Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique

Atherogenesis takes place in cholesterol-fed rabbits when circulating concentrations of endogenous cortisol are increased and inflammation suppressed

Atherosclerosis is an inflammatory disease, but the response of the endogenous anti-inflammatory system during this process has not been evaluated previously. Cortisol is the end product of this anti-inflammatory system, but is also able to activate cellular processes that induce atherogenesis; however, it is unknown whether atherogenesis occurs when circulating concentrations of endogenous cortisol are increased or when they are decreased. We have evaluated the counter-regulatory responses of cortisol and interleukin-1beta (IL-1beta) during the short- and long-term responses to vascular injury in rabbits fed a 2% cholesterol diet. In the short-term group (n=18), serum cortisol and IL-1beta concentrations were measured after 10, 20 and 30 days. Rabbits developed hypercholesterolemia and hypercortisolemia, with only modest increases in IL-1beta. Although inflammation was low-grade, atherogenesis took place, with subintimal lipid accumulation evident on day 30. In the second group (n=18), we evaluated variables after 40, 60 and 90 days. This group developed hypercholesterolemia, but serum cortisol concentrations were inappropriately normal, while IL-1beta concentrations were elevated 8.6-fold; advanced atherosclerotic plaques were evident on days 60 and 90. These results show that atherogenesis occurs when high endogenous cortisol levels are suppressing inflammation, and are consistent with a promotion of early atherogenesis by high cortisol concentrations.

Influence of specific nutrients on progression of atherosclerosis, vascular function, haemostasis and inflammation in coronary heart disease patients: a systematic review

Epidemiological evidence suggests that the diet influences CHD risk, although the protective effects of dietary intervention for patients in diseased states has gained less attention. Secondary care prevention strategies for patients often involves drug therapy that is expensive and can result in undesirable side effects. Therefore, it is potentially beneficial to utilise other strategies, such as diet, in the management of CHD. A systematic review was conducted to examine the effects of specific nutrients on progression of atherosclerosis, vascular function, haemostasis and inflammation in CHD patients. Results show substantial evidence for the efficacy ofn–3 oils in reducing cardiovascular mortality and one mechanism may be related to the stabilisation of vulnerable atherosclerotic plaques, although the effects on progression of atherosclerosis, haemostatic activity and vascular inflammation remain equivocal. Promising data also exist for the efficacy of flavonoid-rich foods for improving endothelial function, although strong clinical endpoint evidence is lacking. The variation in the efficacy of certain nutrients in CHD patients may be explained by genetics, existing risk factors, psychosocial factors and methodological issues, although these are often not adequately taken into consideration. We conclude that there is a need to undertake more appropriately designed trials in specific clinical populations, controlling for additional lifestyle and risk factors, examining potential interactions with medications, and also establishing methods to increase compliance to dietary recommendations before specific nutrients can be widely prescribed for secondary prevention. Future research should also utilise techniques that provide a direct measure of atherosclerosis.

The role of internists during epidemics, outbreaks, and bioterrorist attacks

Internists are well-positioned to play significant roles in recognizing and responding to epidemics, outbreaks, and bioterrorist attacks. They see large numbers of patients with various health problems and may be the patients' only interaction with the medical community for symptoms resulting from infectious diseases and injuries from radiation, chemicals, and/or burns. Therefore, Internists must understand early warning signs of different bioterrorist and infectious agents, proper reporting channels and measures, various ways that they can assist the public health response, and roles of different local, state, and federal agencies. In addition, it is important to understand effects of a public health disaster on clinic operations and relevant legal consequences.

Mental stress and coronary artery disease: a multidisciplinary guide

Research suggests that acute and chronic stress are risk factors for the development and progression of coronary artery disease. Much of this work is multidisciplinary, using unfamiliar concepts deriving from disciplines other than cardiology and medicine. This article addresses and clarifies, for the cardiologist, some of the key concepts and issues in this area and provides an overview of evidence linking acute and chronic stress to cardiac pathology. Areas addressed include definitions and measurement of mental stress, methodological issues in stress research, and distinctions between stress and variables such as personality, emotion, and depression. Mental stress is a multifactorial process involving the environment, individual experiences and coping, and a set of neuroendocrine, autonomic, cardiovascular, and other systemic physiologic responses. There are difficulties identifying a single consensus physiologic stress measure because of individual differences in perceptions and physiologic response patterns. Nonetheless, important associations exist between mental stress and clinically relevant cardiovascular end points. As multidisciplinary research in this area continues, one major goal is the better integration of psychosocial knowledge and measures with cardiology research and practice.

Neuroendocrine and Behavioral Mechanisms Mediating the Relationship between Anger Expression and Cardiovascular Risk: Assessment Considerations and Improvements

The hypothesis that intense anger experience may increase risk for or exacerbate cardiovascular diseases has been under active theoretical and empirical interest for decades. Biopsychological models of disease suggest that persons displaying exaggerated physiological responses to acute emotional or stressful states are at a greater risk to develop cardiovascular disorders. The last two decades have witnessed active work to refine means by which anger expression can be assessed, and laboratory research has produced evidence suggesting that certain expression styles may predict enhanced physiological responses to acute stress. In this paper, we review methodological and definition issues related to the assessment of anger, and we summarize recent improvements on the assessment of anger expression. We also review recent studies addressing the association between anger and cardiovascular diseases, and we present potential neuroendocrine and behavioral mechanisms through which anger expression may increase risk for cardiovascular disease.

Acute depressed mood as a trigger of acute coronary syndromes

BACKGROUND

Some cases of acute coronary syndrome (ACS) may be triggered by emotional states such as anger, but it is not known if acute depressed mood can act as a trigger.

METHODS

295 men and women with a verified ACS were studied. Depressed mood in the two hours before ACS symptom onset was compared with the same period 24 hours earlier (pair-matched analysis), and with usual levels of depressed mood, using case-crossover methods.

RESULTS

46 (18.2%) patients experienced depressed mood in the two hours before ACS onset. The odds of ACS following depressed mood were 2.50 (95% confidence intervals 1.05 to 6.56) in the pair-matched analysis, while the relative risk of ACS onset following depressed mood was 4.33 (95% confidence intervals 3.39 to 6.11) compared with usual levels of depressed mood. Depressed mood preceding ACS onset was more common in lower income patients (p = .032), and was associated with recent life stress, but was not related to psychiatric status.

CONCLUSIONS

Acute depressed mood may elicit biological responses that contribute to ACS, including vascular endothelial dysfunction, inflammatory cytokine release and platelet activation. Acute depressed mood may trigger potentially life-threatening cardiac events.

Fatalities after taking ibogaine in addiction treatment could be related to sudden cardiac death caused by autonomic dysfunction

Ibogaine is the most important alkaloid of the Central African Iboga-shrub. It is the central drug in Gabonian initiation ceremonies in which it is used to cause a near-death experience. In Western countries it is used in private clinics to treat addiction. However, in the United States and most European countries it is classified as an illegal drug because at least eight persons have died after having taken Ibogaine. These fatalities occurred in most cases several days after ingestion or following the intake of very small doses. There is no conclusive explanation at the present time for these deaths. We hypothesize, that these deaths may be a result of cardiac arrhythmias, caused by a dysregulation of the autonomic nervous system. Ibogaine affects the autonomic nervous system by influencing several neurotransmitter-systems and the fastigial nucleus. The cerebellar nucleus responds to small doses with a stimulation of the sympathetic system, leading to a fight or flight reaction. High doses, however, lead to a vagal dominance: a "feigned death". The risk of cardiac arrhythmias is increased in situations of sympathetic stimulation or coincidence of a high parasympathetic tonus and a left-sided sympathetic stimulation. This could occur under influence of small doses of ibogaine and also at times of exhaustion with a high vagal tonus, when sudden fear reactions could cause a critical left-sided sympathetic stimulation. Gabonian healers prevent these risks by isolating their patients from normal life and by inducing a trance-state with right-hemispheric and vagal dominance for several days.

Natural and unnatural triggers of myocardial infarction

Previous analyses have suggested that factors that stimulate the sympathetic nervous system and catecholamine release can trigger acute myocardial infarction. The wake-up time, Mondays, winter season, physical exertion, emotional upset, overeating, lack of sleep, cocaine, marijuana, anger, and sexual activity are some of the more common triggers. Certain natural disasters such as earthquakes and blizzards have also been associated with an increase in cardiac events. Certain unnatural triggers may play a role including the Holiday season. Holiday season cardiac events peak on Christmas and New Year. A number of hypotheses have been raised to explain the increase in cardiac events during the holidays, including overeating, excessive use of salt and alcohol, exposure to particulates, from fireplaces, a delay in seeking medical help, anxiety or depression related to the holidays, and poorer staffing of health care facilities at this time. War has been associated with an increase in cardiac events. Data regarding an increase in cardiac events during the 9/11 terrorist attack have been mixed. Understanding the cause of cardiovascular triggers will help in developing potential therapies.

Pathophysiological processes underlying emotional triggering of acute cardiac events

Acute negative emotional states may act as triggers of acute coronary syndrome (ACS), but the biological mechanisms involved are not known. Heightened platelet activation and hemodynamic shear stress provoked by acute stress may contribute. Here we investigated whether patients whose ACS had been preceded by acute anger, stress, or depression would show heightened hemodynamic and platelet activation in response to psychophysiological stress testing. We studied 34 male patients an average of 15 months after they had survived a documented ACS. According to an interview conducted within 5 days of hospital admission, 14 men had experienced acute negative emotion in the 2 h before symptom onset, and 20 men had not experienced any negative emotion. Hemodynamic variables and platelet activation were monitored during performance of challenging color-word interference and public speaking tasks and over a 2-h poststress recovery period. The emotion trigger group showed significantly greater increases in monocyte-platelet, leukocyte-platelet, and neutrophil-platelet aggregate responses to stress than the nontrigger group, after adjusting for age, body mass, smoking status, and medication. Monocyte-platelet aggregates remained elevated for 30 min after stress in the emotion trigger group. The emotion trigger group also showed poststress delayed recovery of systolic pressure and cardiac output compared with the nontrigger group. These results suggest that some patients with coronary artery disease may be particularly susceptible to emotional triggering of ACS because of heightened platelet activation in response to psychological stress, coupled with impaired hemodynamic poststress recovery.

Platelets, coronary heart disease, and stress

Coronary heart disease is the leading cause of death in Western society, and its development is associated with chronic stress and other psychosocial factors. Atherosclerosis, the disorder underlying this disease, is an inflammatory process in which leukocytes interact with structurally intact but dysfunctional endothelium of the arteries. Platelets play a key role in this process by binding to leukocytes and promoting their recruitment to the endothelium. Platelet-leukocyte interactions also stimulate the release of pro-inflammatory and pro-thrombotic factors which promote atherosclerosis. Elevated circulating levels of platelet-leukocyte aggregates have been reported in cardiac patients and in individuals of low socioeconomic status, a factor associated with chronic psychological stress. Increased platelet activation has also been observed in individuals prone to depression or hostility, and in people subject to high levels of work stress. Acute psychological stress increases circulating platelet-leukocyte aggregates in healthy individuals and this effect is prolonged in cardiac patients. Platelet activation may be a mechanism linking psychosocial stress with increased coronary risk, and may also play a role in the emotional triggering of acute coronary syndromes in patients with advanced coronary disease.

Triggering of acute coronary syndromes by physical exertion and anger: clinical and sociodemographic characteristics

OBJECTIVE

To investigate the role of vigorous physical exertion and anger as triggers of acute coronary syndromes (ACS) and to identify the clinical and sociodemographic correlates of triggering.

DESIGN

Prospective observational clinical cohort study.

SETTING

Four coronary care units in the London area.

PATIENTS

295 men and women with electrocardiographically and biochemically verified ACS.

MAIN OUTCOME MEASURES

Physical exertion in the 1 h and anger in the 2 h before symptom onset were assessed with structured interviews. Control periods were the equivalent hours one day earlier and usual rates over the past six months. Data were analysed by case-crossover methods.

RESULTS

Physical exertion was reported by 10% and anger by 17.4% of patients in the hazard period. The risk of ACS onset after physical exertion compared with light or no activity was 3.50 (95% confidence interval (CI) 1.37 to 10.6). The risk of onset with anger was 2.06 (95% CI 1.12 to 3.92). Physical exertion during the hazard period was related to an absence of premonitory symptoms, presentation with an ST elevation myocardial infarction (STEMI), low socioeconomic deprivation and higher future cardiovascular risk. Anger during the hazard period was more common in younger, socioeconomically deprived patients who presented with a STEMI.

CONCLUSIONS

Triggers are relevant across the spectrum of ACS. The distinct clinical and sociodemographic factors associated with physical exertion and anger suggest that different pathophysiological processes may be involved.

[Management of cardiac arrest in a German soccer stadium. Structural, process and outcome quality]

BACKGROUND

In Germany there is a lack of data about the quality of emergency medical care in mass gatherings. The following report reflects our experience with management of cardiac arrest events as an example for the most critical medical emergency in a soccer stadium.

METHODS

The Fritz-Walter Stadium is a well-known soccer arena with a crowd capacity of 46,600. Emergency medical care is provided by a 2-tiered system consisting of 3 emergency physicians and 65 ambulance personnel and paramedics. Resuscitation was conducted according to the guidelines of the European Resuscitation Council and American Heart Association.

RESULTS

Within 80 months, 13 witnessed cardiac arrests occurred, all in males. In each case the initial rhythm was ventricular fibrillation, 6 patients collapsed before or after the match. Basic life support was usually provided within 2 min, defibrillation and advanced life support within 4 min, 77% regained spontaneous circulation, and 62% survived without neurologic deficits.

CONCLUSION

Cardiac arrest is a relatively frequent event in a soccer stadium. Due to a well organised response system, the survival rate exceeded by far the corresponding figures reported by public health systems.

Frequency of distress and fear of dying during acute coronary syndromes and consequences for adaptation

Experiencing an acute coronary syndrome (ACS) may provoke a range of negative emotional responses, including acute distress and fear of dying. The frequency of these emotional states has rarely been assessed. This study examined the presence and severity of the fear of dying and acute distress in 184 patients with ACS and analyzed its correlates and consequences. Intense distress and fear of dying was reported by 40 patients (21.7%) and moderate fear and distress by 95 patients (51.6%). Intense distress and fear was associated with female gender (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.07 to 2.49), lower levels of education (OR 2.44, 95% CI 1.02 to 5.87), greater chest pain (OR 5.33, 95% CI 1.40 to 20.4), and emotional upset in the 2 hours before onset of ACS (OR 2.70, 95% CI 1.13 to 6.45). Having no acute distress or fear was more common in patients who exercised regularly (OR 3.32, 95% CI 1.35 to 8.18) and who did not initially attribute the chest pain to cardiac causes (OR 2.67, 95% CI 1.10 to 6.47). No association was found with cardiovascular disease history, objective measures of clinical severity, or with clinical presentation of ACS. Acute distress and fear of dying predicted greater depression and anxiety 1 week after ACS (p=0.006), and elevated levels of depression at 3 months (p=0.009), after adjustment for age, gender, and negative affect. In conclusion, distress and fear during the initial stages of an ACS may trigger subsequent depression and anxiety, thereby promoting poorer prognosis and greater morbidity with time.