR interval significantly increased. Our findings suggested that the heart beat can be controlled by volition and is related to some special areas in the cortex.

Brain-heart interactions and cardiac ventricular arrhythmias

A wide range of evidence implicates the brain as playing a significant role in ventricular arrhythmias and sudden cardiac death. The mechanism is thought to involve the intermediary of the autonomic nervous system. Here we briefly consider possible mechanisms by which central neural processing may modulate the myocardial electrophysiology and hence the arrhythmia substrate.

Interaction between cognition, emotion, and the autonomic nervous system

The mind and body are intrinsically and dynamically coupled. Perceptions, thoughts and feelings change, and respond to, the state of the body. This chapter describes the integration of cognitive and affective processes with the autonomic control of bodily arousal, focusing on reciprocal effects of autonomic responses on decision making, error detection, memory and emotions. Neuroimaging techniques are beginning to detail the neuronal substrates mediating these interactions between mental and physiological states, implicating cortical regions (specifically insular and cingulate cortices) alongside subcortical (amygdala) and brainstem (notably dorsal pons) in these mechanisms. The extent to which bodily states influence mental processes is determined in part by "interoceptive sensitivity," an index of individual differences in the ability to detect one's own bodily sensations. Moreover, the misidentification or misattribution of interoceptive responses is implicated in a number of pathologies such as depersonalization, schizophrenia, and anxiety. Increasing knowledge of the mechanisms of body-mind interactions has wide ranging implications, from decision making to empathy, and may serve elucidate potential avenues of intervention for stress-sensitive conditions in which psychological, cognitive, and emotional factors impact on the expression of physical symptoms.

Modulation of human motoneuron activity by a mental arithmetic task

This study aimed to determine whether the performance of a mental task affects motoneuron activity. To this end, the tonic discharge pattern of wrist extensor motor units was analyzed in healthy subjects while they were required to maintain a steady wrist extension force and to concurrently perform a mental arithmetic (MA) task. A shortening of the mean inter-spike interval (ISI) and a decrease in ISI variability occurred when MA task was superimposed to the motor task. Aloud and silent MA affected equally the rate and variability of motoneuron discharge. Increases in surface EMG activity and force level were consistent with the modulation of the motor unit discharge rate. Trial-by-trial analysis of the characteristics of motor unit firing revealed that performing MA increases activation of wrist extensor SMU. It is suggested that increase in muscle spindle afferent activity, resulting from fusimotor drive activation by MA, may have contributed to the increase in synaptic inputs to motoneurons during the mental task performance, likely together with enhancement in the descending drive. The finding that a mental task affects motoneuron activity could have consequences in assessment of motor disabilities and in rehabilitation in motor pathologies.

On the embodiment of emotion regulation: interoceptive awareness facilitates reappraisal

The ability to cognitively regulate emotional responses to aversive events is essential for mental and physical health. One prerequisite of successful emotion regulation is the awareness of emotional states, which in turn is associated with the awareness of bodily signals [interoceptive awareness (IA)]. This study investigated the neural dynamics of reappraisal of emotional responses in 28 participants who differed with respect to IA. Electroencephalography was used to characterize the time course of emotion regulation. We found that reappraisal was accompanied by reduced arousal and significant modulation of late neural responses. What is more, higher IA facilitated downregulation of affect and was associated with more pronounced modulation of underlying neural activity. Therefore, we conclude that IA not only advances the consolidation of somatic markers required for guiding individual behaviour but also creates processing advantages in tasks referring to these bodily markers.

[Cardiac complications of acute brain injury]

The clinical importance of cardiovascular consequences resulting from cerebral injury has long been recognized. However, interactions between the brain and the cardiovascular system remain poorly defined and their importance for the management of patients suffering from acute brain injury is largely underestimated. This should have profound consequences on treatment strategies during anaesthesia and intensive cares of these patients, taking into account not only brain perfusion, but also cardiovascular optimisation. This report summarizes the main data available regarding the cardiovascular consequences of brain death, traumatic brain injury, stroke and epilepsy.

Brain responses to cardiac electrical stimulation: a new EEG method for evaluating cardiac sensation

Although cardiac sensation, such as palpitation or chest pain, is common and is sometimes a malignant sign of heart diseases, the mechanism by which the human brain responds to afferent signals from the heart remains unclear. In this study, we investigated whether electrical stimulation of the heart provokes brain responses in humans. We examined 15 patients (age: 65.4 ± 3.1 years old, 11 males and 4 females) implanted with either a cardiac pacemaker or cardiac resynchronization therapy (CRT) device. Electroencephalogram (EEG) was simultaneously recorded from the vertex during right ventricular pacing at 70-100 beats/min at baseline (1.5 V) and intense (6-8 V) stimulation sessions. We evaluated brain responses to cardiac electrical stimulation by measuring cerebral potentials that were obtained by subtracting the average of 100 EEG waves triggered by cardiac pacing during baseline stimulation from those during the intense stimulation. Intense stimulation of the cardiac pacemaker or CRT device reproducibly induced cardiac sensation in 6 out of the 15 patients; namely, the remaining 9 patients showed no reproducible response. Brain responses were evident by averaging cerebral potentials from all of the 15 patients and those from 6 patients with reproducible cardiac sensation. To the best our knowledge, this is the first report that demonstrates the brain responses to cardiac electrical stimulation in humans. This new method should be useful for examining pathophysiology of cardiac diseases with pathological cardiac sensation, including cardiac anxiety and silent myocardial ischemia.

Anger, emotion, and arrhythmias: from brain to heart

Strong emotion and mental stress are now recognized as playing a significant role in severe and fatal ventricular arrhythmias. The mechanisms, although incompletely understood, include central processing at the cortical and brain stem level, the autonomic nerves and the electrophysiology of the myocardium. Each of these is usually studied separately by investigators from different disciplines. However, many are regulatory processes which incorporate interactive feedforward and feedback mechanisms. In this review we consider the whole as an integrated interactive brain-heart system.

Baroreceptor activation attenuates attentional effects on pain-evoked potentials

Focused attention typically enhances neural nociceptive responses, reflected electroencephalographically as increased amplitude of pain-evoked event-related potentials (ERPs). Additionally, pain-evoked ERPs are attenuated by hypertension and baroreceptor activity, through as yet unclear mechanisms. There is indirect evidence that these two effects may interact, suggesting that baroreceptor-related modulation of nociception is more than a low-level gating phenomenon. To address this hypothesis, we explored in a group of healthy participants the combined effects of cue-induced expectancy and baroreceptor activity on the amplitude of pain-evoked ERPs. Brief nociceptive skin stimuli were delivered during a simple visual task; half were preceded by a visual forewarning cue, and half were unpredictable. Nociceptive stimuli were timed to coincide either with systole (maximum activation of cardiac baroreceptors) or with diastole (minimum baroreceptor activation). We observed a strong interaction between expectancy and cardiac timing for the amplitude of the P2 ERP component; no effects were observed for the N2 component. Cued stimuli were associated with larger P2 amplitude, but this effect was abolished for stimuli presented during baroreceptor activation. No cardiac timing effect was observed for un-cued stimuli. Taken together, these findings suggest a close integration of cognitive-affective aspects of expectancy and baroreceptor influences on pain, and as such may cast further light on mechanisms underlying mental and physiological contributions to clinical pain.

Effects of mental tasks on the cardiorespiratory synchronization

The cardiovascular and respiratory systems are functionally related to each other, but it is unclear if the cerebral cortex can affect their interaction. The effect of a mental task on the synchronization between cardiovascular and respiratory systems was investigated in the article. Electroencephalogram (EEG), electrocardiogram (ECG) and respiratory signal (RES) were collected from 29 healthy male subjects during the mental arithmetic (MA) task and the synchrogram was used to estimate the strength of cardiorespiratory synchronization. Our results showed that MA task significantly increased the breath rate, the heart rate and the EEG power spectral energy in theta band at FC3, FC4 and C4 electrodes (p<0.01), decreased the duration of cardiorespiratory synchronization epochs (p<0.05). Moreover the duration of cardiorespiratory synchronization epochs during MA task was negatively correlated with the EEG power spectral energy in theta band at FC3, FC4 and C4 electrodes and the sympathetic activity (p<0.05). The results demonstrated that ANS and cerebral cortex are implicated in the changes of cardiorespiratory synchronization during MA task.

Visceral brain-body information transfer

Organisms interact with their environments through various afferent (sensory) and efferent (motor) mechanisms. While the usual environment of interest has been external to the organism, the internal environment is also of fundamental importance. This article briefly reviews many of the interactive mechanisms between the brain and the visceral environment, along with identification of relevant brain structures and linkages related to these peripheral functions (particularly the hypothalamus). Afferent and efferent neural (autonomic nervous system) and chemical (endocrine, immune, and blood-brain barrier and circumventricular organs) pathways are described, and potential unifying principles (emotion and, especially, homeostasis, including allostasis and stress) are identified. The importance of bidirectional (afferent, efferent) communication is emphasized. These systems of visceral brain-body information transfer are major connections between the central nervous system and the body through which and by which many psychosomatic processes occur.

The usefulness of psychophysiology in the maintenance of cognitive life

In connection with the 14th World Congress of Psychophysiology--the Olympics of the Brain--IOP2008, held in my native Sankt-Petersburg, I am happy to state that the conceptualization of Psychophysiology as forming the objective scientific bases upon which the investigation and understanding of human cognitive and emotional processes became possible, was born in this country in 1886, under the wise leadership and personal initiatives of my Grandfather, the great Vladimir Michailovich Bechterev, whose contribution in the Experimental and Clinical Psychophysiology and Human Brain Sciences have been invaluable. The purpose of my present essay is to share with you some of my views and thoughts about the importance of Psychophysiology for the maintenance of daily intellectual life from childhood to adulthood and through the aging process.

The rebirth of neuroscience in psychosomatic medicine, Part II: clinical applications and implications for research

During the second half of the last century, biopsychosocial research in psychosomatic medicine largely ignored the brain. Neuroscience has started to make a comeback in psychosomatic medicine research and promises to advance the field in important ways. In this paper we briefly review select brain imaging research findings in psychosomatic medicine in four key areas: cardiovascular regulation, visceral pain in the context of functional gastrointestinal disorders, acute and chronic somatic pain and placebo. In each area, there is a growing literature that is beginning to define a network of brain areas that participate in the functions in question. Evidence to date suggests that cortical and subcortical areas that are involved in emotion and emotion regulation play an important role in each domain. Neuroscientific research is therefore validating findings from previous psychosomatic research and has the potential to extend knowledge by delineating the biological mechanisms that link mind and body more completely and with greater specificity. We conclude with a discussion of the implications of this work for how research in psychosomatic medicine is conducted, the ways in which neuroscientific advances can lead to new clinical applications in psychosomatic contexts, the implications of this work for the field of medicine more generally, and the priorities for research in the next 5 to 10 years.

Repolarization changes induced by mental stress in normal subjects and patients with coronary artery disease: effect of nitroglycerine

OBJECTIVES

Mental stress can significantly affect ventricular repolarization, which could potentially trigger arrhythmias. We compared the effect of mental stress on repolarization indexed by the amplitude and area of the T wave in patients with coronary artery disease (CAD) and healthy subjects.

METHODS

Fourteen healthy controls (11 M, mean age 42 years) and 14 patients with stable CAD (12 M, mean age 64) underwent a mental stress protocol consisting of mental arithmetic followed by a speech (5 minutes each), which was performed on two occasions following either nitroglycerine (NTG) or placebo. Multiple 12-lead electrocardiograms were acquired and repolarization was analyzed using automatically measured T wave amplitude (T(amp)) and area (T(area)).

RESULTS

When preceded by placebo the overall effect of mental stress, whether induced by arithmetic or speech, was significantly different in CAD patients compared with controls, with a decrease in T(amp) and T(area) in controls and an increase in patients; e.g., change in T(amp) during arithmetic -20 +/- 3 microV in controls versus 4 +/- 2 microV in patients, p < .001, and during speech -9 +/- 3 microV in controls versus 7 +/- 1 microV in patients, p < .001. Following NTG, the effect of stress on repolarization was similar in the 2 groups, with a reversed effect, i.e., decrease instead of increase in T(amp) and T(area) in CAD patients.

CONCLUSIONS

The effect of mental stress on ventricular repolarization is significantly different in CAD patients compared with healthy controls. These differences are considerably reduced by NTG.

Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction

Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by a stressful event and has a clinical presentation that is indistinguishable from a myocardial infarction. We review the best evidence regarding the pathophysiology, clinical features, investigation, and management of ABS. The incidence of ABS is estimated to be 1% to 2% of patients presenting with an acute myocardial infarction. The pathophysiology remains unknown, but catecholamine mediated myocardial stunning is the most favored explanation. Chest pain and dyspnea are the typical presenting symptoms. Transient ST elevation may be present on the electrocardiogram, and a small rise in cardiac troponin T is invariable. Typically, there is hypokinesis or akinesis of the mid and apical segments of the left ventricle with sparing of the basal systolic function without obstructive coronary lesions. Supportive treatment leads to spontaneous rapid recovery in nearly all patients. The prognosis is excellent, and a recurrence occurs in <10% of patients. Apical ballooning syndrome should be included in the differential diagnosis of patients with an apparent acute coronary syndrome with left ventricular regional wall motion abnormality and absence of obstructive coronary artery disease, especially in the setting of a stressful trigger.

The mystery of sudden death: mechanisms for risks

This review addresses the possible overlapping mechanisms that may apply to the risk of sudden unexpected death occurring in epilepsy and in cardiac disease. It explores the interaction between the central and peripheral autonomic nervous systems and the cardiopulmonary systems. Included is a discussion of the potential interactive role of genetically determined subtle cardiac risk factors for arrhythmias with a predisposition for seizure-related cardiac arrhythmias. We address the possible mechanisms that are operant in producing both epileptogenic and cardiogenic arrhythmias. Finally, we speculate about potential preventive measures to minimize the risk of both sudden unexpected death in epilepsy and sudden cardiac death.