Aspects of the influence of psychic stress on angina pectoris

A music intervention to reduce anxiety before vascular angiography procedures

Patients scheduled for vascular angiography are often anxious and frightened. High levels of anxiety may result in more difficult and painful procedures. Past research has reported mixed results for anxiety reduction techniques in other procedures settings, such as education, cognitive-behavioral skills, coping and relaxation skills, combinations of techniques, and music. Music as an intervention for pre-procedural anxiety prior to vascular angiography has not been studied. A randomized controlled trial of 170 patients was undertaken to determine whether 15 minutes of self-selected music reduced pre-procedure anxiety. The State Trait Anxiety Inventory was used to measure patients' anxiety. One-hundred sixty-six men and 4 women comprised the sample with an average age of 66.8 years (SD 9.95, range 37 to 85 years). Patients who listened to music (n=89) reduced their anxiety score from 38.57 (SD 10.46) to 35.2 (SD 9.7), while those who did not listen to music (n=81) reduced their anxiety score from 36.23 (SD 10.54) to 35.1 (SD 10.59); the difference between the groups was statistically significant (t=1.95, df 161, p=0.05). Pulse achieved a statistically significant reduction in the music group (t=2.45, df 167, p=0.02). Music is a noninvasive nursing intervention that patients enjoy and reduces their anxiety and their pulse rate. Further research should address using music to reduce anxiety in other interventional vascular angiography settings with equal numbers of men and women and comparing self-selected versus investigator-selected music.

Correlations between preprocedure mood and clinical outcome in patients undergoing coronary angioplasty

We studied the relationship between mood and mood shift immediately before percutaneous coronary intervention (PCI) and 3 end points: total ischemic burden during PCI, adverse cardiac end points (ACE) after PCI, and death by 6-month follow up. Patients (n = 119) with unstable angina or myocardial infarction completed a visual analog scale (VAS) twice before PCI; before and after a session of stress relaxation, imagery, or touch; or approximately 30 minutes apart for patients assigned to prayer or to standard care. VAS included happiness, satisfaction, calm, hope, worry, shortness of breath, fear, and sadness. We observed a significant correlation between higher hope score before PCI and lower ischemic burden. Patients who experienced ACE had significantly lower hope and happiness scores than those who did not. Patients who survived to 6 months had significantly greater increases in worry and in hope. Our data suggest correlations between simple mood assessments before PCI and clinical outcomes during and after the procedure. More study is needed to understand whether attempts to alter patient mood can affect clinical outcomes.

Integrative noetic therapies as adjuncts to percutaneous intervention during unstable coronary syndromes: Monitoring and Actualization of Noetic Training (MANTRA) feasibility pilot

BACKGROUND

Patients undergoing percutaneous coronary intervention (PCI) for unstable coronary syndromes have substantial emotional and spiritual distress that may promote procedural complications. Noetic (nonpharmacologic) therapies may reduce anxiety, pain and distress, enhance the efficacy of pharmacologic agents, or affect short- and long-term procedural outcomes.

METHODS

The Monitoring and Actualization of Noetic Training (MANTRA) pilot study examined the feasibility of applying 4 noetic therapies-stress relaxation, imagery, touch therapy, and prayer-to patients in the setting of acute coronary interventions. Eligible patients had acute coronary syndromes and invasive angiography or PCI. Patients were randomized across 5 treatment groups: the 4 noetic and standard therapies. Questionnaires completed before PCI reflected patients' religious beliefs and anxiety. Index hospitalization end points included post-PCI ischemia, death, myocardial infarction, heart failure, and urgent revascularization. Mortality was followed up for 6 months after hospitalization.

RESULTS

Of eligible patients, 88% gave informed consent. Of 150 patients enrolled, 120 were assigned to noetic therapy; 118 (98%) completed their therapeutic assignments. All clinical end points were available for 100% of patients. Results were not statistically significant for any outcomes comparisons. There was a 25% to 30% absolute reduction in adverse periprocedural outcomes in patients treated with any noetic therapy compared with standard therapy. The lowest absolute complication rates were observed in patients assigned to off-site prayer. All mortality by 6-month follow-up was in the noetic therapies group. In patients with questionnaire scores indicating a high level of spiritual belief, a high level of personal spiritual activity, a low level of community-based religious involvement, or a high level of anxiety, noetic therapies appeared to show greater reduction in absolute in-hospital complication rates compared with standard therapy.

CONCLUSIONS

Acceptance of noetic adjuncts to invasive therapy for acute coronary syndromes was excellent, and logistics were feasible. No outcomes differences were significant; however, index hospitalization data consistently suggested a therapeutic benefit with noetic therapy. Of all noetic therapies, off-site intercessory prayer had the lowest short- and long-term absolute complication rates. Definitive demonstration of treatment effects of this magnitude would be feasible in a patient population about 4 times that of this pilot study. Absolute mortality differences make safety considerations a mandatory feature of future clinical trials in this area.

Influence of physical exertion on early isoproterenol-induced heart injury

The effect of swimming instantly following an injection of isoproterenol was studied in rats in whom the administration of the drug caused changes in the cardiac muscle. The animals were compared with those of a group kept only under normal cage activity after the administration. Oxygen inhalation in the exercised group of rats was higher than in the sedentary group and after 4 minutes of measuring, continually remained at a higher level. It was determined that swimming prevented the early death of the rats. This was more pronounced in the animals of higher body weight. The extent of myocardial damage in the exercised group was markedly smaller. The intensity of enzyme reaction, SDH, LDH and G6PDH, in the area of undamaged tissue was the same in both the exercised and sedentary groups, in areas of damage it was minimal. The intensity of alpha GP was lowered in the exercised group, but in the sedentary group it was lowered throughout the entire section. Electron optic examination of the tissue, which under the light microscope appeared normal, revealed no substantial differences between the exercised and sedentary groups. We presume that the better condition of the rats was in part due to the peripheral breakdown of the catecholamine owing to the increased blood flow created by muscular activity.

Cardiovascular responses to emotional stress (quiz interview) in post-myocardial infarction patients and matched control subjects

In this investigation, 30 male post-myocardial infarction patients and 30 male control subjects matched according to age and occupation were given a 12-minute tape-recorded stress quiz described by Schiffer et al. Cardiovascular responses (electrocardiogram, heart rate, systolic, blood pressure, and diastolic blood pressure) to emotional stimuli were monitored in a laboratory setting at rest before the quiz and at two-minute intervals during the quiz. Heart rate and blood pressure values were significantly higher during the quiz than at rest for both patient and control groups. There was a significantly higher response for diastolic pressure and a significantly lower response for heart rate in the patient group compared with the control group. In the analysis for occupational status in the entire population, systolic pressure was significantly higher for the executives than for non-executives. Subgroup analyses of patients with angina, hypertension and/or ECG changes (N = 12) revealed a significantly higher diastolic pressure response than found in either the patients without these symptoms (N = 18) or in the controls (N = 30). In comparison to exercise test results, the emotional stress test (quiz) elicited somewhat more PVC's but less ST segment depression. These results support previous reports suggesting that emotional stress testing may be a valid tool in the diagnosis of coronary heart disease and in determining the physiological mechanisms which underlie the association between emotional stress and coronary heart disease.

The injury-vasospasm hypothesis of ischemic heart disease, revisited

The injury-vasospasm hypothesis of IHD was discussed in relation to coronary artery autoregulation and the anoxic-feedback mechanism. Observations in the recent literature, not usually attributed to spasm, were examined in light of this phenomenon. This includes reperfusion models of experimental AMI, the association of AMI with myocarditis, and findings in AMI and SCD as necrotic microlesions, prodromata, and epicardial arterial plaque rupture and hemorrhage. The disparity between the severity of coronary disease and the occurrence of the various types of IHD suggest that atherosclerosis itself does not precipitate attacks of chest pain. It was emphasized that plaque rupture due to spasm might help induce CAT. With exercise, the possible importance of the autoregulatory system was explored in the prevention and induction of AMI and SCD, and the improvement of AP. The role of spasm in IHD should be defined.

The quiz electrocardiogram: a new diagnostic and research technique for evaluating the relation between emotional stress and ischemic heart disease

To evaluate possible cardiovascular effects of emotional stress, a specially designed 12 minute tape-recorded stress quiz was administered to 43 subjects while blood pressure and the electrocardiogram were monitored. For the entire group, the heart rate and blood pressure rose from respective control levels of 76 beats/min and 136/87 mm Hg to a mean during the quiz of 87 beats/min and 158/94 mm Hg. This difference was highly significant. Of the 43 subjects, 33 were classified as executives and 10 as nonexecutives. There were three groups of executives: control and angina with and without a history of hypertension. Both groups of executives with angina responded with a significantly higher heart rate than that of the executive control group. Blood pressure response was significantly greater in executives with angina and hypertension than in the other groups. Heart rate and systolic blood pressure responses to the quiz were lower in nonexecutives with angina than in executives with angina. During the quiz, 10 of 14 executives with angina had S-T segment depression greater than 0.5 mm; of these, 7 evidenced greater than 1.0 mm depression, andin 3 of these the depression was greater than 1.5 mm and in 2 greater than or equal to 2.0 mm. None of the executive control subjects had S-T depression greater than 0.5 mm Among nonexecutives, 2 had S-T depression greater than 0.5 mm but none greater than 1.0 mm S-T depression. Seventeen of the patients also were given a bicycle exercise tolerance test. There was a significant correlation between S-T depression in response to exercise and to the quiz (r = 0.63; P less than 0.01). The quiz electrocardiogram is presented as a new research technique and diagnostic test for evaluating the relation of emotional stress to ischemic heart disease.