Mental stress as an acute trigger of ischemic left ventricular dysfunction and blood pressure elevation in coronary artery disease

Effects of Psychological Stress on Vascular Physiology: Beyond the Current Imaging Signal

PURPOSE OF REVIEW

This review describes the effects of psychological stress on the physiology of the entire vascular system, from individual cellular components to macrovascular and microvascular responses, and highlights the importance of the vascular system in the context of current limitations in cardiac imaging for evaluation of the cardiovascular response to mental stress.

RECENT FINDINGS

The physiological responses that mediate vascular changes are based on evolutionary needs, but there is increasing evidence that the long-term consequences of psychological stress can precipitate the development and progression of cardiovascular disease (CVD). While there is an extensive body of literature describing localized physiological responses or overt cardiovascular manifestations, often framed within the organ-specific scope of cardiovascular imaging, there has not been a comprehensive description of the global vascular effects of psychological stress. Given the global nature of these processes, targeted cardiovascular imaging modalities may be insufficient. Here we approach the vascular response to mental stress systematically, describing the effects on the endothelium, vascular smooth muscle, and adventitia. We then address the mental stress effects on large vessels and the microvascular compartment, with a discussion of the role of microvascular resistance in the pathophysiology of mental stress-induced myocardial ischemia. Vascular responses to psychological stress involve complex physiological processes that are not fully characterized by routine cardiovascular imaging assessments. Future research incorporating standardized psychological assessments targeted toward vascular mechanisms of stress responses is required to guide the development of behavioral and therapeutic interventions.

[Suicidal behavior in light of COVID-19 outbreak: Clinical challenges and treatment perspectives]

OBJECTIVE

The COVID-19 pandemic affected today more than 3,000,000 worldwide, and more than half of humanity has been placed in quarantine. The scientific community and the political authorities fear an epidemic of suicide secondary to this crisis. The aim of this review is to analyze the impact of the COVID-19 pandemic on the dimensions of the suicidal process and its interaction with the various risk factors. We also propose innovative strategies to manage suicidal behavior in the context of pandemic.

METHODS

We carried out a narrative review of international publications dealing with major pandemics (COVID-19, SARS) and their influence on suicidal vulnerability.

RESULTS

Many factors are likely to increase the emergence of suicidal ideation and suicide attempts during this crisis. Social distancing and quarantine could increase the feeling of disconnection and the perception of social pain in vulnerable individuals. Some populations at high suicidal risk could be further impacted by the current pandemic: the elderly, medical staff and individuals exposed to economic insecurity. Several innovative tools adapted to the constraints of social distancing and quarantine may prevent suicide risk: e-health, VigilanS, buddhist-derived practices and art engagement.

CONCLUSIONS

This unprecedented crisis may interact with certain dimensions of the suicidal process. However, it is time to innovate. Several suicide prevention tools all have their place in new modes of care and should be tested on a large scale.

Myocardial perfusion imaging study of CO(2)-induced panic attack

Chest pain is often seen alongside with panic attacks. Moreover, panic disorder has been suggested as a risk factor for cardiovascular disease and even a trigger for acute coronary syndrome. Patients with coronary artery disease may have myocardial ischemia in response to mental stress, in which panic attack is a strong component, by an increase in coronary vasomotor tone or sympathetic hyperactivity setting off an increase in myocardial oxygen consumption. Indeed, coronary artery spasm was presumed to be present in cases of cardiac ischemia linked to panic disorder. These findings correlating panic disorder with coronary artery disease lead us to raise questions about the favorable prognosis of chest pain in panic attack. To investigate whether myocardial ischemia is the genesis of chest pain in panic attacks, we developed a myocardial perfusion study through research by myocardial scintigraphy in patients with panic attacks induced in the laboratory by inhalation of 35% carbon dioxide. In conclusion, from the data obtained, some hypotheses are discussed from the viewpoint of endothelial dysfunction and microvascular disease present in mental stress response.

Panic attack triggering myocardial ischemia documented by myocardial perfusion imaging study. A case report

BACKGROUND

Chest pain, a key element in the investigation of coronary artery disease is often regarded as a benign prognosis when present in panic attacks. However, panic disorder has been suggested as an independent risk factor for long-term prognosis of cardiovascular diseases and a trigger of acute myocardial infarction.

OBJECTIVE

Faced with the extreme importance in differentiate from ischemic to non-ischemic chest pain, we report a case of panic attack induced by inhalation of 35% carbon dioxide triggering myocardial ischemia, documented by myocardial perfusion imaging study.

DISCUSSION

Panic attack is undoubtedly a strong component of mental stress. Patients with coronary artery disease may present myocardial ischemia in mental stress response by two ways: an increase in coronary vasomotor tone or a sympathetic hyperactivity leading to a rise in myocardial oxygen consumption. Coronary artery spasm was presumed to be present in cases of cardiac ischemia linked to panic disorder. Possibly the carbon dioxide challenge test could trigger myocardial ischemia by the same mechanisms.

CONCLUSION

The use of mental stress has been suggested as an alternative method for myocardial ischemia investigation. Based on translational medicine objectives the use of CO2 challenge followed by Sestamibi SPECT could be a useful method to allow improved application of research-based knowledge to the medical field, specifically at the interface of PD and cardiovascular disease.

Usefulness of laboratory mental stress test in patients with stable coronary artery disease

BACKGROUND AND HYPOTHESIS

Many episodes of ischemia in daily life are silent occurring during sedentary activities and may be related to mental stress. In 35 patients with stable angina and positive exercise test awaiting bypass surgery, we investigated whether laboratory mental stress tests would trigger ischemia of a comparable severity to that occurring in daily life and attempted to elucidate some of the underlying mechanisms.

METHODS

All patients underwent exercise testing, personality assessment, 2-day Holter monitoring, and laboratory mental stress tests while on their usual medications.

RESULTS

Only four patients (12%) had positive mental stress test (ST depression > or = 0.1 mV). All episodes were silent and usually associated with fast heart rate (> 90 beats/min). In contrast, ambulatory ischemia was common (average duration of 51 min per 24 h), and at least one episode was recorded in 27 patients (77%) including the 4 with positive test. Patients with positive mental stress test had a higher heart rate during testing (124 +/- 24 vs. 86 +/- 16 beats/min, p < 0.01), and a shorter exercise time and time to 1 mm ST depression on cycle ergometry than those with negative mental stress test. None of the four patients were on beta blockers. There was no difference in personality inventory between the two groups. Comparisons between patients with and without positive mental stress test revealed no difference in the duration and frequency of ambulatory ischemia, or in the occurrence of silent ischemia. However, the heart rate at onset of ambulatory ischemia tended to be higher in the patients with positive mental stress test (96 +/- 9 vs. 62 +/- 43, p = 0.07). Further subgroup analysis in patients without beta blockers (4 mental stress test positive and 18 negative) showed similar results.

CONCLUSIONS

Laboratory mental stress test is a weak inducer of ischemia detected by electrocardiographic monitoring in patients with frequent ambulatory ischemia. Wall motion evaluation during mental stress test may improve sensitivity. While larger scale studies may determine its clinical role, the present study illustrated that patients with heightened heart rate response to mental stress were identified in whom beta blockers could be the drug of choice.

Triggers of acute coronary syndromes

Despite recent progress in prevention of coronary heart disease, approximately 50% of the deaths from coronary artery disease continue to occur out of hospital, and many major cardiac events occur in individuals not previously known to be at risk. These facts create the need to identify the acute causes of myocardial infarction (MI) and sudden death, which has led to a rapid growth in interest over the last 15 years in the field of triggering research. Since initial observations that the incidence of MI onset was time and activity dependent with circadian, circaseptan, and circannual variation, triggering of MI by heavy exertion, sexual activity, anger, mental stress, cocaine and marijuana use, and exposure to air pollution has been demonstrated. Study of the pathophysiological changes produced by these triggers may provide novel therapeutic and preventive targets by a more thorough understanding of vulnerable plaque disruption and coronary thrombosis.

Psychosocial stress and cardiovascular disease: pathophysiological links

The remarkable decline in cardiovascular disease (CVD) experienced in developed countries over the last 40 years appears to have abated. Currently, many CVD patients continue to show cardiac events despite optimal treatment of traditional risk factors. This evidence suggests that additional interventions, particularly those aimed at nontraditional factors, might be useful for continuing the decline. Psychosocial stress is a newly recognized (nontraditional) risk factor that appears to contribute to all recognized mechanisms underlying cardiac events, specifically, (a) clustering of traditional cardiovascular risk factors, (b) endothelial dysfunction, (c) myocardial ischemia, (d) plaque rupture, (e) thrombosis, and (f) malignant arrhythmias. A better understanding of the behavioral and physiologic associations between psychosocial stress and CVD will assist researchers in identifying effective approaches for reducing or reversing the damaging effects of stress and may lead to further reductions of CVD morbidity and mortality.

New evidence for the spasm-of-resistance-vessel concept of ischemic diseases

The spasm of resistance vessel (S-RV) concept of ischemic diseases avers that S-RV representing vascular autoregulatory dysfunction directly induces symptoms in ischemic diseases. The most important ischemic diseases, ischemic heart disease (IHD) and stroke, generally are not attributed to S-RV, and new evidence will be provided in this communication that S-RV induces IHD and stroke. Hypertension and the ischemic disorders of migraine and Raynaud's disease have been attributed to S-RV and to vascular dysregulation, and this information was used to help structure the study. It was found that these disorders are closely associated with IHD and stroke, and this is consistent with S-RV and vascular dysregulation as the mechanism for IHD and stroke. Also, it was found that multiple risk factors for IHD foster S-RV and are risk factors for hypertension, migraine, Raynaud's disease, and stroke, and this supports S-RV as the mechanism for IHD and stroke.

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.

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

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The experience of people awaiting coronary artery bypass graft surgery: the Icelandic experience

Prolonged waiting for major elective surgery has been a problem in several Western countries for many years. In Iceland coronary artery bypass graft (CABG) surgery was installed in 1986 and this descriptive study was conducted to describe systematically the experience of Icelandic people waiting for CABG surgery with the purpose of gaining information about what nursing services these people need during the waiting period. The survey used a mailed questionnaire developed by the authors. The target population consisted of people awaiting coronary artery bypass graft surgery at the National University Hospital in Iceland, at two predetermined days with a 10-month interval. The return rate was 81.8% (n = 72). Mean time on the waiting list was 5 to 6 months. The waiting for surgery had negative effects on the work and daily life of the majority of the subjects and they were dissatisfied with their health status. Prominent symptoms were fatigue, shortness of breath, chest pain, anxiety and depression. Most patients (86.6%) experienced stress with 28.4% of them reporting a serious level of stress. The majority reported considerable negative influences of their illness on their spouse and family, particularly on their emotional condition. The conclusion drawn is that shortening the waiting period for CABG surgery should be a primary objective; however, that may be unlikely with the present Icelandic health care system. Therefore, helping the individuals and their families live with the lengthy wait is a necessity.

Stress-induced hemodynamic and hemostatic changes in patients with systemic hypertension: effect of verapamil

Stress-induced hemodynamic and hemostatic responses may acutely trigger atherosclerotic plaque disruption and thrombosis leading to myocardial infarction. This study was designed to evaluate the responses to three stressors and to determine if once-daily sustained release verapamil (Verelan) modified these responses. We studied 13 patients with mild to moderate hypertension in a randomized, double-blind, placebo-controlled crossover trial. After 4 weeks of therapy, patients were evaluated following assumption of the upright posture, mental stress, and cold pressor test. During placebo, the stressors produced an increase in systolic pressure (144 +/- 2 to 167 +/- 3 mmHg, p < 0.001), heart rate (70 +/- 2 to 77 +/- 2 beats/ min, p < 0.001), and platelet aggregability to adenosine diphosphate (threshold concentration fell from 2.8 +/- 0.4 to 1.9 +/- 0.1 microM, p = 0.05) and epinephrine (3.4 +/- 0.9 to 1.6 +/- 0.6 microM, p < 0.001). Verapamil lowered systolic pressure at baseline (144 +/- 2 to 134 +/- 2 mmHg, p < 0.001), and after stress (167 +/- 3 to 154 +/- 3 mmHg, p < 0.001), but did not alter the absolute increase with stress. During verapamil, platelet reactivity did not increase with stress, and the post-stress response to epinephrine was reduced (higher threshold concentration) compared with placebo (3.9 +/- 1.3 vs. 1.5 +/- 0.3 microM, p = 0.05). Verapamil also reduced the response to collagen (increased lag time) at baseline and after stress (111 +/- 9 vs. 91 +/- 3 s, p < 0.01). We conclude that verapamil blunted potentially harmful stress-induced hemodynamic and hemostatic changes. Further studies are required to determine whether these effects translate into a lower incidence of acute cardiovascular events.

Angina: an update for dentistry

Advances in medicine have dramatically altered the diagnosis and treatment of angina and the prognosis for patients with this condition. The authors review current medical practices and make recommendations for the dental management of patients.

Abnormal left ventricular ejection fraction response to mental stress and exercise in cardiomyopathy

BACKGROUND

A decline in left ventricular (LV) ejection fraction in response to mental stress and exercise is regarded as an indicator of myocardial ischemia. In patients with LV dysfunction, the ejection fraction is sensitive to afterload, which increases during stress. Thus, the effects of mental stress and exercise on LV systolic function in patients with cardiomyopathy were examined.

METHODS

The ambulatory nuclear VEST (Capintec, Inc., Ramsey, N.J.) was used to monitor LV ejection fraction in patients with cardiomyopathy (10 idiopathic and 9 ischemic). Patients underwent a series of mental stress tests (serial 7s, Stroop color, and Paced auditory addition) and treadmill exercise. Heart rate, systolic blood pressure, and LV ejection fraction were measured.

RESULTS

Mental stress and exercise increased heart rate and systolic blood pressure. For idiopathic cardiomyopathy, LV ejection fraction decreased during serial 7s, Stroop color, Paced auditory addition and exercise by -8% +/- 6%, -7% +/- 5%, -7% +/- 3%, -9% +/- 10%, respectively. For ischemic cardiomyopathy, LV ejection fraction declined by -4% +/- 3%, -7% +/- 5%, -6% +/- 3%, -2% +/- 6% during the same stress tests. There was no difference between the idiopathic and ischemic groups. Each patient showed a 5% or greater decline in LV ejection fraction during one mental stress test. There was an inverse relation between changes in LV ejection fraction and systolic blood pressure during all mental stress tests and exercise (r = -0.47, p < 0.0001).

CONCLUSIONS

In patients with depressed baseline systolic function, the decline in systolic function during mental stress and exercise could be related in part to increases in LV afterload.

Cardiovascular reactivity, Type A behavior, and coronary heart disease: comparisons between myocardial infarction patients and controls during laboratory-induced stress

Cardiovascular responses to a series of laboratory stressors were examined in middle-aged Type A and Type B men. The subjects were 30 patients with diagnosed myocardial infarction (NYHA Class 1) and 26 age-matched healthy controls. All subjects were nonsmokers in the normotensive range, and none were on medication. Blood pressure, heart rate, forearm blood flow and resistance, and impedance cardiography-determined response variables were obtained during performance and recovery periods of both mental and physical tasks. The patients showed elevated reactivity in systolic blood pressure and cardiac output and prolonged systolic time ratio during mental stress tasks and elevated total peripheral resistance and lower cardiac output and stroke volume during physical tasks, as compared with control subjects. Thus, the difference in blood pressure reactivity between patients and controls appeared to be primarily dependent on the vascular component during physical tasks, whereas the mental tasks promoted a hemodynamic response pattern more consistent with beta adrenergic activation. Type A men, irrespective of coronary status, showed larger systolic and diastolic blood pressure response to both mental and physical stress than did Type B men.

Induction of silent myocardial ischemia with mental stress testing: relation to the triggers of ischemia during daily life activities and to ischemic functional severity

OBJECTIVES

This study examined the relations among the triggers of ischemia during the activities of daily life, mental stress-induced ischemia in the laboratory and functional severity of ischemia on exercise testing.

BACKGROUND

Myocardial ischemia is readily induced with exercise testing, but most episodes of ischemia in daily life occur during relatively sedentary activities. Although mental and emotional arousal are known to trigger myocardial ischemia, mental stress testing induces ischemia in only approximately 50% of patients with active coronary disease. It is not known whether such patients are particularly susceptible to nonexertional ischemia during daily activity.

METHODS

We studied 45 men (mean age +/- SD 58 +/- 9 years) with coronary artery disease by means of 48-h Holter ambulatory electrocardiography for ST segment analysis and quantification of physical and mental activity with a structured diary system. These data were cross-tabulated with new left ventricular dyssynchrony (detected on two-dimensional echocardiography) induced by two mental stressors and by bicycle exercise.

RESULTS

During mental stress testing, 24 patients (53%) (Group I) had a new wall motion abnormality; the other 21 patients (Group II) did not. The average wall motion dyssynchrony score increased from 1.20 +/- 0.29 to 1.34 +/- 0.36 (p = 0.001), but the increase was less than that with exercise stress (1.52 +/- 0.41, p = 0.001). The total duration of ischemia during sedentary activities was greater in Group I (22.9 +/- 24.5 min) than in Group II (3.6 +/- 3.9 min, p = 0.025). Group I had more ischemic events while sedentary (23 of 290 diary entries) than did Group II (8 of 256 diary entries, p = 0.015). The magnitude of dyssynchrony with mental stress and the number of mental stressors capable of triggering ischemia were related to severity of ischemia with exercise.

CONCLUSIONS

Patients with ischemia during mental stress testing also have increased ischemia during sedentary activities in daily life. This finding may reflect greater functional severity of coronary artery disease or a propensity toward coronary vasoconstriction while sedentary.

Psychophysiological effects of cardiac rehabilitation in post-myocardial infarction patients

Psychophysiological reactivity and cardiovascular functioning were assessed in 40 patients with coronary heart disease before and after taking part in either a Type A modification training program or a control condition. Treated patients showed an overall attenuated heart rate (HR) response and prolonged diastolic time to mental stress performance, during recovery and rest periods, as compared lo control patients. No other measure, including impedance-cardiography-derived measures, differentiated the two groups. The treatment group showed reduction from before lo after treatment in 24-hr minimum IIR level and decreased frequencies of premature ventricular contractions, whereas the control group showed an opposite trend. Results from an exercise test suggested the same direction for resting IIR and double-product levels. The two groups did not differ in maximal systolic and diastolic blood pressure or in maximal double-product levels, despite a differential development, in favor of the treatment group, in maximal work capacity.

Patients' responses to postponement of coronary artery bypass graft surgery

The purpose of this study was to determine the thoughts and feelings of patients (n = 24) awaiting coronary artery bypass graft (CABG) surgery and, in particular, the thoughts and feeling of those patients (n = 17) whose surgical procedure was postponed. On average these patients waited four additional days before the surgery could be performed. Patients reported that the most difficult part of CABG surgery was the wait itself. Those whose CABG surgery was postponed expressed anger and disappointment, had additional tests, procedures and medication, extended hospital stays and increased costs.