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Nan N, Feng L, Dong W, Gao B, Zuo H, Mi H, Wang G, Song X, Zhang H. The prognostic study of mental stress-induced myocardial ischemia in coronary revascularization patients with depression/anxiety: rationale and design. BMC Cardiovasc Disord 2023; 23:235. [PMID: 37142999 PMCID: PMC10157980 DOI: 10.1186/s12872-023-03246-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) frequently occurs in patients with coronary artery disease (CAD), and is even more common in patients with co-occurring CAD and depression/anxiety. MSIMI appears to be a poor prognostic factor for CAD, but existing data on depression/anxiety patients are limited. METHODS This cohort study will consecutively screen 2,647 CAD patients between 2023 and 2025. Included subjects will need to have received coronary revascularization and also have depression and/or anxiety at baseline. This study will enroll 360 subjects who meet the criteria. Two mental stress tests will be carried out in each patient at 1 month and 1 year timelines after coronary revascularization, using Stroop color word tests. MSIMI will be assessed by 99 m-Tc-sestamibi myocardial perfusion imaging. The endothelial function will be assessed by EndoPAT. Furthermore, we will dynamically monitor patients' health and mental conditions every 3 months. The mean follow-up time will be 1 year. The primary endpoint is the major adverse cardiac events, a composite of all-cause death, cardiac death, myocardial infarction, stroke, or unplanned revascularization. Secondary endpoints will include overall health and mental conditions. The reproducibility of mental stress combined with myocardial perfusion for detecting MSIMI and comparisons between coronary stenosis and ischemic segments will also be included. CONCLUSIONS This cohort study will provide information on MSIMI outcomes in CAD patients who also have comorbid depression/anxiety after revascularization. In addition, understanding the long-term dynamics of MSIMI and the match between coronary stenosis and ischemia will provide insight into MSIMI mechanisms. TRAIL REGISTRATION ChiCTR2200055792, 2022.1.20, www.medresman.org.cn.
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Affiliation(s)
- Nan Nan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Lei Feng
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital, Advanced Innovation Center for Human Brain Protection, Capital Medical University, NO.5 DeWai AnKang Hutong Xicheng District, Beijing, 100088, China
| | - Wei Dong
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Bingyu Gao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Huijuan Zuo
- Department of Community Health Research, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Hongzhi Mi
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital, Advanced Innovation Center for Human Brain Protection, Capital Medical University, NO.5 DeWai AnKang Hutong Xicheng District, Beijing, 100088, China
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China.
| | - Hongjia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University; Beijing Lab for Cardiovascular Precision Medicine; Key Laboratory of Medical Engineering for Cardiovascular Disease, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
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Sara JDS, Toya T, Ahmad A, Clark MM, Gilliam WP, Lerman LO, Lerman A. Mental Stress and Its Effects on Vascular Health. Mayo Clin Proc 2022; 97:951-990. [PMID: 35512885 PMCID: PMC9058928 DOI: 10.1016/j.mayocp.2022.02.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 01/13/2023]
Abstract
Coronary artery disease continues to be a major cause of morbidity and mortality despite significant advances in risk stratification and management. This has prompted the search for alternative nonconventional risk factors that may provide novel therapeutic targets. Psychosocial stress, or mental stress, has emerged as an important risk factor implicated in a higher incidence of cardiovascular events, and although our understanding of this far ranging and interesting phenomenon has developed greatly over recent times, there is still much to be learned regarding how to measure mental stress and how it may impact physical health. With the current coronavirus disease 2019 global pandemic and its incumbent lockdowns and social distancing, understanding the potentially harmful biological effects of stress related to life-changing events and social isolation has become even more important. In the current review our multidisciplinary team discusses stress from a psychosocial perspective and aims to define psychological stress as rigorously as possible; discuss the pathophysiologic mechanisms by which stress may mediate cardiovascular disease, with a particular focus to its effects on vascular health; outline existing methods and approaches to quantify stress by means of a vascular biomarker; outline the mechanisms whereby psychosocial stressors may have their pathologic effects ultimately transduced to the vasculature through the neuroendocrine immunologic axis; highlight areas for improvement to refine existing approaches in clinical research when studying the consequences of psychological stress on cardiovascular health; and discuss evidence-based therapies directed at reducing the deleterious effects of mental stress including those that target endothelial dysfunction. To this end we searched PubMed and Google Scholar to identify studies evaluating the relationship between mental or psychosocial stress and cardiovascular disease with a particular focus on vascular health. Search terms included "myocardial ischemia," "coronary artery disease," "mental stress," "psychological stress," "mental∗ stress∗," "psychologic∗ stress∗," and "cardiovascular disease∗." The search was limited to studies published in English in peer-reviewed journals between 1990 and the present day. To identify potential studies not captured by our database search strategy, we also searched studies listed in the bibliography of relevant publications and reviews.
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Key Words
- cad, coronary artery disease
- cbt, cognitive behavioral therapy
- cvd, cardiovascular disease
- fmd, flow-mediated dilatation
- il, interleukin
- mi, myocardial infarction
- ms, mental stress
- msimi, mental stress induced myocardial ischemia
- pat, peripheral arterial tonometry
- ped, peripheral endothelial dysfunction
- pet, positron emission tomography
- rh, reactive hyperemia
- ses, socioeconomic status
- tnf, tumor necrosis factor
- vsmc, vascular smooth muscle cells
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Affiliation(s)
| | - Takumi Toya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ali Ahmad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Wesley P Gilliam
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Lliach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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Vaccarino V, Almuwaqqat Z, Kim JH, Hammadah M, Shah AJ, Ko YA, Elon L, Sullivan S, Shah A, Alkhoder A, Lima BB, Pearce B, Ward L, Kutner M, Hu Y, Lewis TT, Garcia EV, Nye J, Sheps DS, Raggi P, Bremner JD, Quyyumi AA. Association of Mental Stress-Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease. JAMA 2021; 326:1818-1828. [PMID: 34751708 PMCID: PMC8579237 DOI: 10.1001/jama.2021.17649] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/17/2021] [Indexed: 12/14/2022]
Abstract
Importance Mental stress-induced myocardial ischemia is a recognized phenomenon in patients with coronary heart disease (CHD), but its clinical significance in the contemporary clinical era has not been investigated. Objective To compare the association of mental stress-induced or conventional stress-induced ischemia with adverse cardiovascular events in patients with CHD. Design, Setting, and Participants Pooled analysis of 2 prospective cohort studies of patients with stable CHD from a university-based hospital network in Atlanta, Georgia: the Mental Stress Ischemia Prognosis Study (MIPS) and the Myocardial Infarction and Mental Stress Study 2 (MIMS2). Participants were enrolled between June 2011 and March 2016 (last follow-up, February 2020). Exposures Provocation of myocardial ischemia with a standardized mental stress test (public speaking task) and with a conventional (exercise or pharmacological) stress test, using single-photon emission computed tomography. Main Outcomes and Measures The primary outcome was a composite of cardiovascular death or first or recurrent nonfatal myocardial infarction. The secondary end point additionally included hospitalizations for heart failure. Results Of the 918 patients in the total sample pool (mean age, 60 years; 34% women), 618 participated in MIPS and 300 in MIMS2. Of those, 147 patients (16%) had mental stress-induced ischemia, 281 (31%) conventional stress ischemia, and 96 (10%) had both. Over a 5-year median follow-up, the primary end point occurred in 156 participants. The pooled event rate was 6.9 per 100 patient-years among patients with and 2.6 per 100 patient-years among patients without mental stress-induced ischemia. The multivariable adjusted hazard ratio (HR) for patients with vs those without mental stress-induced ischemia was 2.5 (95% CI, 1.8-3.5). Compared with patients with no ischemia (event rate, 2.3 per 100 patient-years), patients with mental stress-induced ischemia alone had a significantly increased risk (event rate, 4.8 per 100 patient-years; HR, 2.0; 95% CI, 1.1-3.7) as did patients with both mental stress ischemia and conventional stress ischemia (event rate, 8.1 per 100 patient-years; HR, 3.8; 95% CI, 2.6-5.6). Patients with conventional stress ischemia alone did not have a significantly increased risk (event rate, 3.1 per 100 patient-years; HR, 1.4; 95% CI, 0.9-2.1). Patients with both mental stress ischemia and conventional stress ischemia had an elevated risk compared with patients with conventional stress ischemia alone (HR, 2.7; 95% CI, 1.7-4.3). The secondary end point occurred in 319 participants. The event rate was 12.6 per 100 patient-years for patients with and 5.6 per 100 patient-years for patients without mental stress-induced ischemia (adjusted HR, 2.0; 95% CI, 1.5-2.5). Conclusions and Relevance Among patients with stable coronary heart disease, the presence of mental stress-induced ischemia, compared with no mental stress-induced ischemia, was significantly associated with an increased risk of cardiovascular death or nonfatal myocardial infarction. Although these findings may provide insights into mechanisms of myocardial ischemia, further research is needed to assess whether testing for mental stress-induced ischemia has clinical value.
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Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zakaria Almuwaqqat
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeong Hwan Kim
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Muhammad Hammadah
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Atlanta VA Medical Center, Decatur, Georgia
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anish Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ayman Alkhoder
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bruno B. Lima
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ernest V. Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathon Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David S. Sheps
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, Gainesville
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Zhang L, Bao Y, Wang X, Zhou Y, Tao S, Xu W, Liu M. A meta-analysis on the prevalence, associated factors and diagnostic methods of mental stress induced myocardial ischemia. J Transl Med 2020; 18:218. [PMID: 32471451 PMCID: PMC7257246 DOI: 10.1186/s12967-020-02383-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/16/2020] [Indexed: 11/27/2022] Open
Abstract
Background The high prevalence of mental stress induced myocardial ischemia (MSIMI) causes double risk of adverse cardiac events in patients with MSIMI. However, multiple types of mental stress, diagnostic techniques, and diagnostic measurements may increase the complexity and heterogeneity in the assessment of MSIMI. Therefore, we performed this meta-analysis to assess the prevalence, associated factors, and diagnostic methods of MSIMI. Methods We systematically searched PubMed, EMBACE, Web of Science, CNKI, Wanfang through 1 Feb 2020 in English and Chinese. Review Manager (RevMan) Version 5.3 and Stata 12.0 were used for data analyses. Results Twenty articles were enrolled. The pooled estimates for the prevalence of MSIMI in CAD patients was 32%. Potential associated factors of MSIMI involved history of post myocardial infarction (MI), or coronary artery bypass graft (CABG) (RR: 1.29, 95% CI 1.00–1.66, P = 0.05; RR: 1.59, 95% CI 1.00–2.52, P = 0.05). Evidence supported that diagnostic methods could influence the prevalence of MSIMI. Significant differences of MSIMI prevalence were found in different types of mental stress (Public Speaking: 22%; Mental arithmetic: 26%; Anger recall: 34%; Two types: 37%; Three or more than three types: 43%, P = 0.02), diagnostic techniques (SPECT: 26%; RNV: 38%; ECG: 16%; Echocardiography: 41%; Two types: 43%, P < 0.0001), and diagnostic measurements (LVEF decrease: 19%; WMA: 51%; ST depression: 16%; MPD: 26%; Two or more than two measurements: 45%, P < 0.00001). Moreover, univariate meta-regression demonstrated that MSIMI was linked with mental stress (exp(b): 1.0508, SE: 0.0201, P: 0.018). Conclusions This meta-analysis implicated that patients with diabetes, post MI or CABG might be more vulnerable to MSIMI. However, the prevalence of MSIMI could be influenced by diagnostic methods, especially the adopted types of mental stress, diagnostic techniques and measurements. Therefore, it is necessary to formulate a standard diagnostic method for MSIMI, which should be adequate, assessable, and affordable worldwide. Registration PROSPERO. Online Protocol: CRD42020162822.
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Affiliation(s)
- Lijun Zhang
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yanping Bao
- National Institute on Drug Dependence, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 10091, China.
| | - Xi Wang
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yuxin Zhou
- Department of Anatomy and Neurobiology, Boston University, Boston, USA
| | - Shuhui Tao
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.,School of Basic Medical Sciences, Henan University, Kaifeng, China
| | - Wan Xu
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Meiyan Liu
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
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Hammadah M, Sullivan S, Pearce B, Mheid IA, Wilmot K, Ramadan R, Tahhan AS, O’Neal WT, Obideen M, Alkhoder A, Abdelhadi N, Kelli HM, Ghafeer MM, Pimple P, Sandesara P, Shah AJ, Hosny KM, Ward L, Ko YA, Sun YV, Weng L, Kutner M, Bremner JD, Sheps DS, Esteves F, Raggi P, Vaccarino V, Quyyumi AA. Inflammatory response to mental stress and mental stress induced myocardial ischemia. Brain Behav Immun 2018; 68:90-97. [PMID: 28986223 PMCID: PMC5808921 DOI: 10.1016/j.bbi.2017.10.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 09/17/2017] [Accepted: 10/02/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) is associated with increased risk of adverse cardiovascular outcomes, yet the underlying mechanisms are not well understood. We measured the inflammatory response to acute laboratory mental stress in patients with coronary artery disease (CAD) and its association with MSIMI. We hypothesized that patients with MSIMI would have a higher inflammatory response to mental stress in comparison to those without ischemia. METHODS Patients with stable CAD underwent 99mTc sestamibi myocardial perfusion imaging during mental stress testing using a public speaking stressor. MSIMI was determined as impaired myocardial perfusion using a 17-segment model. Inflammatory markers including interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), matrix metallopeptidase 9 (MMP-9) and high-sensitivity C reactive protein (hsCRP) were measured at rest and 90 min after mental stress. Results were validated in an independent sample of 228 post-myocardial infarction patients. RESULTS Of 607 patients analyzed in this study, (mean age 63 ± 9 years, 76% male), 99 (16.3%) developed MSIMI. Mental stress resulted in a significant increase in IL-6, MCP-1, and MMP-9 (all p <0.0001), but not hsCRP. However, the changes in these markers were similar in those with and without MSIMI. Neither resting levels of these biomarkers, nor their changes with mental stress were significantly associated with MSIMI. Results in the replication sample were similar. CONCLUSION Mental stress is associated with acute increases in several inflammatory markers. However, neither the baseline inflammatory status nor the magnitude of the inflammatory response to mental stress over 90 min were significantly associated with MSIMI.
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Affiliation(s)
- Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Ibhar Al Mheid
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Kobina Wilmot
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ronnie Ramadan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ayman Samman Tahhan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Wesley T. O’Neal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Malik Obideen
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ayman Alkhoder
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Naser Abdelhadi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Heval Mohamed Kelli
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Mohamad Mazen Ghafeer
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Pratik Pimple
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Pratik Sandesara
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Amit J. Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States,Atlanta VA Medical Center, Decatur, GA, United States
| | - Kareem Mohammed Hosny
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Yi-An Ko
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Lei Weng
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA, United States,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - David S. Sheps
- University of Florida Health Science Center, Department of Medicine, Division of Cardiovascular Medicine, Gainesville, FL, United States
| | - Fabio Esteves
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States,Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
| | - Arshed A. Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States,Corresponding authors at: Emory University, Department of Cardiology, Emory University School of medicine, 1462 Clifton Road N.E. Suite 507, Atlanta GA 30322. (V. Vaccarino), (A.A. Quyyumi)
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Usefulness of Myocardial Annular Velocity Change During Mental Stress to Predict Cardiovascular Outcome in Patients With Coronary Artery Disease (From the Responses of Mental Stress-Induced Myocardial Ischemia to Escitalopram Treatment Trial). Am J Cardiol 2017; 120:1495-1500. [PMID: 28917493 DOI: 10.1016/j.amjcard.2017.07.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 11/20/2022]
Abstract
Mental stress-induced myocardial ischemia is common and a prognostic factor of adverse cardiovascular outcomes in patients with coronary artery disease (CAD). The present study aimed at examining associations between mental stress-induced myocardial annular velocity (MAV) and cardiovascular outcome in patients with CAD. MAV, specifically, diastolic early (e'), diastolic late (a'), and systolic (s') velocities were obtained at rest and during mental stress testing in 224 patients with clinically stable CAD. Using Cox regression models, age, sex, and baseline-adjusted mental stress-induced MAV measures were examined as predictors of a priori defined composite event term that comprised all-cause mortality and/or nonfatal cardiovascular events, resulting in an unplanned hospitalization (major adverse cardiovascular events [MACE]). Median follow-up was 4 years. The sample was predominantly male, Caucasian with New York Heart Association functional class I and a mean age of 63 ± 10.2 years. MS-induced changes in e' (hazard ratio [HR] = .73) and s' (HR = .73) were significant (p <0.05) predictors of MACE, and the change in a' (HR = .74) was marginal (p = 0.05). The pattern of the relation for each MAV measure was such that patients with a greater decrease in e' and/or s' velocity had a higher probability of experiencing an MACE, and the association of the change in a' and MACE was marginal (p = 0.05), but the same tendency. The associations between MS-induced values of e' and a' for MACE were independent of resting levels. Mental stress-induced MAV changes independently predict an adverse cardiovascular outcome in patients with stable CAD.
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Hammadah M, Alkhoder A, Al Mheid I, Wilmot K, Isakadze N, Abdulhadi N, Chou D, Obideen M, O'Neal WT, Sullivan S, Tahhan AS, Kelli HM, Ramadan R, Pimple P, Sandesara P, Shah AJ, Ward L, Ko YA, Sun Y, Uphoff I, Pearce B, Garcia EV, Kutner M, Bremner JD, Esteves F, Sheps DS, Raggi P, Vaccarino V, Quyyumi AA. Hemodynamic, catecholamine, vasomotor and vascular responses: Determinants of myocardial ischemia during mental stress. Int J Cardiol 2017; 243:47-53. [PMID: 28571621 PMCID: PMC5532063 DOI: 10.1016/j.ijcard.2017.05.093] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/13/2017] [Accepted: 05/23/2017] [Indexed: 01/07/2023]
Abstract
AIMS Mental stress-induced myocardial ischemia (MSIMI) in patients with coronary artery disease (CAD) is associated with adverse cardiovascular outcomes. We aim to assess hemodynamic, neuro-hormonal, endothelial, vasomotor and vascular predictors of MSIMI. METHODS AND RESULTS We subjected 660 patients with stable CAD to 99mTc sestamibi myocardial perfusion imaging at rest, with mental (speech task) and with conventional (exercise/pharmacological) stress. Endothelium-dependent flow-mediated dilation (FMD), microvascular reactivity [reactive hyperemia index (RHI)] and arterial stiffness [pulse wave velocity (PWV)] were measured at rest and 30-min after mental stress. The digital microvascular vasomotor response during mental stress was assessed using peripheral arterial tonometry (PAT). A total of 106(16.1%) patients had MSIMI. Mental stress was accompanied by significant increases in rate-pressure-product (heart rate x systolic blood pressure; RPP), epinephrine levels and PWV, and significant decreases in FMD and PAT ratio denoting microvascular constriction. In comparison to those with no MSIMI, patients with MSIMI had higher hemodynamic and digital vasoconstrictive responses (p<0.05 for both), but did not differ in epinephrine, endothelial or macrovascular responses. Only presence of ischemia during conventional stress (OR of 7.1, 95%CI of 4.2, 11.9), high hemodynamic response (OR for RPP response≥vs<ROC cutoff of 1.8, 95%CI of 1.1, 2.8), and high digital vasoconstriction (OR for PAT ratio<vs≥ROC cutoff of 2.1, 95%CI of 1.3, 3.3) were independent predictors of MSIMI. CONCLUSION Ischemia during conventional stress testing and hemodynamic and vasoconstrictive responses to mental stress can help predict subjects with CAD at greater risk of developing MSIMI.
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Affiliation(s)
- Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ayman Alkhoder
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ibhar Al Mheid
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Kobina Wilmot
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Nino Isakadze
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Naser Abdulhadi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Danielle Chou
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Malik Obideen
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Wesley T O'Neal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Ayman Samman Tahhan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Heval Mohamed Kelli
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ronnie Ramadan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Pratik Pimple
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Pratik Sandesara
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Atlanta VA Medical Center, Decatur, GA, United States
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Yan Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Irina Uphoff
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Ernest V Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA, United States; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, United States
| | - Fabio Esteves
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States
| | - David S Sheps
- University of Florida Health Science Center, Department of Medicine, Division of Cardiovascular Medicine, United States
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States.
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Positive and Negative Affect Is Related to Experiencing Chest Pain During Exercise-Induced Myocardial Ischemia. Psychosom Med 2017; 79:395-403. [PMID: 28009652 DOI: 10.1097/psy.0000000000000427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Silent myocardial ischemia is thought to be associated with worse cardiovascular outcomes due to a lack of perception of pain cues that initiate treatment seeking. Negative affect (NA) has been associated with increased pain reporting and positive affect (PA) with decreased pain reporting, but these psychological factors have not been examined within the context of myocardial ischemia. This study evaluated the associations between PA, NA, and chest pain reporting in patients with and without ischemia during exercise testing. METHODS A total of 246 patients referred for myocardial perfusion single-photon emission computed tomography exercise stress testing completed the positive and negative affect schedule-expanded version, a measure of PA and NA. Presence of chest pain and myocardial ischemia were evaluated using standardized protocols. RESULTS Logistic regression analyses revealed that for every 1-point increase in NA, there was a 13% higher chance for ischemic patients (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02 to 1.26) and an 11% higher chance in nonischemic patients (OR = 1.11; 95% CI = 1.03 to 1.19) to report chest pain. A significant interaction of PA and NA on chest pain reporting (β = 0.02; 95% CI = 0.002 to 0.031) was also observed; nonischemic patients with high NA and PA reported more chest pain (57%) versus patients with low NA and low PA (13%), with high NA and low PA (17%), and with high PA and low NA (7%). CONCLUSIONS Patients who experience higher NA are more likely to report experiencing chest pain. In patients without ischemia, high NA and PA was also associated with a higher likelihood of reporting chest pain. Results suggest that high levels of PA as well as NA may increase the experience and/or reporting of chest pain.
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Abstract
OBJECTIVE Mental stress-induced myocardial ischemia (MSIMI) is a common phenomenon in patients with coronary artery disease (CAD), but contemporary studies of its prognostic significance and its underlying pathophysiology are limited. METHODS We prospectively enrolled patients with confirmed CAD in the Mental Stress Ischemia Prognosis Study (MIPS) between 2011 and 2014. All patients underwent mental stress testing using a standardized public speaking task, and ischemia was detected by Tc-sestamibi myocardial perfusion imaging. Patients also underwent conventional stress testing for myocardial ischemia (CSIMI) using exercise or pharmacological stress testing. Furthermore, digital microvascular flow, endothelial function, arterial stiffness, and blood sample collections were performed before, during, and after mental stress. Two-year adverse clinical outcomes are being assessed. RESULTS Six-hundred ninety-five patients completed baseline enrollment in the MIPS. Their mean (standard deviation) age was 62.9 (9.1) years, 72% were men, 30% were African American, and 32% had a history myocardial infarction. The prevalence of MSIMI and CSIMI is 16.1% and 34.7%, respectively. A total of 151 patients (22.9%) had only CSIMI, 28 (4.2%) had only MSIMI, and 78 (11.8%) had both MSIMI and CSIMI. Patients with ischemia had a lower ejection fraction and higher prevalence of previous coronary artery bypass grafting compared with those without inducible ischemia (p < .050). The prevalence of obstructive CAD was not statistically different between patients with and without MSIMI (p = .426); in contrast, it was higher in patients with CSIMI (p < .001). CONCLUSIONS The MIPS data will provide useful information to assess the prognostic significance and underlying mechanisms of MSIMI.
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Paine NJ, Bacon SL, Pelletier R, Arsenault A, Diodati JG, Lavoie KL. Do Women With Anxiety or Depression Have Higher Rates of Myocardial Ischemia During Exercise Testing Than Men? CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 9:S53-61. [PMID: 26908861 DOI: 10.1161/circoutcomes.115.002491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women diagnosed with coronary artery disease (CAD) typically experience worse outcomes relative to men, possibly through diagnosis and treatment delays. Reasons for these delays may be influenced by mood and anxiety disorders, which are more prevalent in women and have symptoms (eg, palpitations and fatigue) that may be confounded with CAD. Our study examined sex differences in the association between mood and anxiety disorders and myocardial ischemia in patients with and without a CAD history presenting for exercise stress tests. METHODS AND RESULTS A total of 2342 patients (women n=760) completed a single photon emission computed tomographic exercise stress test (standard Bruce Protocol) and underwent a psychiatric interview (The Primary Care Evaluation of Mental Disorders) to assess mood and anxiety disorders. Ischemia was assessed using single photon emission computed tomography, with odds ratio used to calculate the effect of sex and mood/anxiety on the presence of ischemia during stress testing by CAD history in a stratified analyses, adjusted for relevant covariates. There was a sex by anxiety interaction with ischemia in those without a CAD history (P=0.015): women with anxiety were more likely to exhibit ischemia during exercise than women without anxiety (odds ratio, 1.75; 95% confidence interval, 1.05-2.89). No significant effects were observed for men nor mood. CONCLUSIONS Women with anxiety and no CAD history had higher rates of ischemia than women without anxiety. Results suggest that anxiety symptoms, many of which overlap with those of CAD, might mask CAD symptoms among women (but not men) and contribute to referral and diagnostic delays. Further research is needed to confirm this hypothesis.
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Affiliation(s)
- Nicola J Paine
- From the Department of Exercise Science, Concordia University, Montréal, Quebec, Canada (N.J.P., S.L.B.); Montréal Behavioural Medicine Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (N.J.P., S.L.B., A.A., K.L.L.); Department of Psychology, University of Quebec at Montreal, Montréal, Quebec, Canada (K.L.L.); Division of Clinical Epidemiology, McGill University Health Centre, Montréal, Quebec, Canada (R.P.); Research Centre, Montreal Heart Institute, Montréal, Quebec, Canada (A.A.); and Research Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (J.G.D.)
| | - Simon L Bacon
- From the Department of Exercise Science, Concordia University, Montréal, Quebec, Canada (N.J.P., S.L.B.); Montréal Behavioural Medicine Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (N.J.P., S.L.B., A.A., K.L.L.); Department of Psychology, University of Quebec at Montreal, Montréal, Quebec, Canada (K.L.L.); Division of Clinical Epidemiology, McGill University Health Centre, Montréal, Quebec, Canada (R.P.); Research Centre, Montreal Heart Institute, Montréal, Quebec, Canada (A.A.); and Research Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (J.G.D.)
| | - Roxanne Pelletier
- From the Department of Exercise Science, Concordia University, Montréal, Quebec, Canada (N.J.P., S.L.B.); Montréal Behavioural Medicine Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (N.J.P., S.L.B., A.A., K.L.L.); Department of Psychology, University of Quebec at Montreal, Montréal, Quebec, Canada (K.L.L.); Division of Clinical Epidemiology, McGill University Health Centre, Montréal, Quebec, Canada (R.P.); Research Centre, Montreal Heart Institute, Montréal, Quebec, Canada (A.A.); and Research Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (J.G.D.)
| | - André Arsenault
- From the Department of Exercise Science, Concordia University, Montréal, Quebec, Canada (N.J.P., S.L.B.); Montréal Behavioural Medicine Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (N.J.P., S.L.B., A.A., K.L.L.); Department of Psychology, University of Quebec at Montreal, Montréal, Quebec, Canada (K.L.L.); Division of Clinical Epidemiology, McGill University Health Centre, Montréal, Quebec, Canada (R.P.); Research Centre, Montreal Heart Institute, Montréal, Quebec, Canada (A.A.); and Research Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (J.G.D.)
| | - Jean G Diodati
- From the Department of Exercise Science, Concordia University, Montréal, Quebec, Canada (N.J.P., S.L.B.); Montréal Behavioural Medicine Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (N.J.P., S.L.B., A.A., K.L.L.); Department of Psychology, University of Quebec at Montreal, Montréal, Quebec, Canada (K.L.L.); Division of Clinical Epidemiology, McGill University Health Centre, Montréal, Quebec, Canada (R.P.); Research Centre, Montreal Heart Institute, Montréal, Quebec, Canada (A.A.); and Research Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (J.G.D.)
| | - Kim L Lavoie
- From the Department of Exercise Science, Concordia University, Montréal, Quebec, Canada (N.J.P., S.L.B.); Montréal Behavioural Medicine Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (N.J.P., S.L.B., A.A., K.L.L.); Department of Psychology, University of Quebec at Montreal, Montréal, Quebec, Canada (K.L.L.); Division of Clinical Epidemiology, McGill University Health Centre, Montréal, Quebec, Canada (R.P.); Research Centre, Montreal Heart Institute, Montréal, Quebec, Canada (A.A.); and Research Centre, Hôpital du Sacré-Coeur à Montréal, Montréal, Quebec, Canada (J.G.D.).
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Abstract
Mental stress and emotional arousal can act as triggers of acute myocardial infarction and other adverse cardiovascular outcomes. Experimental research examining mechanisms of the adverse interplay between mind and heart has led to the discovery of mental stress-induced cardiac dysfunction or myocardial ischemia (MSIMI). Evidence about the prevalence, clinical significance, and mechanistic bases of MSIMI outlines a wide range of central and peripheral bio-pathologic processes that are associated with emotions and behaviors. MSIMI is recognized as an integrated and intermediate biomarker underpinning the negative mind-heart interplay. Particularly, MSIMI research paves the way toward investigations aiming more specifically at recognizing the susceptibilities of individuals who are prone to respond adversely to the psycho-social-environmental stress. This article reviews recent literature on MSIMI research following the comprehensive review of Strike and Steptoe Eur Heart J 24:690-703, 2003. Further, this article outlines the main steps in the identification of the specific bio-pathologic manifestations of the cardiovascular system to emotional stress. Finally, a speculative description is provided of future directions in better searching for areas that may be critical targets in resolving adverse mind-heart interplays.
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Affiliation(s)
- Wei Jiang
- Duke University Medical Center, Box 3366, Durham, NC, 27710, USA,
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Boyle SH, Matson WR, Velazquez EJ, Samad Z, Williams RB, Sharma S, Thomas B, Wilson JL, O'Connor C, Jiang W. Metabolomics analysis reveals insights into biochemical mechanisms of mental stress-induced left ventricular dysfunction. Metabolomics 2015; 11:571-582. [PMID: 25983674 PMCID: PMC4431771 DOI: 10.1007/s11306-014-0718-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mental stress induced left ventricular dysfunction (LVD) has been associated with a greater risk of adverse events in coronary heart disease (CHD) patients independent of conventional risk indicators. The underlying biochemical mechanisms of this cardiovascular condition are poorly understood. Our objective was to use metabolomics technology to identify biochemical changes that co-occur with mental stress-induced LVD in patients with clinically stable CHD. Participants were adult CHD patients who were recruited for mental stress-induced myocardial ischemia screening. For this study, we randomly selected 30 patients representing the extremes of the mental stress-induced left ventricular ejection fraction (LVEF) change distribution; 15 who showed LVD (i.e. LVEF reduction ≥5) and 15 who showed a normal left ventricular response (NLVR; i.e. a LVEF increase of ≥5) to three mental stressors. An electrochemistry based metabolomics platform was used to profile pre- and post-stress serum samples yielding data for 22 known compounds, primarily within the tyrosine, tryptophan, purine and methionine pathways. There were significant stress-induced changes in several compounds. A comparison between the NLVR and LVD groups showed significant effects for kynurenine (p = .036, N-acetylserotonin (p = .054), uric acid (p = .015), tyrosine (p = .019) and a trend for methionine (p = .065); the NLVR group showed a significantly greater stress-induced reduction in all of those compounds compared to the LVD group. Many of these biochemicals have been implicated in other stress-related phenomena and are plausible candidates for mechanisms underlying LVD in response to mental stress.
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Affiliation(s)
- Stephen H. Boyle
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3366, Durham, NC 27710, USA
| | - Wayne R. Matson
- Department of Systems Biochemistry, Counterpoint Health Solutions Inc, Bedford, MA, USA
| | - Eric J. Velazquez
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Zainab Samad
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Redford B. Williams
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3366, Durham, NC 27710, USA
| | - Swati Sharma
- Department of Systems Biochemistry, Counterpoint Health Solutions Inc, Bedford, MA, USA
| | - Beena Thomas
- Department of Systems Biochemistry, Counterpoint Health Solutions Inc, Bedford, MA, USA
| | - Jennifer L. Wilson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3366, Durham, NC 27710, USA
| | | | - Wei Jiang
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3366, Durham, NC 27710, USA, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Jiang W, Boyle SH, Ortel TL, Samad Z, Velazquez EJ, Harrison RW, Wilson J, Kuhn C, Williams RB, O’Connor CM, Becker RC. Platelet aggregation and mental stress induced myocardial ischemia: Results from the Responses of Myocardial Ischemia to Escitalopram Treatment (REMIT) study. Am Heart J 2015; 169:496-507.e1. [PMID: 25819856 PMCID: PMC4382806 DOI: 10.1016/j.ahj.2014.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 12/15/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) is common in patients with ischemic heart disease (IHD) and associated with a poorer cardiovascular prognosis. Platelet hyperactivity is an important factor in acute coronary syndrome. This study examined associations between MSIMI and resting and mental stress-induced platelet activity. METHODS Eligible patients with clinically stable IHD underwent a battery of 3 mental stress tests during the recruitment phase of REMIT study. MSIMI was assessed by echocardiography and electrocardiography. Ex vivo platelet aggregation in response to ADP, epinephrine, collagen, serotonin, and combinations of serotonin plus ADP, epinephrine, and collagen were evaluated as was platelet serotonin transporter expression. RESULTS Of the 270 participants who completed mental stress testing, and had both resting and post-stress platelet aggregation evaluation , 43.33% (n=117) met criteria for MSIMI and 18.15% (n=49) had normal left ventricular response to stress (NLVR). The MSIMI group, relative to the NLVR groups, demonstrated heightened mental stress-induced aggregation responses, as measured by area under the curve, to collagen 10μM (6.95[5.54] vs. -14.23[8.75].; P=0.045), epinephrine 10μM (12.84[4.84] vs. -6.40[7.61].; P=0.037) and to serotonin 10 μM plus ADP 1 μM (6.64[5.29] vs. -27.34[8.34]; P<.001). The resting platelet aggregation and serotonin transporter expression, however, were not different between the two groups. CONCLUSIONS These findings suggest that the dynamic change of platelet aggregation caused by mental stress may underlie MSIMI. While the importance of these findings requires additional investigation, they raise concern given the recognized relationship between mental stress-induced platelet hyperactivity and cardiovascular events in patients with IHD.
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14
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Underlying inflammation has no impact on the oxidative stress response to acute mental stress. Brain Behav Immun 2014; 40:182-90. [PMID: 24675034 DOI: 10.1016/j.bbi.2014.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/06/2014] [Accepted: 03/13/2014] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Mental stress is considered to be a trigger for acute myocardial infarction (MI), with inflammation thought to provide a mechanism. Inflammation is reciprocally linked to oxidative stress, which has also been implicated in MI. The purpose of this study was to assess the effects of experimentally-induced inflammation on the oxidative stress response to mental stress in healthy participants. METHODS Healthy males undertook one of two inflammatory stimuli: typhoid vaccination (Vaccination paradigm, N=17) or eccentric exercise (Eccentric exercise paradigm, N=17). All participants completed a mental arithmetic stress task twice (within-subject design): 6h after the inflammatory stimulus, and during a control non-inflammation condition. Blood samples were taken before, immediately and 30min after the stress task. Plasma was assessed for interleukin-6 (IL-6), protein carbonyls (PC), lipid hydroperoxides (LOOH), total antioxidant capacity (TAC) and nitric oxide metabolites (NOx). RESULTS Vaccination paradigm: IL-6, PC and NOx were significantly higher in the vaccination condition, relative to the control condition (p<.05). PC, TAC, LOOH and NOx were unchanged in response to mental stress in both the vaccination and control conditions. Eccentric Exercise paradigm: IL-6 and TAC were significantly higher in the eccentric exercise condition (p<.05), relative to the control condition. PC, TAC and NOx were unchanged in response to mental stress in both the eccentric exercise and control conditions. CONCLUSIONS Two different inflammatory paradigms were successful in increasing selective plasma markers of inflammation and oxidative stress prior to a mental stress task. However, experimentally induced transient inflammation had no impact on mental stress-induced changes in plasma LOOH, PC, TAC or NOx in young healthy participants.
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Wei J, Rooks C, Ramadan R, Shah AJ, Bremner JD, Quyyumi AA, Kutner M, Vaccarino V. Meta-analysis of mental stress-induced myocardial ischemia and subsequent cardiac events in patients with coronary artery disease. Am J Cardiol 2014; 114:187-92. [PMID: 24856319 PMCID: PMC4126399 DOI: 10.1016/j.amjcard.2014.04.022] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 04/23/2014] [Accepted: 04/23/2014] [Indexed: 02/02/2023]
Abstract
Mental stress-induced myocardial ischemia (MSIMI) has been associated with adverse prognosis in patients with coronary artery disease (CAD), but whether this is a uniform finding across different studies has not been described. We conducted a systematic review and meta-analysis of prospective studies examining the association between MSIMI and adverse outcome events in patients with stable CAD. We searched PubMed, EMBASE, Web of Science, and PsycINFO databases for English language prospective studies of patients with CAD who underwent standardized mental stress testing to determine presence of MSIMI and were followed up for subsequent cardiac events or total mortality. Our outcomes of interest were CAD recurrence, CAD mortality, or total mortality. A summary effect estimate was derived using a fixed-effects meta-analysis model. Only 5 studies, each with a sample size of <200 patients and fewer than 50 outcome events, met the inclusion criteria. The pooled samples comprised 555 patients with CAD (85% male) and 117 events with a range of follow-up from 35 days to 8.8 years. Pooled analysis showed that MSIMI was associated with a twofold increased risk of a combined end point of cardiac events or total mortality (relative risk 2.24, 95% confidence interval 1.59 to 3.15). No heterogeneity was detected among the studies (Q=0.39, I2=0.0%, p=0.98). In conclusion, although few selected studies have examined the association between MSIMI and adverse events in patients with CAD, all existing investigations point to approximately a doubling of risk. Whether this increased risk is generalizable to the CAD population at large and varies in patient subgroups warrant further investigation.
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Affiliation(s)
- Jingkai Wei
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Cherie Rooks
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ronnie Ramadan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Kutner
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
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Paine NJ, Ring C, Aldred S, Bosch JA, Wadley AJ, Veldhuijzen van Zanten JJCS. Eccentric-exercise induced inflammation attenuates the vascular responses to mental stress. Brain Behav Immun 2013; 30:133-42. [PMID: 23376168 DOI: 10.1016/j.bbi.2013.01.082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 01/15/2013] [Accepted: 01/23/2013] [Indexed: 10/27/2022] Open
Abstract
Mental stress has been identified as a trigger of myocardial infarction (MI), with inflammation and vascular responses to mental stress independently implicated as contributing factors. This study examined whether inflammation moderates the vascular responses to mental stress. Eighteen healthy male participants completed a stress task under two counter balanced conditions. In the exercise condition, a morning bout of eccentric exercise (12×5 repetitions of unilateral eccentric knee extension at 120% intensity of concentric one repetition maximum) was used to increase levels of inflammatory-responsive cytokines during an afternoon stress session scheduled 6h later. In the control condition, participants sat and relaxed for 45min, 6h prior to the afternoon stress session. Forearm blood flow, calf blood flow (measured in the leg which completed the exercise task), blood pressure, heart rate and cardiac output were assessed at rest and in response to mental stress. As expected, interleukin-6 was higher (p=.02) 6h post exercise, i.e., at the start of the stress session, as compared to the no-exercise control condition. Mental stress increased forearm blood flow, calf blood flow, blood pressure, heart rate, and cardiac output in both conditions (p's<.001). Stress-induced calf blood flow was attenuated in the exercise condition compared to the control condition (p<.05) which was not the case for forearm blood flow. This study found that the inflammatory response to eccentric exercise attenuated the vascular responses to mental stress locally at the site of eccentric exercise-induced inflammation. The observed impairment in vascular responses to stress associated with increased levels of inflammation suggests a mechanism through which inflammation might increase the risk for MI.
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Affiliation(s)
- Nicola J Paine
- School of Sport and Exercise Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom.
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Jiang W, Samad Z, Boyle S, Becker RC, Williams R, Kuhn C, Ortel TL, Rogers J, Kuchibhatla M, O'Connor C, Velazquez EJ. Prevalence and clinical characteristics of mental stress-induced myocardial ischemia in patients with coronary heart disease. J Am Coll Cardiol 2013; 61:714-22. [PMID: 23410543 DOI: 10.1016/j.jacc.2012.11.037] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 11/26/2012] [Accepted: 11/27/2012] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate the prevalence and clinical characteristics of mental stress-induced myocardial ischemia. BACKGROUND Mental stress-induced myocardial ischemia is prevalent and a risk factor for poor prognosis in patients with coronary heart disease, but past studies mainly studied patients with exercise-induced myocardial ischemia. METHODS Eligible patients with clinically stable coronary heart disease, regardless of exercise stress testing status, underwent a battery of 3 mental stress tests followed by a treadmill test. Stress-induced ischemia, assessed by echocardiography and electrocardiography, was defined as: 1) development or worsening of regional wall motion abnormality; 2) left ventricular ejection fraction reduction ≥ 8%; and/or 3) horizontal or downsloping ST-segment depression ≥ 1 mm in 2 or more leads lasting for ≥ 3 consecutive beats during at least 1 mental test or during the exercise test. RESULTS Mental stress-induced ischemia occurred in 43.45%, whereas exercise-induced ischemia occurred in 33.79% (p = 0.002) of the study population (N = 310). Women (odds ratio [OR]: 1.88), patients who were not married (OR: 1.99), and patients who lived alone (OR: 2.24) were more likely to have mental stress-induced ischemia (all p < 0.05). Multivariate analysis showed that compared with married men or men living with someone, unmarried men (OR: 2.57) and married women (OR: 3.18), or living alone (male OR: 2.25 and female OR: 2.72, respectively) had higher risk for mental stress-induced ischemia (all p < 0.05). CONCLUSIONS Mental stress-induced ischemia is more common than exercise-induced ischemia in patients with clinically stable coronary heart disease. Women, unmarried men, and individuals living alone are at higher risk for mental stress-induced ischemia. (Responses of Myocardial Ischemia to Escitalopram Treatment [REMIT]; NCT00574847).
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Affiliation(s)
- Wei Jiang
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Miller PS, Evangelista LS, Giger JN, Dracup K, Doering LV. Clinical and socio-demographic predictors of postoperative vital exhaustion in patients after cardiac surgery. Heart Lung 2013; 42:98-104. [PMID: 23453010 PMCID: PMC4455925 DOI: 10.1016/j.hrtlng.2013.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/04/2013] [Accepted: 01/04/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Vital exhaustion, a psychological state characterized by extreme fatigue, is an independent predictor of future cardiac events. However, the attributes of vital exhaustion following coronary artery bypass (CABG) surgery are poorly understood. OBJECTIVE The study objective was to assess correlates of vital exhaustion following CABG surgery. METHODS In a descriptive, exploratory study, 42 patients who had CABG surgery were evaluated for exhaustion 4-8 weeks post-hospital discharge. Demographic and clinical data were obtained from self-report and medical chart review. RESULTS Of the total sample (mean age 67.9 ± 12.5, 90% male, 70% Caucasian, 3.12 ± 1.3 grafts), approximately 41% reported exhaustion. When compared to their exhausted post-CABG counterpart, non-exhausted post-CABG patients had a significantly higher frequency of preoperative insulin use. Exhausted patients were significantly more likely to have higher left ventricular ejection fraction ([LVEF], OR: 1.07, p = 0.04), and elevated hemoglobin (OR: 2.98, p = 0.03) and eosinophils (OR: 1.02, p = 0.02) than those who were not exhausted. CONCLUSION Clinicians should evaluate all patients for exhaustion post-CABG surgery; patients with elevated LVEF, hemoglobin, and eosinophil levels warrant increased scrutiny.
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Affiliation(s)
- Pamela S. Miller
- Postdoctoral Scholar, School of Nursing, University of California, San Francisco, 2 Koret Way, N411Y, Box 0606, San Francisco, California, USA 94143-0606
| | - Lorraine S. Evangelista
- Associate Professor, Program in Nursing Science, College of Health Sciences, University of California, Irvine, 231 Irvine Hall, Irvine, California, USA 92697-3959
| | - Joyce Newman Giger
- Professor, School of Nursing, University of California, Los Angeles BOX 956919, 5-234 Factor Los Angeles, California, USA, 90095-6919
| | - Kathleen Dracup
- Professor, School of Nursing, University of California, San Francisco, 2 Koret Way, N631, Box 0610, San Francisco, California, USA 94143-0610
| | - Lynn V. Doering
- Professor, School of Nursing, University of California, Los Angeles BOX 956918, 4-250 Factor Los Angeles, California, USA, 90095-6918
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Abstract
Considerable progress has been made during the past decade in research on cardiovascular effects of stress. Early-life stressors, such as childhood abuse and early socioeconomic adversity, are linked to increased cardiovascular morbidity in adulthood. Our updated meta-analyses of prospective studies published until 2011 show a 1.5-fold (95% confidence interval 1.2-1.9) increased risk of coronary heart disease among adults experiencing social isolation and a 1.3-fold (1.2-1.5) excess risk for workplace stress; adverse metabolic changes are one of the underlying plausible mechanisms. Stress, anger, and depressed mood can act as acute triggers of major cardiac events; the pooled relative risk of acute coronary syndrome onset being preceded by stress is 2.5 (1.8-3.5) in case-crossover studies. Stress is also implicated in the prognosis of cardiovascular disease and in the development of stress (takotsubo) cardiomyopathy. A major challenge over the next decade is to incorporate stress processes into the mainstream of cardiovascular pathophysiological research and understanding.
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Affiliation(s)
- Andrew Steptoe
- Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, United Kingdom.
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Abstract
OBJECTIVES The aim of this study was to examine the associations between depressive symptoms and mental stress-induced myocardial ischemia (MSIMI) in patients with coronary heart disease (CHD). METHODS Adult patients with documented CHD were recruited for baseline mental stress and exercise stress screening testing as a part of the enrollment process of the Responses of Myocardial Ischemia to Escitalopram Treatment trial. Patients were administered the Beck Depression Inventory II and the Center for Epidemiologic Studies Depression Scale. After a 24-48-hour β-blocker withdrawal, participants completed three mental stress tests followed by a treadmill exercise test. Ischemia was defined as a) any development or worsening of any wall motion abnormality and b) reduction of left ventricular ejection fraction at least 8% by transthoracic echocardiography and/or ischemic ST-segment change by electrocardiography during stress testing. MSIMI was considered present when ischemia occurred in at least one mental test. Data were analyzed using logistic regression adjusting for age, sex, and resting left ventricular ejection fraction. RESULTS One hundred twenty-five (44.2%) of 283 patients were found to have MSIMI, and 93 (32.9%) had ESIMI. Unadjusted analysis showed that Beck Depression Inventory II scores were positively associated with the probability of MSIMI (odds ratio = 0.1.30: 95% confidence interval = 1.06-1.60, p = .013) and number of MSIMI-positive tasks (all p < .005). These associations were still significant after adjustment for covariates (p values <.05). CONCLUSIONS In patients with CHD, depressive symptoms were associated with a higher probability of MSIMI. These observations may enhance our understanding of the mechanisms contributing to the association of depressive symptoms to future cardiovascular events. Trial Registration Clinicaltrials.gov identifier: NCT00574847.
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Schwartz BG, French WJ, Mayeda GS, Burstein S, Economides C, Bhandari AK, Cannom DS, Kloner RA. Emotional stressors trigger cardiovascular events. Int J Clin Pract 2012; 66:631-9. [PMID: 22698415 DOI: 10.1111/j.1742-1241.2012.02920.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS To describe the relation between emotional stress and cardiovascular events, and review the literature on the cardiovascular effects of emotional stress, in order to describe the relation, the underlying pathophysiology, and potential therapeutic implications. MATERIALS AND METHODS Targeted PUBMED searches were conducted to supplement the authors' existing database on this topic. RESULTS Cardiovascular events are a major cause of morbidity and mortality in the developed world. Cardiovascular events can be triggered by acute mental stress caused by events such as an earthquake, a televised high-drama soccer game, job strain or the death of a loved one. Acute mental stress increases sympathetic output, impairs endothelial function and creates a hypercoagulable state. These changes have the potential to rupture vulnerable plaque and precipitate intraluminal thrombosis, resulting in myocardial infarction or sudden death. CONCLUSION Therapies targeting this pathway can potentially prevent acute mental stressors from initiating plaque rupture. Limited evidence suggests that appropriately timed administration of beta-blockers, statins and aspirin might reduce the incidence of triggered myocardial infarctions. Stress management and transcendental meditation warrant further study.
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Affiliation(s)
- B G Schwartz
- Heart Institute, Good Samaritan Hospital, Los Angeles, CA, USA
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Abstract
The physiological reaction to psychological stress, involving the hypothalamic-pituitary-adrenocortical and sympatho-adrenomedullary axes, is well characterized, but its link to cardiovascular disease risk is not well understood. Epidemiological data show that chronic stress predicts the occurrence of coronary heart disease (CHD). Employees who experience work-related stress and individuals who are socially isolated or lonely have an increased risk of a first CHD event. In addition, short-term emotional stress can act as a trigger of cardiac events among individuals with advanced atherosclerosis. A stress-specific coronary syndrome, known as transient left ventricular apical ballooning cardiomyopathy or stress (Takotsubo) cardiomyopathy, also exists. Among patients with CHD, acute psychological stress has been shown to induce transient myocardial ischemia and long-term stress can increase the risk of recurrent CHD events and mortality. Applications of the 'stress concept' (the understanding of stress as a risk factor and the use of stress management) in the clinical settings have been relatively limited, although the importance of stress management is highlighted in European guidelines for cardiovascular disease prevention.
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Schwartz BG, Mayeda GS, Burstein S, Economides C, Kloner RA. When and why do heart attacks occur? Cardiovascular triggers and their potential role. Hosp Pract (1995) 2010; 38:144-152. [PMID: 20890064 DOI: 10.3810/hp.2010.06.308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Coronary heart disease affects 7.6% of the population in the United States, where > 900,000 myocardial infarctions (MIs) occur annually. Approximately half of all MIs have an identifiable clinical trigger. Myocardial ischemia, MI, sudden cardiac death, and thrombotic stroke each occur with circadian variation and peak after waking in the morning. In addition, physical exertion and mental stress are common precipitants of MI. Waking in the morning, physical exertion, and mental stress influence a number of physiologic parameters, including blood pressure, heart rate, plasma epinephrine levels, coronary blood flow, platelet aggregability, and endothelial function. Upregulation of sympathetic output and catecholamines increase myocardial oxygen demand and can decrease myocardial oxygen supply and promote thrombosis. Ischemia ensues when myocardial oxygen demand exceeds supply. Increases in blood pressure and ventricular contractility increase intravascular shear stress and may cause vulnerable atherosclerotic plaques to rupture, forming a nidus for thrombosis that can precipitate MI. Numerous clinical triggers of MI have been identified, including blizzards, the Christmas and New Year's holidays, experiencing an earthquake, the threat of violence, job strain, Mondays for the working population, sexual activity, overeating, smoking cigarettes, smoking marijuana, using cocaine, and particulate air pollution. Avoiding clinical triggers or participating in therapies that prevent clinical triggers from precipitating cardiac events could potentially postpone clinical events by several years and improve cardiovascular morbidity and mortality. Direct or indirect evidence suggests that the risk of triggered MIs is reduced with β-blockers, aspirin, statins, stress management, and transcendental meditation.
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Affiliation(s)
- Bryan G Schwartz
- Heart Institute, Good Samaritan Hospital, Los Angeles, CA 90017-2395, USA
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