Triggers of angina and ST-segment depression in ambulatory patients with coronary artery disease: evidence for an uncoupling of angina and ischemia

Ischemia and no obstructive coronary arteries in patients with stable ischemic heart disease

A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed.

Gender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV Medicine

Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men, yet women continue to have delays in diagnosis and treatment. The lack of recognition of sex-specific biological and socio-cultural gender-related differences in chest pain presentation of CAD may, in part, explain these disparities. Sex and gender differences in pain mechanisms including psychological susceptibility, the autonomic nervous system (ANS) reactivity, and visceral innervation likely contribute to chest pain differences. CAD risk scores and typical/atypical angina characterization no longer appear relevant and should not be used in women and men. Women more often have ischemia with no obstructive CAD (INOCA) and myocardial infarction, contributing to diagnostic and therapeutic equipoise. Existing knowledge demonstrates that chest pain often does not relate to obstructive CAD, suggesting a more thoughtful approach to percutaneous coronary intervention (PCI) and medical therapy for chest pain in stable obstructive CAD. Emerging knowledge regarding the central and ANS and visceral pain processing in patients with and without angina offers explanatory mechanisms for chest pain and should be investigated with interdisciplinary teams of cardiologists, neuroscientists, bio-behavioral experts, and pain specialists. Improved understanding of sex and gender differences in chest pain, including biological pathways as well as sociocultural contributions, is needed to improve clinical care in both women and men.

Facial Expressions of Emotions During Pharmacological and Exercise Stress Testing: the Role of Myocardial Ischemia and Cardiac Symptoms

Background

Negative emotions have been linked to ischemic heart disease, but existing research typically involves self-report methods and little is known about non-verbal facial emotion expression. The role of ischemia and anginal symptoms in emotion expression was examined.

Methods

Patients undergoing cardiac stress testing (CST) using bicycle exercise or adenosine with myocardial perfusion imaging were included (N = 256, mean age 66.8 ± 8.7 year., 43% women). Video images and emotion expression (sadness, anxiety, anger, and happiness) were analyzed at baseline, initial CST , maximal CST, recovery. Nuclear images were evaluated using SPECT.

Results

Ischemia (N = 89; 35%) was associated with higher levels of sadness (p = .017, d = 0.34) and lower happiness (p = .015, d = 0.30). During recovery, patients with both ischemia and anginal symptoms had the highest sadness expression (F (3,254) = 3.67, p = .013, eta² = 0.042) and the lowest happiness expression (F (3, 254) = 4.19, p = .006, eta² = .048).

Conclusion

Sadness and reduced happiness were more common in patients with ischemia. Also, anginal symptoms were associated with more negative emotions.

Gender in cardiovascular medicine: chest pain and coronary artery disease

Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality among women and men yet women are more often underdiagnosed, have a delay in diagnosis, and/or receive suboptimal treatment. An implicit gender-bias with regard to lack of recognition of sex-related differences in presentation of IHD may, in part, explain these differences in women compared with men. Indeed, existing knowledge demonstrates that angina does not commonly relate to obstructive coronary artery disease (CAD). Emerging knowledge supports an inclusive approach to chest pain symptoms in women, as well as a more thoughtful consideration of percutaneous coronary intervention for angina in stable obstructive CAD, to avoid chasing our tails. Emerging knowledge regarding the cardiac autonomic nervous system and visceral pain pathways in patients with and without obstructive CAD offers explanatory mechanisms for angina. Interdisciplinary investigation approaches that involve cardiologists, biobehavioural specialists, and anaesthesia/pain specialists to improve angina treatment should be pursued.

Severity of Chest Pain among Acute Myocardial Infarction Patients with Diagonal Branch Vessel Disease: A Pilot Study

Introduction: Acute myocardial infarction (AMI) patients present with variable clinical manifestations such as shortness of breath, nausea, etc. among which chest pain is the most common. Previous studies have reported that the clinical presentation of AMI patients with branch vessel disease is indistinguishable from epicardial coronary vessel disease. However, our experience suggests patients with branch vessel disease experience severe chest pain, especially those with a diagonal branch. Therefore, we aim to study the association of chest pain severity with isolated diagonal branch vessel disease as a culprit vessel in AMI patients.

Methods: It is a retrospective case-control design, where 10 cases and 40 historic controls were recruited in the study. Cases were patients with isolated diagonal branch disease, whereas controls were patients with epicardial vessel disease in AMI. We reviewed Coronary Angiograms of adult patients who presented with acute myocardial infarction and had undergone coronary angiography at Aga Khan University Hospital, Karachi (AKUH). Information on pain scores was measured using the Numeric Pain Rating Scale (NRS) before administration of analgesics. Other relevant variables were also recorded on a pre-structured questionnaire.

Results: The mean age of all the participants in the study was 60 ± 11.0 years, with 16% of the patients being women. Among all AMI patients, the intensity of chest pain in patients with isolated diagonal branch vessel disease was 2.6 units higher as compared to those with other epicardial coronary vessel diseases (p-value: <0.001; 95% CI: 1.67 - 3.46).

Conclusion: This preliminary study indicates severe chest pain can be a differentiating symptom in AMI patients with diagonal branch disease. It emphasizes clinicians to look for a possibility of a diagonal branch as a culprit vessel in AMI for better judgment, as it is often overlooked. future studies may be conducted at multiple centers for larger sample size and better generalizability.

Illness perceptions, mood and quality of life: a systematic review of coronary heart disease patients

OBJECTIVE

To examine published literature investigating the relationship between illness perceptions, mood and quality of life (QoL) in coronary heart disease (CHD) populations.

METHODS

Key databases were systematically searched (CINAHL, Medline, PsycINFO, Scopus and Web of Science) for studies matching the inclusion criteria between November 2011 and February 2012. References of included studies were examined and key authors contacted. Studies were subject to a quality control check.

RESULTS

21 studies met the inclusion criteria. A synthesis of the results found that illness perceptions were correlated to and predicted QoL and mood across CHD diagnoses. Specific illness perceptions (control, coherence and timeline) were found to be important for patients that had experienced an unexpected medical event, such as myocardial infarction.

CONCLUSION

The results of this study provide support that illness perceptions are related to outcomes across CHD populations and disease progression, however the results do not selectively support one particular model. Recommendations are consistent with cardiac rehabilitation guidelines. Further research should focus on the systemic impact of illness perceptions.

Psychological and physiological predictors of angina during exercise-induced ischemia in patients with coronary artery disease

OBJECTIVE

This study compares sensory-biological, cognitive-emotional, and cognitive-interpretational factors in predicting angina on an exercise treadmill test (ETT).

METHODS

A total of 163 patients with ETT-induced ischemia and coronary artery disease in the National Heart, Lung, and Blood Institute Psychophysiological Investigations of Myocardial Ischemia study were given an ETT, during which 79 patients reported angina. We assessed the following as potential predictors of self-reported anginal pain: sensory-biological factors (β-endorphin reactivity, hot pain threshold, and maximal ST-segment depression), cognitive-emotional factors (negative affect and symptom perception), and cognitive-interpretational factors (self-reported history of exercise-induced angina). Models were covariate adjusted with predictors examined individually and as part of component blocks.

RESULTS

Logistic regression revealed that history of angina (odds ratio [OR] = 17.41, 95% confidence interval = 7.16-42.34) and negative affect (OR = 1.65, 95% confidence interval = 1.17-2.34), but not maximal ST-segment depression, hot pain threshold, β-endorphin reactivity, or symptom perception, were significant predictors of angina on the ETT. The sensory-biological block was not significantly predictive of anginal pain (χ(2)block = 5.15, p = .741). However, the cognitive-emotional block (χ(2)block = 11.19, p = .004) and history of angina (cognitive-interpretation; χ(2)block = 54.87, p < .001) were predictive of ETT angina. A model including all variables revealed that only history of angina was predictive of ETT pain (OR = 16.39, p < .001), although negative affect approached significance (OR = 1.45, p = .07).

CONCLUSIONS

In patients with ischemia, cognitive-emotional and cognitive-interpretational factors are important predictors of exercise angina.

Myocardial ischemia, reperfusion, and infarction in chronically instrumented, intact, conscious, and unrestrained mice

In the United States alone, the National Heart, Lung, and Blood Institute (NHLBI) has invested several hundred million dollars in pursuit of myocardial infarct-sparing therapies. However, due largely to methodological limitations, this investment has not produced any notable clinical application or cardioprotective therapy. Among the major methodological limitations is the reliance on animal models that do not mimic the clinical situation. In this context, the limited use of conscious animal models is of major concern. In fact, whenever possible, studies of cardiovascular physiology and pathophysiology should be conducted in conscious, complex models to avoid the complications associated with the use of anesthesia and surgical trauma. The mouse has significant advantages over other experimental models for the investigation of infarct-sparing therapies. The mouse is inexpensive, has a high throughput, and presents the ability of one to create genetically modified models. However, successful infarct-sparing therapies in anesthetized mice or isolated mouse hearts may not be successful in more complex models, including conscious mice. Accordingly, a conscious mouse model of myocardial ischemia and reperfusion has the potential to be of major importance for advancing the concepts and methods that drive the development of infarct-sparing therapies. Therefore, we describe, for the first time, the use of an intact, conscious, and unrestrained mouse model of myocardial ischemia-reperfusion and infarction. The conscious mouse model permits occlusion and reperfusion of the left anterior descending coronary artery in an intact, complex model free of the confounding influences of anesthetics and surgical trauma. This methodology may be adopted for advancing the concepts and ideas that drive cardiovascular research.

Symptoms of anxiety and depression are correlates of angina pectoris by recent history and an ischemia-positive treadmill test in patients with documented coronary artery disease in the pimi study

Objective. We tested the association of specific psychological characteristics in patients having stable coronary disease with the reporting of anginal symptoms during daily activities, and positive exercise testing. Methods. One hundred and ninety-six patients with documented CAD enrolled in the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study completed an anginal history questionnaire and a battery of psychometric tests. They also underwent standardized exercise treadmill tests. Results. Patients with a recent history of angina were more likely to be female, and had higher Beck Depression (P = .002), State Anxiety (P = .001), Trait Anxiety (P = .03), Harm Avoidance (P = .04) and Muscle Tension (P = .004) scores than patients who had no recent history of angina. Along with several treadmill variables indicating more severe disease state and reduced exercise tolerance, patients who developed angina on a positive treadmill test also displayed higher scores on the Beck Depression Inventory (P = .003) and State Anxiety (P = .004) scales. Conclusions. Several psychological characteristics, and most notably anxiety and depression, are strong correlates of recent angina and angina in the presence of ischemia provoked by treadmill testing.

Psychic trauma as cause of death

AIM

of study Psychic trauma is described as the action of 'an emotionally overwhelming factor' capable of causing neurovegetative alterations leading to transitory or persisting bodily changes. The medico-legal concept of psychic trauma and its definition as a cause in penal cases is debated. The authors present three cases of death after psychic trauma, and discuss the definition of cause within the penal ambit of identified 'emotionally overwhelming factors'.

MATERIALS AND METHODS

The methodological approach to ascertainment and criterion-based assessment in each case involved the following phases: (1) examination of circumstantial evidence, clinical records and documentation; (2) autopsy; (3) ascertainment of cause of death; and (4) ascertainment of psychic trauma, and its coexisting relationship with the cause of death.

RESULTS

The results and assessment of each of the three cases are discussed from the viewpoint of the causal connotation of psychic trauma. In the cases presented, psychic trauma caused death, as deduced from assessment of the type of externally caused emotional insult, the subjects' personal characteristics and the circumstances of the event causing death.

CONCLUSIONS

In cases of death due to psychic trauma, careful methodological ascertainment is essential, with the double aim of defining 'emotionally overwhelming factors' as a significant cause of death from the penal point of view, and of identifying the responsibility of third parties involved in the death event and associated dynamics of homicide.

An integrated approach to the diagnosis and treatment of anxiety within the practice of cardiology

Coronary heart disease (CHD) is the leading cause of death and disability in the United States and in highly industrialized countries. Many modifiable psychosocial risk factors have been identified and can affect the course of cardiac illness. These include the negative emotional states of depression, anxiety, stress, anger/hostility, and social isolation. Anxiety has been found to increase the risk of developing CHD in healthy subjects and can lead to worsening of existing CHD. There is much overlap and confusion throughout the research literature between what authors define as anxiety, stress, Type A behavioral pattern, and anger/hostility.There is a need for better screening within the practice of cardiology for these psychosocial risk factors to ensure better integration of mental health services. Established screening tools such as the Beck Anxiety Inventory, Patient Health Questionnaire-9, Zung Self-Rating Anxiety Scale, and the Hamilton Anxiety Scale are described and compared with the newer Screening Tool for Psychologic Distress as part of the initial work-up of every cardiac patient. Recommendations are made using the author's Anxiety Treatment Algorithm regarding when to refer to a mental health professional along with how to reduce stigma and provide more integrated care. The diagnosis and treatment of anxiety disorders is reviewed, with attention to selective serotonin reuptake inhibitors, benzodiazepines, cognitive-behavioral therapy, stress reduction, and behavioral medicine group programs. These group programs are recommended because they help to overcome social isolation and counsel patients on how to adapt to a healthy lifestyle. Better clinical outcome research is needed that specifically addresses the question of whether the treatment of anxiety and anxiety disorders can affect the course of cardiac illness.

Angina pectoris during daily activities and exercise stress testing: The role of inducible myocardial ischemia and psychological distress

Physicians often consider angina pectoris to be synonymous with myocardial ischemia. However, the relationship between angina and myocardial ischemia is highly variable and we have little insight into the sources of this variability. We investigated the relationship of inducible myocardial ischemia on SPECT stress perfusion imaging to angina reported with routine daily activities during the previous four weeks (N=788) and to angina reported during an exercise stress test (N=371) in individuals with confirmed or suspected coronary disease referred for clinical testing. We found that angina experienced during daily life is more strongly and consistently associated with psychological distress and the personal threat associated with angina than with inducible myocardial ischemia. In multivariable models, the presence of any angina during routine activities over the prior month was significantly associated with age, perceived risk of myocardial infarction, and anxiety when compared to those with no reported angina in the past month. Angina during daily life was not significantly associated with inducible myocardial ischemia on stress perfusion imaging in bivariate or multivariable models. In contrast, angina experienced during exercise stress testing was significantly related to image and ECG ischemia, though it was also significantly associated with anxiety. These results suggest that angina frequency over the previous four weeks is more strongly associated with personal threat and psychosocial distress than with inducible myocardial ischemia. These results lend support to angina treatment strategies that aim to reduce threat and distress as well as to reduce myocardial ischemia.

Silent ischemia: silent after all?

OBJECTIVE

To examine the association of nonpain symptoms in men and women with exercise-related silent ischemia, as well as the independence of these findings from other clinical factors.

METHODS

A prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging. Analyses were performed on 60 women and 155 men with no angina but medical perfusion imaging evidence of ischemia during exercise.

MEASURES

The presence of various non-pain-related symptoms. Ischemia is indicated by myocardial perfusion defects on exercise stress testing with single photon emission computed tomography.

RESULTS

Women reported more nonangina symptoms than men (P<0.05). They experienced fatigue, hot flushes, tense muscles, shortness of breath and headaches more frequently (P<0.05). Symptoms relating to muscle tension and diaphoresis were associated with ischemia after controlling for pertinent clinical covariates. However, the direction of association differed according to sex and history of coronary artery disease events or procedures. Sensitivity of the detection models showed modest improvements with the addition of these symptoms.

CONCLUSIONS

While patients who experience silent ischemia experience a number of nonpain symptoms, those symptoms may not be sufficiently specific to ischemia, nor sensitive in detecting ischemia, to be of particular help to physicians in the absence of other clinical information.

Psychological stress and cardiovascular disease

There is an enormous amount of literature on psychological stress and cardiovascular disease. This report reviews conceptual issues in defining stress and then explores the ramifications of stress in terms of the effects of acute versus long-term stressors on cardiac functioning. Examples of acute stressor studies are discussed in terms of disasters (earthquakes) and in the context of experimental stress physiology studies, which offer a more detailed perspective on underlying physiology. Studies of chronic stressors are discussed in terms of job stress, marital unhappiness, and burden of caregiving. From all of these studies there are extensive data concerning stressors' contributions to diverse pathophysiological changes including sudden death, myocardial infarction, myocardial ischemia, and wall motion abnormalities, as well as to alterations in cardiac regulation as indexed by changes in sympathetic nervous system activity and hemostasis. Although stressors trigger events, it is less clear that stress "causes" the events. There is nonetheless overwhelming evidence both for the deleterious effects of stress on the heart and for the fact that vulnerability and resilience factors play a role in amplifying or dampening those effects. Numerous approaches are available for stress management that can decrease patients' suffering and enhance their quality of life.

An interactive model of pain and myocardial ischemia

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

Screening, diagnosis & monitoring of depression/distress in CHF patients

Objective and validated measures of depression/distress (anxiety and anger) are available and readily usable at the bedside or in clinic. Foremost among these is the Patient's Health Questionnaire--an adaptation of DSM IV criteria for Major Depressive Disorder that permits administration and scoring by nursing or physician personnel, and quantification of the intensity of depression. A score of 10 or greater indicates a need for evaluation/treatment. Because of patient denial/minimization/alexithymia, PHQ negatives should undergo further screening by having a spouse or friend complete a depression/distress rating scale. The only standardized, normed, and validated spouse/friend scale presently available is the Ketterer Stress Symptom Frequency Checklist, which is available by internet.

Emotional antecedents of hot flashes during daily life

OBJECTIVE

Hot flashes are among the most frequently reported menopausal symptoms. However, little is known about factors associated with their occurrence. Moreover, despite the wide use of self-report hot flash measures, little is known about their concordance with physiological flashes. This study evaluated emotional and behavioral antecedents of subjectively and objectively measured hot flashes during daily life. It also examined individual differences predicting concordance between objective and subjective hot flashes.

METHODS

Forty-two perimenopausal or postmenopausal women (mean age = 50.5 +/- 4.8 years) reporting daily hot flashes completed 2 days of ambulatory sternal skin conductance monitoring, behavioral diaries 3 times an hour, and psychometric questionnaires. Hot flashes meeting objective physiological criteria and subjectively reported flashes not meeting physiological criteria were assessed. Likelihood of hot flashes following emotions and activities were examined in a case-crossover analysis.

RESULTS

Relative to nonflash control times, objective hot flashes were more likely after increased happiness, relaxation, and feelings of control, and less likely after increased frustration, sadness, and stress. Conversely, subjective hot flashes not meeting physiological criteria were more likely after increased frustration and decreased feelings of control. Questionnaires revealed increased negative mood and negative attitudes were associated with fewer objective flashes and higher false-positive reporting rates.

CONCLUSION

Increased positive and decreased negative emotions were associated with objective hot flashes, whereas increased negative and decreased positive emotions were associated with subjective flashes not meeting physiological criteria. The anecdotal association between negative emotions and hot flashes may be the result of self-reported flashes lacking physiological corroboration.

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.

Is type A behavior really a trigger for coronary heart disease events?

OBJECTIVE

The purpose of this study was to compare chronic with acute mechanisms by which Type A might predict incident coronary heart disease (CHD).

METHOD

The study included 2394 men aged 50 to 64 years who were assessed for CHD, Type A behavior, and CHD risk factors. Type A was assessed using the Jenkins Activity Survey (JAS), the Bortner scale, and the Framingham scale. Further examinations were completed at 5 and 9 years for incident CHD.

RESULTS

After 9 years, there was no increased risk of CHD associated with any Type A score. Nevertheless, high Bortner scores were associated with increased risk of incident CHD at 5 years and high JAS and Bortner scores were associated with a decreased risk between 5 and 9 years. Further analysis of Type A scores on time to first coronary event found strong inverse associations for all type A scores (JAS = 205 -0.49 months to first event, 95% CI = -0.20, -0.78, p =.001) (Bortner = 176 -0.27 months; 95% CI = -0.10, -0.44; p =.002) (Framingham = 0.44 -0.0011 months; 95% CI = -0.0002, -0.0019; p =.01).

CONCLUSIONS

The data show Type A is a strong predictor of when incident coronary heart disease (or coronary event) will occur rather than if it will occur. These findings suggest that Type A increases exposure to potential triggers, rather than materially affecting the process of atherosclerosis.

Association of hypoglycemia and cardiac ischemia: a study based on continuous monitoring

OBJECTIVE

In some studies intensive diabetes treatment in patients with type 2 diabetes may be associated with increased cardiovascular events. It is not clear whether these events are related to hypoglycemic episodes. To determine whether episodes of hypoglycemia were more likely to be associated with cardiac ischemia than normoglycemia or hyperglycemia, we carried out a study in 21 patients with coronary artery disease (CAD) and type 2 diabetes treated with insulin who had good glycemic control.

RESEARCH DESIGN AND METHODS

We carried out 72-h continuous glucose monitoring along with simultaneous cardiac Holter monitoring for ischemia. Patients also recorded symptoms of cardiac ischemia (chest pain) and symptoms of hypoglycemia.

RESULTS

Satisfactory continuous glucose monitoring system recordings were obtained in 19 patients. We recorded 54 episodes of hypoglycemia (blood glucose <70 mg/dl; 26 of these were symptomatic) and 59 episodes of hyperglycemia (blood glucose >200 mg/dl; none symptomatic). Of the 54 episodes of hypoglycemia, 10 were associated with symptoms of chest pain, during 4 of which electrocardiographic abnormalities were documented. In contrast, only 1 episode of chest pain occurred during 59 episodes of hyperglycemia. No chest pain or electrocardiographic abnormalities occurred when the blood glucose was within the normal range. The difference between the frequency of ischemia during hypoglycemia and the frequency during both hyperglycemia and normoglycemia was statistically significant (P < 0.01). There were 50 episodes during which the blood glucose changed by >100 mg over a 60-min period, and ischemic symptoms occurred during 9 of these episodes (P < 0.01 compared with stable normoglycemia or hyperglycemia).

CONCLUSIONS

Hypoglycemia is more likely to be associated with cardiac ischemia and symptoms than normoglycemia and hyperglycemia, and it is particularly common in patients who experience considerable swings in blood glucose. These data may be important in the institution of insulin treatment and attempting near-normal glycemia in patients with known CAD. Further research is needed to determine strategies to prevent ischemia associated with hypoglycemia.

Psychosocial effects of enhanced external counterpulsation in the angina patient: a second study

Enhanced external counterpulsation (EECP) is a noninvasive technique that has shown promise in the treatment of ischemic coronary artery disease. Patients undergoing EECP were tested for alterations in psychosocial state associated with treatment. Overall perception of health and quality of life improved with EECP. There was also significant improvement in levels of depression, anxiety, and somatization but no change in levels of anger or hostility. On most measures, change was more significant for subjects who showed objective evidence of resolution of ischemia. Given the known predictive relationship between depression and mortality from cardiac disease, the improvement in depression scores through EECP indicates a finding of potential importance that may warrant further study in future research.

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.

Psychological factors affecting a medical condition: ischemic coronary heart disease

The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.

Cognitive adaptation as a predictor of new coronary events after percutaneous transluminal coronary angioplasty

OBJECTIVE

We tested whether the psychological components of cognitive adaptation theory would predict new coronary events after a first percutaneous transluminal coronary angioplasty (PTCA).

METHODS

A consecutive sample of patients treated successfully with PTCA were enrolled in the study. Of 343 patients approached, 303 (88%) agreed to participate and were interviewed shortly before hospital discharge. We measured the components of cognitive adaptation theory (optimism, self-esteem, and mastery) during the interview. Five patients were excluded from the analysis because of early, in-hospital reocclusion. New cardiac events (coronary artery bypass grafting, PTCA, myocardial infarction, or disease progression) were examined within 6 months of the first PTCA. We obtained 6-month follow-up data on 98% of patients.

RESULTS

The cognitive adaptation index predicted new cardiac events, even when demographic variables and medical variables thought to predict restenosis were statistically controlled (p = .02).

CONCLUSIONS

These results suggest that persons who respond to their illness by perceiving control over their futures, by having positive expectations about their futures, and by holding a positive view of themselves seem to be at less risk for a new cardiac event after a first PTCA.

Symptomatic myocardial ischemia and everyday life: implications for clinical use of interactive monitoring

In coronary heart disease (CHD), pathological myocardial ischemic changes do not always occur with the symptom of heart pain. Methodological problems make it difficult to examine the factors that influence silent and symptomatic myocardial ischemia in everyday life. This study uses a computer-assisted monitoring system with an interactive Holter ECG, an actometer, and an electronic diary. Self-report measurements indicate that symptomatic patients tend toward increased neuroticism, whereas asymptomatic patients engage in beneficial and active coping skills more frequently. The results of the monitoring study demonstrate the same degree of ischemia in silent and symptomatic episodes. However, these episodes show differences in certain psychological context variables. Symptomatic episodes are linked to high subjective strain and severe tension. Because angina pectoris is not a reliable warning signal of myocardial ischemia, the use of the interactive monitoring system is recommended for educating CHD patients on how to cope with excessive strain in everyday life.

Enhanced cardiovascular and catecholamine responses in women with depressive symptoms

To test the hypothesis that cardiovascular and sympathetic nervous system responses before and during behavioral stressors are exaggerated among subjects with depressed mood who do not have clinical depressive disorder. Sixty healthy women aged 18-49 were initially asked to complete the Beck Depression Inventory (BDI). The 15 with the highest (Depressive Symptom group) and the 15 with the lowest BDI scores (Control group) underwent stress testing including baseline, postural challenge, a speech task describing responses to a recent anger-arousing experience and recovery. Both systolic and diastolic blood pressure levels were higher in the Depressive Symptom group during baseline, challenges and recovery. This group also showed shorter pre-ejection period (a marker of enhanced cardiac sympathetic activation) and lesser heart rate variability across all test periods. During the speech task only, the Depressive Symptom group exhibited greater increases in plasma norepinephrine and higher cardiac output responses associated with decreased interbeat interval (faster heart rate). These results support the a priori hypothesis regarding enhanced sympathetic and cardiovascular activity. Finally, the BDI scores correlated very highly with lack of perceived emotional social support, reinforcing prior research on the linkage between social isolation and severity of depressive symptoms.

Angina pectoris after recovery from an acute coronary event--the role of psychological factors in Japanese vs North American patients

To determine whether specific psychological characteristics are associated with angina pectoris in clinically stable patients 1 to 6 months after recovery from an acute coronary event, a battery of tests was administered to 92 Japanese and 646 North American participants (22% females) in the Multicenter Study of Myocardial Ischemia. Of these 738 patients, 541 had originally suffered acute myocardial infarction, 188 had unstable angina, and 9 were admitted for other acute ischemic events. At the time of enrollment, an average of 2.7 months after the index event, 205 patients reported having had anginal symptoms during the preceding months. Compared to those who did not report angina, these patients scored higher on a modified Autonomic Perception Questionnaire (p = 0.04) and lower on the Internal Health Locus of Control Scale (p = 0.004). These differences were generalized across the Japanese and North American cohorts. These results indicate that in these patients, angina pectoris was associated with an increased awareness of a wide range of physical symptoms and a decreased sense of personal control over one's own health and prognosis.

Ischemic-like ST-segment changes during Holter monitoring in patients with angina pectoris and normal coronary arteries but negative exercise testing

To evaluate whether Holter electrocardiographic monitoring may improve the detection of ST-segment depression in patients with anginal chest pain and normal coronary arteries, we performed symptom-limited exercise testing and 24-hour Holter monitoring in a group of 38 such patients (27 women, age 54 +/- 8 years). Patients were divided into 2 groups:group X1 included 28 patients with and group X2 10 patients without significant ST-segment depression during exercise testing. There were no significant differences between the 2 groups in age, gender, characteristics of chest pain, exercise duration, heart rate (HR), and blood pressure at peak exercise, but anginal pain during exercise testing was reported by 10 patients of group X1 (36%) and 9 of group X2 (90%) (p <0.01). Episodes of ST-segment depression on Holter monitoring were found in 17 patients of group X1 (61%) and in 5 patients of group X2 (50%) (p = NS). There were no differences between the 2 groups in daily number of ST episodes (3.6 +/- 4 vs 2.8 +/- 5 episodes per patient), symptomatic episodes (8% vs 18%), and duration of the episodes. On average, HR increased significantly, in a similar way, from 15 minutes before ST-segment depression to 1-mm ST in both groups, and its value at the onset of ischemia was similar in the 2 groups (102 +/- 22 vs 109 +/- 18 beats/min, p = NS). Finally, HR at 1-mm ST during Holter monitoring was significantly lower than that observed at 1-mm ST during exercise testing (127 +/- 16 beats/min, p < or = 0.01) in group X1, and it was also lower than that observed at peak exercise (136 +/- 22 beats/min, p < or = 0.01) in group X2. In conclusion, Holter monitoring can significantly increase the detection of ST-segment depression in patients with anginal pain and normal coronary arteries, indicating a cardiac, although not necessarily ischemic, origin of the pain. Indeed, 50% of our patients with negative symptom-limited exercise testing showed spontaneous ST changes, compatible with transient myocardial ischemia, during daily activities. Differences in the response of coronary microvascular tone to exercise testing and to stimuli operating during daily life are likely to play a significant role in determining these findings.

Tenuous link between ischaemic threshold and both ambulatory ischaemia and symptom status over time in stable angina: a 5-year follow-up study

This study evaluates changes in ischaemic threshold over a 5-year period in patients with stable angina pectoris, who did not suffer any intervening cardiac event. Changes in ischaemic threshold are related to alterations in symptomatic status and ambulatory ischaemia. Over long-term follow-up, there is a significant fall in ischaemic threshold in such patients (mean heart rate at onset of ischaemia fell from 104 +/- 17.8 to 97 +/- 17.4 bpm: P < 0.001), but this is not matched by a worsening of either symptoms or ischaemia during daily life. In the 68% of patients that had a reduction in ischaemic threshold of > or = 5 bpm, 68% had either definite reduction or no change in symptoms and 84% had either reduction, abolition or no change in transient ischaemic activity. The dissociation between ischaemic threshold, ambulatory ischaemia and symptoms has implications for long-term monitoring and management of the patient with stable angina.

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.