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

Obstructive Sleep Apnea as a Key Contributor to Mental Stress-Induced Myocardial Ischemia in Female Angina Patients with No Obstructive Coronary Artery Disease

Purpose

Mental stress induced myocardial ischemia (MSIMI) is regarded as the primary cause of the angina with no obstructive coronary artery disease (ANOCA). Obstructive sleep apnea (OSA) is autonomously linked to obstructive coronary heart disease, hypertension, and sudden cardiac death. Similar to the impact of psychological stress on the cardiovascular system, individuals with OSA experience periodic nocturnal hypoxia, resulting in the activation of systemic inflammation, oxidative stress, endothelial dysfunction, and sympathetic hyperactivity. The contribution of OSA to MSIMI in ANOCA patients is unclear. To explore the prevalence of OSA in ANOCA patients and the correlation between OSA and MSIMI, a prospective cohort of female ANOCA patients was recruited.

Patients and Methods

We recruited female patients aged 18 to 75 years old with ANOCA and evaluated MSIMI using positron emission tomography-computed tomography. Subsequently, Level III portable monitors was performed to compare the relationship between OSA and MSIMI.

Results

There is higher REI (7.8 vs 2.6, P=0.019), ODI (4.7 vs 9.2, P=0.028) and percentage of OSA (67.74% vs 33.33%, P=0.004) in MSIMI patients. The patients diagnosed with OSA demonstrated higher myocardial perfusion imaging scores (SSS: 1.5 vs 3, P = 0.005, SDS: 1 vs 3, P = 0.007). Adjusted covariates, the risk of developing MSIMI remained 3.6 times higher in OSA patients (β=1.226, OR = 3.408 (1.200-9.681), P = 0.021).

Conclusion

Patients with MSIMI exhibit a greater prevalence of OSA. Furthermore, the myocardial blood flow perfusion in patients with OSA is reduced during mental stress.

Cardiovascular disease, self-care and emotional regulation processes in adult patients: balancing unmet needs and quality of life

BACKGROUND

Cardiovascular disease is a chronic non-communicable illness that causes more than half of all deaths across Europe. Unhealthy lifestyle, inadequate adherence to medical prescriptions, themselves associated with psycho-emotional disorders are considered risk factors for reduced quality of life as well physical condition.

OBJECTIVE

Aim of our study was to understand predictive factors for disease management by evaluating psychological aspects, self-care processes and emotional regilati0on in CVD outpatients.

METHODS

An observational study was conducted. Sixty-one patients, age 18-75 years (M 56.4 ± sd 12.0), diagnosed with CVD participated in the study. The psychological battery was administered during clinical follow-up oriented to detect emotional and psychological dimensions as well adaptive behavioral and quality of life by standardized questionnaire/scales.

RESULTS

Finding showed that emotional dysregulation might influence QoL, particularly significant effect of awareness (β= 0.022; SE = 1.826; p < 0.002), goals (β = - 0.54; SE = 1.48; p < 0.001) and clarity (β = - 0.211; SE = 2.087; p < 0.003). The results also suggest that the mediated effect accounted for awareness index was 18.7% (R² = 0.187) of the variance; goals index 62.8% (R² = 0.628) of the variance and, then significant mediated effect of clarity was 58.8% (R² = 0.588) of the variance. This evidence suggests that the relationship between triggers and QoL is mediated by emotional dysregulation indexes.

CONCLUSION

In clinical practice psychological screening can be an effective tool for detecting predictive factors in the management of the CVD patient's health and adherence to medical treatment: the screening of predictive psychological factors for allowing a good clinical condition management and a self-care empowerment aimed at increasing psychological well-being and the Quality of Life by planning adequate integrated and multidisciplinary support.

Mental Stress and Cardiovascular Health-Part I

Epidemiological studies have shown that a substantial proportion of acute coronary events occur in individuals who lack the traditional high-risk cardiovascular (CV) profile. Mental stress is an emerging risk and prognostic factor for coronary artery disease and stroke, independently of conventional risk factors. It is associated with an increased rate of CV events. Acute mental stress may develop as a result of anger, fear, or job strain, as well as consequence of earthquakes or hurricanes. Chronic stress may develop as a result of long-term or repetitive stress exposure, such as job-related stress, low socioeconomic status, financial problems, depression, and type A and type D personality. While the response to acute mental stress may result in acute coronary events, the relationship of chronic stress with increased risk of coronary artery disease (CAD) is mainly due to acceleration of atherosclerosis. Emotionally stressful stimuli are processed by a network of cortical and subcortical brain regions, including the prefrontal cortex, insula, amygdala, hypothalamus, and hippocampus. This system is involved in the interpretation of relevance of environmental stimuli, according to individual’s memory, past experience, and current context. The brain transduces the cognitive process of emotional stimuli into hemodynamic, neuroendocrine, and immune changes, called fight or flight response, through the autonomic nervous system and the hypothalamic–pituitary–adrenal axis. These changes may induce transient myocardial ischemia, defined as mental stress-induced myocardial ischemia (MSIMI) in patients with and without significant coronary obstruction. The clinical consequences may be angina, myocardial infarction, arrhythmias, and left ventricular dysfunction. Although MSIMI is associated with a substantial increase in CV mortality, it is usually underestimated because it arises without pain in most cases. MSIMI occurs at lower levels of cardiac work than exercise-induced ischemia, suggesting that the impairment of myocardial blood flow is mainly due to paradoxical coronary vasoconstriction and microvascular dysfunction.

Psychological factors of suspect coronary microvascular dysfunction in patients undergoing SPECT imaging

BACKGROUND

Patients with myocardial ischemia in the absence of obstructive coronary artery disease (CAD) often experience anginal complaints and are at risk of cardiac events. Stress-related psychological factors and acute negative emotions might play a role in these patients with suspect coronary microvascular dysfunction (CMD).

METHODS AND RESULTS

295 Patients (66.9 ± 8.7 years, 46% women) undergoing myocardial perfusion single-photon-emission computed tomography (MPI-SPECT), were divided as follows: (1) a non-ischemic reference group (n = 136); (2) patients without inducible ischemia, but with a history of CAD (n = 62); (3) ischemia and documented CAD (n = 52); and (4) ischemia and suspect CMD (n = 45). These four groups were compared with regard to psychological factors and acute emotions. Results revealed no differences between the groups in psychological factors (all P > .646, all effect sizes d < .015). State sadness was higher for patients with suspect CMD (16%) versus the other groups (P = .029). The groups did not differ in the association of psychological factors or emotions with anginal complaints (all P values > .448).

CONCLUSION

Suspect CMD was not associated with more negative psychological factors compared to other groups. State sadness was significantly higher for patients with suspect CMD, whereas no differences in state anxiety and other psychological factors were found.

Christmas holiday triggers of myocardial infarction

Objectives: Christmas holidays have been associated with the highest incidence of myocardial infarction (MI). We wanted to assess possible triggers of MI during Christmas. Design: A nationwide, retrospective postal survey with case-control design. All individuals suffering an MI during the Christmas holidays 2018 and 2019 in Sweden were identified through the SWEDEHEART registry and a control group matched in age and gender with chronic coronary syndrome who did not seek medical attention during Christmas were asked for participation. Subjects completed a questionnaire asking them to rate 27 potential MI-triggers as having occurred more or less than usual. Results: A total of 189 patients suffering an MI on Christmas Eve, Christmas Day, or Boxing Day, and 157 patients in the control group responded to the questionnaire, representing response rates of 66% and 62%, respectively. Patients with MI on Christmas experienced more stress (37% vs. 21%, p = .002), depression (21% vs. 11%, p = .024), and worry (26% vs. 10%, p < .001) compared to the control group. The food and sweets consumption was increased in both groups, but to a greater extent in the control group (33% vs. 50%, p = .002 and 32% vs. 43%, p = .031). There were no increases in quarrels, anger, economic worries, or reduced compliance with medication. Conclusions: Patients suffering MI on Christmas holiday experienced higher levels of stress and emotional distress compared to patients with chronic coronary syndrome, possibly contributing to the phenomenon of holiday heart attack. Understanding what factors increase the number of MI on Christmas may help reduce the excess number of MIs and cardiovascular burden.

Anxiety, Mental Stress, and Sudden Cardiac Arrest: Epidemiology, Possible Mechanisms and Future Research

Sudden cardiac arrest (SCA) is a leading cause of mortality and morbidity in affluent societies, which underscores the need to identify persons at risk. The etiology of SCA is however complex, with predisposing and precipitating factors interacting. Although anxiety and mental stress have been linked to SCA for decades, their precise role and impact remain unclear and the biological underpinnings are insufficiently understood. In this paper, we systematically reviewed various types of observational studies (total n = 20) examining the association between anxiety or mental stress and SCA. Multiple methodological considerations challenged the summarizing and interpretation of the findings. For anxiety, the overall picture suggests that it predisposes for SCA in physically healthy populations (unadjusted OR = 2.44; 95% CI: 1.06-5.59; n = 3). However, in populations at risk for SCA (n = 4), associations were heterogeneous but not significant. Anxiety may partly predispose to SCA by contributing to other risk factors such as cardiovascular disease and diabetes mellitus via mechanisms such as unhealthy lifestyle and metabolic abnormalities. Mental stress appears to precipitate SCA, presumably by more directly impacting on the cardiac ion channels that control the heart's electrical properties. This may lead to ventricular fibrillation, the arrhythmia that underlies SCA. To advance this field of research, experimental studies that unravel the underlying biological mechanisms are deemed important, and most easily designed for mental stress as a precipitating factor because of the short timeframe. These proof-of-concept studies should examine the whole pathway from the brain to the autonomic nervous system, and eventually to cardiac ion channels. Ultimately, such studies may facilitate the identification of persons at risk and the development of novel preventive strategies.

Forgiveness: Moving on can be healthy

Forgiveness as a procedure has been gaining prominence. The objective of this article is to provide the basics of forgiveness as an intervention so primary care clinicians can facilitate its use. These clinicians include but are not limited to physicians, nurses, medical assistants, pharmacy professionals, physical therapists, social workers, psychologists, case managers, and clergy. This narrative explains the rationale for understanding forgiveness as a procedure and ways to explain it. To assist clinicians and patients in making informed decisions, samples of forgiveness research are included that describe its positive relationship to specific physical health situations. The article also describes an evidence-based forgiveness therapy, circumstances in which it is harmful to forgive oneself or others, describes the limitations of this article, and suggests future directions.

Confederates in the Attic: Posttraumatic Stress Disorder, Cardiovascular Disease, and the Return of Soldier's Heart

Da Costa originally described Soldier's Heart in the 19th Century as a syndrome that occurred on the battlefield in soldiers of the American Civil War. Soldier's Heart involved symptoms similar to modern day posttraumatic stress disorder (PTSD) as well as exaggerated cardiovascular reactivity felt to be related to an abnormality of the heart. Interventions were appropriately focused on the cardiovascular system. With the advent of modern psychoanalysis, psychiatric symptoms became divorced from the body and were relegated to the unconscious. Later, the physiology of PTSD and other psychiatric disorders was conceived as solely residing in the brain. More recently, advances in psychosomatic medicine led to the recognition of mind-body relationships and the involvement of multiple physiological systems in the etiology of disorders, including stress, depression PTSD, and cardiovascular disease, has moved to the fore, and has renewed interest in the validity of the original model of the Soldier's Heart syndrome.

Altered Effective Connectivity of Central Autonomic Network in Response to Negative Facial Expression in Adults With Cannabis Use Disorder

BACKGROUND

Cannabis use is associated with an increased risk of stress-related adverse cardiovascular events. Because brain regions of the central autonomic network largely overlap with brain regions related to the neural response to emotion and stress, the central autonomic network may mediate the autonomic response to negative emotional stimuli. We aimed to obtain evidence to determine whether neural connectivity of the central autonomic network is altered in individuals with cannabis use disorder (CUD) when they are exposed to negative emotional stimuli.

METHODS

Effective (directional) connectivity (EC) analysis using dynamic causal modeling was applied to functional magnetic resonance imaging data acquired from 23 subjects with CUD and 23 control subjects of the Human Connectome Project while they performed an emotional face-matching task with interleaving periods of negative-face (fearful/angry) and neutral-shape stimuli. The EC difference (modulatory change) was measured during the negative-face trials relative to the neutral-shape trials.

RESULTS

The CUD group was similar to the control group in nonimaging measures and brain activations but showed greater modulatory changes in left amygdala to hypothalamus EC (positively associated with Perceived Stress Scale score), right amygdala to bilateral fusiform gyri ECs (positively associated with Perceived Stress Scale score), and left ventrolateral prefrontal cortex to bilateral fusiform gyri ECs (negatively associated with Perceived Stress Scale score).

CONCLUSIONS

Left amygdala to hypothalamus EC and right amygdala to bilateral fusiform gyri ECs are possibly part of circuits underlying the risk of individuals with CUD to stress-related disorders. Correspondingly, left ventrolateral prefrontal cortex to bilateral fusiform gyri ECs are possibly part of circuits reflecting a protective mechanism.

Validity of acute cardiovascular outcome diagnoses in European electronic health records: a systematic review protocol

INTRODUCTION

Cardiovascular diseases (CVDs) are among the leading causes of death globally. Electronic health records (EHRs) provide a rich data source for research on CVD risk factors, treatments and outcomes. Researchers must be confident in the validity of diagnoses in EHRs, particularly when diagnosis definitions and use of EHRs change over time. Our systematic review provides an up-to-date appraisal of the validity of stroke, acute coronary syndrome (ACS) and heart failure (HF) diagnoses in European primary and secondary care EHRs.

METHODS AND ANALYSIS

We will systematically review the published and grey literature to identify studies validating diagnoses of stroke, ACS and HF in European EHRs. MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane Library, OpenGrey and EThOS will be searched from the dates of inception to April 2019. A prespecified search strategy of subject headings and free-text terms in the title and abstract will be used. Two reviewers will independently screen titles and abstracts to identify eligible studies, followed by full-text review. We require studies to compare clinical codes with a suitable reference standard. Additionally, at least one validation measure (sensitivity, specificity, positive predictive value or negative predictive value) or raw data, for the calculation of a validation measure, is necessary. We will then extract data from the eligible studies using standardised tables and assess risk of bias in individual studies using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data will be synthesised into a narrative format and heterogeneity assessed. Meta-analysis will be considered when a sufficient number of homogeneous studies are available. The overall quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation tool.

ETHICS AND DISSEMINATION

This is a systematic review, so it does not require ethical approval. Our results will be submitted for peer-review publication.

PROSPERO REGISTRATION NUMBER

CRD42019123898.

Emotion, Social Relationships, and Physical Health: Concepts, Methods, and Evidence for an Integrative Perspective

Emotional characteristics and processes are robust predictors of the development and course of major medical illnesses and premature mortality, as are a variety of indicators of the presence and quality of personal relationships. Despite clear evidence of close interconnection between these two domains of risk and protection, affective characteristics and relationships have largely been studied separately as influences on health. After a recent conference on integrative perspectives on emotions, relationships and health co-sponsored by the American Psychosomatic Society and the Society for Affective Science, the present review builds on prior calls for integration, related theory, and current research to outline what is known about the interconnection of these domains as it specifically relates to their overlapping influences on health. Areas of interest include the following: their interconnected roles over the course of development, which may inform current efforts to understand the influence of early life events on adult health; the parallel positive and negative factors in both domains that could have distinct influences on health; the role of emotion regulation in relationship contexts; and measurement, design, and analysis approaches to capture the dyadic and dynamic aspects of these interconnected influences on health. We conclude with a discussion of an emerging research agenda that includes the following: common biological foundations of affective and relationship processes, the cultural embeddedness of affective and relationship processes, the potential contribution of affective-relational processes to health disparities, and implications for intervention research.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

Early childhood trauma alters neurological responses to mental stress in patients with coronary artery disease

BACKGROUND

Early childhood trauma is known to independently increase adverse outcome risk in coronary artery disease (CAD) patients, although the neurological correlates are not well understood. The purpose of this study was to examine whether early childhood trauma alters neural responses to acute mental stress in CAD patients.

METHODS

Participants (n = 152) with CAD underwent brain imaging with High Resolution Positron Emission Tomography and radiolabeled water during control (verbal counting, neutral speaking) and mental stress (mental arithmetic, public speaking). Traumatic events in childhood were assessed with the Early Trauma Inventory (ETI-SR-SF) and participants were separated by presence (ETI+) or absence (ETI-) of early childhood trauma. Brain activity during mental stress was compared between ETI+ and ETI-.

RESULTS

Compared to ETI-, ETI+ experienced greater (p < 0.005) activations during mental stress within the left anterior cingulate, bilateral frontal lobe and deactivations (p < 0.005) within the left insula, left parahippocampal gyrus, right dorsal anterior cingulate, bilateral cerebellum, bilateral fusiform gyrus, left inferior temporal gyrus, and right parietal lobe. Significant (p < 0.005) positive correlations between brain activation and ETI-SR-SF scores were observed within the left hippocampus, bilateral frontal lobe, left occipital cuneus, and bilateral temporal lobe.

LIMITATIONS

Results in non-CAD samples may differ and ETI may be subject to recall bias.

CONCLUSION

Early childhood trauma exacerbated activations in stress-responsive limbic and cognitive brain areas with direct and indirect connections to the heart, potentially contributing to adverse outcomes in CAD patients.

Brain Correlates of Mental Stress-Induced Myocardial Ischemia

OBJECTIVE

Coronary artery disease (CAD) is a major cause of morbidity and mortality, and despite important advances in our understanding of this disorder, the underlying mechanisms remain under investigation. Recently, increased attention has been placed on the role of behavioral factors such as emotional stress on CAD risk. Brain areas involved in memory and the stress response, including medial prefrontal cortex, insula, and parietal cortex, also have outputs to the peripheral cardiovascular system. The purpose of this study was to assess the effects of mental stress on brain and cardiac function in patients with CAD.

METHODS

CAD patients (N = 170) underwent cardiac imaging with [Tc-99m] sestamibi single-photon emission tomography at rest and during a public speaking mental stress task. On another day, they underwent imaging of the brain with [O-15] water positron emission tomography (PET) during mental stress (arithmetic and public speaking) and control conditions.

RESULTS

Patients with mental stress-induced myocardial ischemia showed increased activation with stress in anterior cingulate, inferior frontal gyrus, and parietal cortex (p < .005). This was seen with both arithmetic stress and public speaking stress. Arithmetic stress was additionally associated with left insula activation, and public speaking with right pre/postcentral gyrus and middle temporal gyrus activation (p < .005).

CONCLUSIONS

These findings suggest that mental stress-induced myocardial ischemia is associated with activation in brain areas involved in the stress response and autonomic regulation of the cardiovascular system. Altered brain reactivity to stress could possibly represent a mechanism through which stress leads to increased risk of CAD-related morbidity and mortality.

Perceived Psychological Traumatic Childbirth in Iranian Mothers: Diagnostic Value of Coping Strategies

Objectives

The aim of this study was to investigate the diagnostic value of a stress coping scale for predicting perceived psychological traumatic childbirth in mothers.

Methods

This cross-sectional study was performed on 400 new mothers (within 48 hours of childbirth). Psychological traumatic childbirth was evaluated using the 4 diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders. Coping was measured using Moss and Billings' Stress Coping Strategies Scale.

Results

The overall mean score of stress coping was 29 ± 14.2. There were 193 (43.8%) mothers that had experienced a psychological traumatic childbirth. A stress coping score ≤ 30, with a sensitivity of 90.16 (95% CI = 85.1-94.0), and a specificity of 87.44 (95% CI = 82.1-91.6), was determined as a predictor of psychological traumatic childbirth. So that among mothers with stress coping scores ≤ 30, 87% had experienced a psychological traumatic childbirth.

Conclusion

Investigating the degree of coping with stress can be used as an accurate diagnostic tool for psychological traumatic childbirth. It is recommended that during pregnancy, problem-solving and stress management training programs be used as psychological interventions for mothers with low levels of stress control. This will ensure that they can better cope with traumatic childbirth and post-traumatic stress in the postpartum stage.

Cardiovascular Events after the Sewol Ferry Disaster, South Korea

BACKGROUND

Major incidents affecting large numbers of people may increase the rate of acute cardiovascular events, even among those who are not directly involved in the incident. It is hypothesized that the MV Sewol ferry disaster (South Korea) would increase the incidence of cardiovascular events nation-wide.

METHODS

Data on all adult patients (&gt;18 years) who were diagnosed with acute cardiovascular events, including acute myocardial infarction (MI), angina, and cardiac arrhythmias, were extracted from the National Emergency Department Information System (NEDIS) from March 15 through June 17, during the years 2011-2014 (four weeks before to eight weeks after the event date). Poisson regression models were used to calculate the incidence rate ratios (IRRs) comparing the weekly changes in the occurrences of cardiovascular events from the week of the Sewol event (April 16-22, 2014) to eight weeks after the disaster (June 11-17, 2014), using the one-month period before Sewol as a reference period (March 15-April 15), adjusting for calendar years (years 2011-2014) and environmental factors.

RESULTS

During the study periods, cardiovascular events were identified in 73,823 patients. Compared to the reference period, the week of the Sewol disaster and the three weeks after the disaster showed a significant increase in the number of acute cardiovascular events, IRRs of 1.09 (95% CI, 1.03-1.15) and 1.08 (95% CI, 1.02-1.15), respectively (P &lt;.01 for both). In particular, there was 21% increase in incidence of arrhythmia (IRR = 1.21; 95% CI, 1.02-1.44; P = .03) during the week of the Sewol disaster compared with the reference period.

CONCLUSION

This study showed a significant increase in the incidence of acute cardiovascular events during the week of, and the three weeks after, the Sewol ferry disaster in 2014. These additional cardiac emergencies may be triggered by emotional stressors related to the event, highlighting the public health importance of indirect exposure to a tragic catastrophe.Kong SY, Song KJ, Shin SD, Ro YS. Cardiovascular events after the Sewol ferry disaster, South Korea. Prehosp Disaster Med. 2019;34(2):142-148.

Brain correlates of stress-induced peripheral vasoconstriction in patients with cardiovascular disease

The influence of acute psychological stress on cardiovascular disease is an emerging public health concern. Identification of brain mechanisms underlying this may aid in the discovery of possible treatments. Acute psychological stress may induce arteriolar vasoconstriction and reduce blood flow to vital organs. We hypothesized that functional changes in brain regions involved with memory and autonomic/emotional regulation are implicated in the vasoconstrictive stress response, including the medial prefrontal cortex (anterior cingulate), insula, and dorsolateral prefrontal cortex. Subjects with a history of coronary artery disease (N = 59) underwent measurement of microvascular vasomotor tone with the EndoPAT device and O-15 positron emission tomography (PET) imaging of the brain during exposure to mental stress and control conditions. The peripheral arterial tonometry (PAT) ratio was calculated as the mean peripheral vasomotor tone during stress divided by the mean tone during rest. Whole brain contrasts were performed between groups above and below the median PAT ratio, and significant contrasts were defined with cutoff p < 0.005. Stress-induced peripheral vasoconstriction (below median PAT ratio) was associated with increased stress activation in insula and parietal cortex, and decreased activation in the medial prefrontal cortex with stress tasks compared to control tasks. These findings demonstrate that stress-induced vasoreactivity is associated with changes in brain responses to stress in areas involved in emotion and autonomic regulation. These findings have important implications on possible treatments for mental stress-induced vascular toxicity.

A Tailored, Bundle Care Intervention Strategy to Reduce Cardiac Mortality During the Hajj: A Population-Based, Before and After Study

BACKGROUND

Hajj is the largest human gathering with over 2 million people. We evaluated the effect of bundle care intervention on mortality.

METHODS

A population-based, before and after study compared the effect of an intervention on mortality. The intervention included recruitment of cardiac team, introducing 24/7 catheterization service, cardiac coordination, standardized cardiac care pathways, and establishment of an effective transportation system.

RESULTS

Cardiac mortality accounted for about 52% of all in-hospital deaths before intervention in 2009. This decreased significantly to 43.3%, 32.5%, and 19.7% in 2009, 2010, and 2011, respectively. In-hospital mortality of acute coronary syndromes was 4.7%, 4.6%, and 3.0%, in the years 2009, 2010, and 2011, respectively. Mortality due to other causes remained largely unaffected. There was no significant change in the national mortality due to cardiac causes over the same period provided a reassurance that the observed improvement in in-hospital acute coronary syndrome mortality was not due to overall improvement in health care. The numbers of cardiac catheterization procedures increased 3-fold and cardiac surgical procedures increased 5-fold between 2009 and 2011.

CONCLUSIONS

In this study, we found that an evidence-based intensive bundle care intervention substantially reduced the cardiac mortality among the pilgrims assembling for Hajj in Makkah.

The Physical Burden of Immunoperception

The previous chapter introduced the ImmunoEmotional Regulatory System (IMMERS). Also, there was a brief discussion about psychological states/psychiatric disorders that so far have been linked to the IMMERS. The present chapter considers another aspect of the IMMERS in which physiological states/physical diseases can be fit to the IMMERS.

Manner of Death Certification After Significant Emotional Stress: An Inter-Rater Variability Study and Review of the Literature

Not commonly seen, the risk of sudden death after significant emotional stress has been reported since antiquity and incorporated into folk wisdom, reflected by phrases such as "scared to death" and "broken heart." A typical "victim" suffers from significant and often life-threatening natural diseases, making determination of the manner of death complicated, and at times controversial. The present study is designed to assess inter-rater variability and nonuniformity and controversy seen in manner of death certification in certain cases of death with significant stress involved in the circumstances of death. Members of the National Association of Medical Examiner (NAME) were surveyed to assess differences in manner of death certification for eight sudden unexpected death scenarios in middle-aged men and women with underlying cardiac disease after significant stressful events including: being chased down a lonely road followed by a verbal confrontation, a roll-over motor vehicle collision (MVC) without injuries, a fall from a wheelchair in a MVC, an alleged armed robbery, an involuntary commitment, an arrest by police, sexual intercourse, and a severe panic attack with breathing problems. In all cases, the autopsy examination revealed hypertensive and arteriosclerotic cardiovascular disease. In all cases, natural diseases were identified as significant contributing condtions, including emphysema in six cases and diabetes mellitus in three. Eighty-six responses were collected. The results show wide inter-rater variability, ranging from very good to poor (Kappa ranges from 0.16 to 0.94). One hundred fifty-five comments were collected. Most of the comments addressed more than one topic and were followed by discussions, open questions, and responders' experiences with previous cases and legal proceedings. Our data show that cases of sudden death after significant stress have almost complete agreement in four cases and very high inter-rater variability in the other four. We propose that a detailed analysis of each case and an algorithmic approach could improve the predictability of the outcomes of death investigations for the legal system and for families.

The Role of Psychological Stress on Heart Autophagy in Mice With Heart Failure

OBJECTIVE

Psychological stress in chronic heart failure (CHF) is associated with systemic neurohormonal and immune system responses and increased mortality. Autophagy refers to the biological process of degradation and recycling of dysfunctional cellular components. We investigated the role of psychological stress on autophagy function in CHF mice.

METHODS

C57BL/6 mice underwent transverse aortic constriction, with or without combined acoustic and restraint stress, and cardiac function was assessed by echocardiography analysis. Serum corticosterone and angiotensin II (Ang II) were determined using enzyme-linked immunosorbent assay (ELISA). Autophagy and oxidative stress were measured with immunohistochemistry and quantitative polymerase chain reaction, and chloroquine and rapamycin were used to detect autophagy flux. In vivo, cardiomyocytes were cultured with or without Ang II or N-acetylcysteine, and autophagy and oxidative stress were also detected.

RESULTS

A 1-week stress exposure significantly increased serum levels of corticosterone and Ang II (p = .000), increased levels of oxidative stress, induced overt heart failure, and increased mortality (p = .002). Furthermore, stress exposure unregulated messenger RNA expression of Bcl-2-interacting coiled-coil protein 1 (10.891 [3.029] versus 4.754 [1.713], p = .001), cysteine-rich domain containing beclin-1 interacting (6.403 [1.813] versus 3.653 [0.441], p = .006), and autophagy 7 (111.696 [4.049] versus 6.189 [1.931], p = .017), increased expression of autophagosomal, and decreased clearance of autophagosomes. In vitro, Ang II significantly increased autophagy flux in cultured cardiomyocytes, which could be partly inhibited by N-acetylcysteine.

CONCLUSIONS

Psychological stress may contribute to the development of CHF by enhancing heart oxidative stress and impairing autophagy flux.

Sleep characteristics and progression of coronary artery calcification: Results from the Heinz Nixdorf Recall cohort study

BACKGROUND AND AIMS

Sleep characteristics are associated with incident cardiovascular diseases (CVD), but there is a lack of studies on the association between sleep characteristics and incidence/progression of coronary artery calcification (CAC).

METHODS

In the Heinz Nixdorf Recall Study, a population-based cohort study in Germany, CAC was assessed by electron-beam tomography at baseline and at 5-year follow-up. In an analysis set of 3043 subjects (age at baseline 45-74 years; 47% men), we fitted logistic and linear regression models to assess associations between self-rated sleep characteristics (nocturnal and total sleep duration; napping; various sleep disorders) and CAC incidence/CAC progression. Progression was measured as 5-year progression factor, as categories of absolute CAC change, and additionally characterized as rapid or slow compared to an extrapolation of baseline CAC values.

RESULTS

We observed barely any association between sleep characteristics and CAC progression regardless of the chosen statistical approach; associations between sleep and CAC incidence were slightly larger, e.g., the geometric mean of the 5-year CAC progression factor was 6.8% (95% confidence interval: -9.5; 25.9) larger for ≤5 h, 2.9% (-7.3; 14.3) larger for 5.1-6.9 h and 7.1% (-2.4; 15.7) smaller for ≥7.5 h total sleep compared to 7- <7.5 h total sleep. For subjects with any regular sleep disorder, the geometric mean of the 5-year CAC progression was 3.5% (-4.7; 11.2) smaller compared to subjects without any regular sleep disorder.

CONCLUSIONS

In this German cohort study, sleep characteristics were barely associated with CAC progression.

Impact of Triggering Events on Outcomes of Acute Heart Failure

BACKGROUND

The onset of acute heart failure is known to be associated with increased physical activity and other specific behaviors that can trigger hemodynamic deterioration. This analysis aimed to describe the distribution of triggers in patients hospitalized for acute heart failure, and investigate their effects on in-hospital outcomes.

METHODS

Consecutive patients hospitalized for acute heart failure between 2010 and 2014 were registered in a multicenter data registration system (72 institutions within Tokyo, Japan). Baseline demographics and in-hospital mortality were extracted from 17,473 patients. Patients with a trigger were grouped based on their triggering event: those with onset during (a) physical activity; (b) sleeping; (c) eating or watching television; (d) bathing or excretion (use of restrooms); and (e) engaging in other activities. These patients were compared with patients without identifiable triggers. Multiple imputation was used for missing data.

RESULTS

Patients were predominantly men (57.1%), with a mean age of 76.0 ± 13.0 years; a triggering event was present in 49.1%. No significant difference in baseline characteristics was noted between groups except for younger age, higher blood pressure, and prevalence of signs of congestion in the trigger-positive group. In-hospital mortality rate was 7.9%. Presence of triggers was positively associated with a reduced risk of in-hospital mortality (adjusted odds ratio 0.79; 95% confidence interval, 0.70-0.90; P = .0003). In a delta-adjusted pattern mixture model, the effect of a triggering event on in-hospital mortality remained consistently significant.

CONCLUSION

Triggering events for acute heart failure can provide additional information for risk prediction. Efforts to identify the triggers should be made to classify patients according to risk group.

Acute triggers of myocardial infarction: A case-crossover study

BACKGROUND

Acute myocardial infarction (AMI) is one of the most preventable non-communicable diseases in human. Identifying triggers of myocardial infarction (MI) and prevention ways of exposure-induced complications can reduce morbidity and mortality in people at risk.

AIM

The aim of this study was to identify the emotional, environmental, physical and chemical dimensions of acute triggers in patients with AMI.

METHODS

This case-crossover study was conducted on 269 patients with AMI, hospitalized at two remedial centers in Rasht in 2015. The study samples were selected by convenient sampling method. Data were collected using researcher-made questionnaire through interviews. Hazard and control periods for each trigger and its effects on the development of MI were studied. The collected data were analyzed using descriptive and analytical statistical methods, Cochran test, and generalized estimating equation (GEE) model with logistics function default in SPSS version 21, and p < 0.05 was considered statistically significant.

RESULTS

The results showed that quarrel (P = 0.008, OR = 2.01) and hearing the sudden news (P = 0.001, OR = 2.19) were the most common emotional triggers. Respiratory infections (P = 0.0001, OR = 6.78) and exposure to hot or cold weather (P = 0.005, OR = 2.19) were the most frequent environmental triggers. Doing heavy activities (P = 0.005, OR = 1.66) and sexual activities (P = 0.003, OR = 2.36) were among the most common physical triggers. High-fat foods consumption and overeating (P = 0.0001, OR = 3.79) were the most frequent chemical triggers of AMI.

CONCLUSION

It seems that given the importance of the triggers in the incidence of AMI, planning is necessary to train vulnerable individuals to reduce exposure to triggers.

The Mental Stress Ischemia Prognosis Study: Objectives, Study Design, and Prevalence of Inducible Ischemia

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.

The Interaction Effects of Meteorological Factors and Air Pollution on the Development of Acute Coronary Syndrome

This study investigated the interaction effects of meteorological factors and air pollutants on the onset of acute coronary syndrome (ACS). Data of ACS patients were obtained from the Taiwan ACS Full Spectrum Registry and comprised 3164 patients with a definite onset date during the period October 2008 and January 2010 at 39 hospitals. Meteorological conditions and air pollutant concentrations at the 39 locations during the 488-day period were obtained. Time-lag Poisson and logistic regression were used to explore their association with ACS incidence. One-day lag atmospheric pressure (AP), humidity, particulate matter (PM_2.5, and PM₁₀), and carbon monoxide (CO) all had significant interaction effects with temperature on ACS occurrence. Days on which high temperatures (>26 °C) and low AP (<1009 hPa) occurred the previous day were associated with a greater likelihood of increased incidence of developing ACS. Typhoon Morakot was an example of high temperature with extremely low AP associated with higher ACS incidence than the daily average. Combinations of high concentrations of PM or CO with low temperatures (<21 °C) and high humidity levels with low temperatures were also associated with increased incidence of ACS. Atmospheric pollution and weather factors have synergistic effects on the incidence of ACS.

Impact of acute psychological stress on cardiovascular risk factors in face of insulin resistance

Individuals with insulin resistance (IR) are at greater risk for cardiovascular disease (CVD). Psychological stress may contribute to develop CVD in IR, although mechanisms are poorly understood. Our aim was to test the hypothesis that individuals with IR have enhanced emotional and physiological responses to acute psychological stress, leading to increased CVD risk. Sixty participants were enrolled into the study, and classified into IR group (n = 31) and insulin sensitive group (n = 29) according to the Quantitative insulin sensitivity check index, which was calculated based on an oral glucose tolerance test. The Trier social stress test, a standardized experimental stress paradigm, was performed on each participant, and emotional and physiological responses were examined. Blood was collected from each subject for insulin, cytokines, and cortisol measurements. Compared with the insulin-sensitive group, individuals with IR had significantly lower ratings of energy and calm, but higher fatigue levels in response to acute stressors. Individuals with IR also showed blunted heart rate reactivity following stress. In addition, the IR status was worsened by acute psychological stress as demonstrated by further increased insulin secretion. Furthermore, individuals with IR showed significantly increased levels of leptin and interleukin-6, but decreased levels of adiponectin, at baseline, stress test, and post-stress period. Our findings in individuals with IR under acute stress would allow a better understanding of the risks for developing CVD and to tailor the interventions for better outcomes.

Is type-D personality trait(s) or state? An examination of type-D temporal stability in older Israeli adults in the community

Background. Type D personality was suggested as a marker of poorer prognosis for patients of cardiovascular disease. It is defined by having a score of 10 or more on both sub-scales of the DS14 questionnaire, Social Inhibition (SI) and Negative Affectivity (NA). As Type D was designed to predict risk, its temporal stability is of prime importance.

Methods. Participants in the current study were 285 community volunteers, who completed the DS14, and other personality scales, at a mean interval of six years.

Results. The prevalence of Type D did not change. The component traits of Type D showed rank order stability. Type D caseness temporal stability was improved by using the sub-scales product as a criterion. Logistic hierarchical regression predicting Type D classification from Time1 demonstrated that the best predictors were Time1 scores on NA and SI, with the character trait of Cooperation, and the alexithymia score adding some predictive power.

Conclusions. The temporal stability of the component traits, and of the prevalence of Type D were excellent. Temporal stability of Type D caseness may be improved by using a product threshold, rather than the current rule. Research is required in order to formulate the optimal timing for Type D measurement for predictive purposes.

Relationship between insomnia symptoms, perceived stress and coping strategies in subjects with arterial hypertension: psychological factors may play a modulating role

OBJECTIVE

The aim of the study was to evaluate perceived stress and coping strategies in people with hypertension, according to the presence of insomnia symptoms and by using a set of variables that included anxiety and depressive symptoms evaluation.

METHODS

A total of 371 hypertensive patients were enrolled during their first visit to the Hypertension Outpatient Unit. The Perceived Stress Scale (PSS), Brief-COPE, Insomnia Severity Index (ISI), Beck Depression Inventory (BDI), Self-rating Anxiety Scale (SAS), and State-Trait Anxiety Inventory (STAI) were administered. Patients with other sleep disorders or with incomplete data (n = 41) were excluded.

RESULTS

Data from 330 hypertensive patients were analyzed (males 51%, mean age 57 ± 13 years). Those with insomnia symptoms (n = 70, 21%) were older (p = 0.02), more frequently females (p = 0.01), and presented with higher PSS (p < 0.001), BDI (p < 0.0001), SAS (p = 0.0003), and STAI (p < 0.0001) scores than those without insomnia symptoms. In a linear regression trait, anxiety (p < 0.0001) and depressive symptoms (p < 0.05) were independent predictors of high PSS. Patients with insomnia symptoms showed lower scores in coping strategies, such as positive reframing (p = 0.03) and emotional support (p = 0.04), and an increased score in behavioral disengagement (p = 0.03). Trait anxiety and insomnia severity were independent predictors of less effective coping strategies.

CONCLUSIONS

People with hypertension and insomnia symptoms showed higher perceived stress and less effective coping strategies than non-insomniacs; psychological factors such as trait anxiety and depressive symptoms may play a modulating role in these relationships. Prevention and treatment of insomnia symptoms and psychological factors should receive high attention for people with hypertension.

Platelet aggregation and mental stress induced myocardial ischemia: Results from the Responses of Myocardial Ischemia to Escitalopram Treatment (REMIT) study

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.

Burden of cardiovascular morbidity and mortality following humanitarian emergencies: a systematic literature review

BACKGROUND

The global burden of cardiovascular mortality is increasing, as is the number of large-scale humanitarian emergencies. The interaction between these phenomena is not well understood. This review aims to clarify the relationship between humanitarian emergencies and cardiovascular morbidity and mortality.

METHODS

With assistance from a research librarian, electronic databases (PubMed, Scopus, CINAHL, and Global Health) were searched in January 2014. Findings were supplemented by reviewing citations of included trials. Observational studies reporting the effect of natural disasters and conflict events on cardiovascular morbidity and mortality in adults since 1997 were included. Studies without a comparison group were not included. Double-data extraction was utilized to abstract information on acute coronary syndrome (ACS), acute decompensated heart failure (ADHF), and sudden cardiac death (SCD). Review Manager 5.0 (Version 5.2, The Nordic Cochrane Centre; Copenhagen Denmark,) was used to create figures for qualitative synthesis.

RESULTS

The search retrieved 1,697 unique records; 24 studies were included (17 studies of natural disasters and seven studies of conflict). These studies involved 14,583 cardiac events. All studies utilized retrospective designs: four were population-based, 15 were single-center, and five were multicenter studies. Twenty-three studies utilized historical controls in the primary analysis, and one utilized primarily geographical controls.

DISCUSSION

Conflicts are associated with an increase in long-term morbidity from ACS; the short-term effects of conflict vary by study. Natural disasters exhibit heterogeneous effects, including increased occurrence of ACS, ADHF, and SCD.

CONCLUSIONS

In certain settings, humanitarian emergencies are associated with increased cardiac morbidity and mortality that may persist for years following the event. Humanitarian aid organizations should consider morbidity from noncommunicable disease when planning relief and recuperation projects.

Lipopolysaccharide-binding protein and leptin are associated with stress-induced interleukin-6 cytokine expression ex vivo in obesity

Obesity is associated with enhanced inflammation and mental stress, but limited information has addressed the potential additive effect of psychological stress on obesity-associated inflammation. This study examined whether obese subjects would elicit a greater host immune response (IL-6 mRNA and cytokine) to lipopolysaccharide (LPS) in response to mental stress. Blood samples for LPS-stimulated IL-6 mRNA and cytokine were collected prior to and following mental stress. Results showed that obese subjects elicited a greater LPS-induced IL-6 along with its mRNA expression following mental stress compared to normal-weight subjects. Stress-induced IL-6 cytokine response to LPS was correlated with the baseline levels of plasma LPS binding protein (LBP) and leptin. These findings are consistent with the idea that endogenous inflammatory agents (e.g., LBP and leptin), often elevated with obesity, enhance inflammatory responses to psychological stress.

Underlying inflammation has no impact on the oxidative stress response to acute mental stress

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.

Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

[Cardiac arrest in spectators in German football stadiums. Precautionary measures, frequency and short-term outcome]

BACKGROUND

Provision of medical care is an important element of safety precautions for visitors of sports arenas. The organizational requirements are especially high if cardiac arrest occurs; how this scenario is managed may thus serve as the ultimate indicator of the quality of stadium medical care. The objectives of this study were to analyze the structures and the resources available for the medical care of spectators in German professional soccer stadiums and to identify the frequency and the primary resuscitation success of cardiac arrest.

MATERIAL AND METHODS

In 2011 a questionnaire-based survey was performed among the clubs of the first and second German soccer leagues regarding medical care of spectators during the seasons 2008/2009 and 2009/2010. The focus was on the qualifications of emergency teams, the equipment and the incidence of cardiac arrest.

RESULTS

A total of 15 stadiums were included (38%) in the survey. The mean number of physicians and emergency medical technicians on site was 0.6/10,000 seats and 16/10,000 seats, respectively. Of the latter, a mean of 82% (minimum 20% and maximum 100%) had received training with automatic external defibrillators. In 87% of the stadiums regular advanced life support training (ALS) was required. The mean number of defibrillators per stadium was 2.8/10,000 seats (minimum 1.3 and maximum 3.8) including 1.7 automatic defibrillators (minimum 0.4 and maximum 2.8). For patient transport, a mean of 0.65 ALS ambulance vehicles per 10,000 seats (minimum 0.14 and maximum 1.46) were available on site. In all stadiums staff members were connected via mobile radio communication with the stadium medical control room. A total of 52 cardiac arrests (=0.25/100,000 spectators) were recorded of which 96% of the patients were transported to hospitals with spontaneous circulation.

CONCLUSIONS

Cardiac arrests are not a rare occurrence in German soccer stadiums. The participating stadiums are overall well prepared for such incidents in terms of organization, staff and technology and due to short response times, the resuscitation success by far surpasses that of the standard emergency medical services. These findings may in addition serve as a motivational example to start resuscitation early in public information campaigns.

Vaccine-induced inflammation attenuates the vascular responses to mental stress

Inflammation is associated with poorer vascular function, with evidence to suggest that inflammation can also impair the vascular responses to mental stress. This study examined the effects of vaccine-induced inflammation on vascular responses to mental stress in healthy participants. Eighteen male participants completed two stress sessions: an inflammation condition having received a typhoid vaccination and a control (non-inflamed) condition. Tumor necrosis factor-alpha and interleukin-6 (p's<.001) increased following vaccination, confirming modest increases in inflammation. Mental stress increased blood flow, blood pressure, heart rate, and cardiac output in both conditions (all p's<.001), but the blood flow response to stress was attenuated having received the vaccination compared to the control condition (p's<.05). These results further implicate the interaction between inflammation and the vasculature as a mechanism through which stress may trigger myocardial infarction.

Early repolarization, acute emotional stress and sudden death

We herein report the case of a 36-year-old man who died suddenly after a fight with another man. Forensic investigations included unenhanced computed tomography, postmortem angiography, autopsy, histology, neuropathology, toxicology, and biochemistry and allowed a traumatic cause of death to be excluded. An electrocardiogram recorded some years prior to death revealed the presence of an early repolarization pattern. Based on the results of all investigations, the cause of death was determined to be cardiac arrhythmia and cardiac arrest during an emotionally stressful event associated with physical assault. Direct third party involvement, however, was excluded, and the manner of death was listed as natural. The case was not pursued any further by the public prosecutor.

Psychosocial risk factors for coronary heart disease

In 2003, the National Heart Foundation of Australia published a position statement on psychosocial risk factors and coronary heart disease (CHD). This consensus statement provides an updated review of the literature on psychosocial stressors, including chronic stressors (in particular, work stress), acute individual stressors and acute population stressors, to guide health professionals based on current evidence. It complements a separate updated statement on depression and CHD. Perceived chronic job strain and shift work are associated with a small absolute increased risk of developing CHD, but there is limited evidence regarding their effect on the prognosis of CHD. Evidence regarding a relationship between CHD and job (in)security, job satisfaction, working hours, effort-reward imbalance and job loss is inconclusive. Expert consensus is that workplace programs aimed at weight loss, exercise and other standard cardiovascular risk factors may have positive outcomes for these risk factors, but no evidence is available regarding the effect of such programs on the development of CHD. Social isolation after myocardial infarction (MI) is associated with an adverse prognosis. Expert consensus is that although measures to reduce social isolation are likely to produce positive psychosocial effects, it is unclear whether this would also improve CHD outcomes. Acute emotional stress may trigger MI or takotsubo ("stress") cardiomyopathy, but the absolute increase in transient risk from an individual stressor is low. Psychosocial stressors have an impact on CHD, but clinical significance and prevention require further study. Awareness of the potential for increased cardiovascular risk among populations exposed to natural disasters and other conditions of extreme stress may be useful for emergency services response planning. Wider public access to defibrillators should be available where large populations gather, such as sporting venues and airports, and as part of the response to natural and other disasters.

Comparison of stress-hemoconcentration correction techniques for stress-induced coagulation

When examining stress effects on coagulation, arithmetic correction is typically used to adjust for concomitant hemoconcentration but may be inappropriate for coagulation activity assays. We examined a new physiologically relevant method of correcting for stress-hemoconcentration. Blood was drawn from healthy men (N = 40) during baseline, mental stress, and recovery, and factor VII activity (FVII:C), factor VIII activity (FVIII:C), activated partial thromboplastin time (APTT), prothrombin time (PT%), fibrinogen, D-dimer, and plasma volume were determined. Three hemoconcentration correction techniques were assessed: arithmetic correction and two reconstitution techniques using baseline plasma or physiological saline. Area-under-the-curve (AUC) was computed for each technique. For FVII:C, uncorrected AUC was significantly greater than AUC corrected arithmetically. For PT%, uncorrected AUC was significantly greater than AUC corrected with saline or arithmetically. For APTT, uncorrected AUC was significantly less than AUC corrected with saline and greater than AUC corrected arithmetically. For fibrinogen, uncorrected AUC was significantly greater than AUC corrected with saline or arithmetically. For D-dimer, uncorrected AUC was significantly greater than AUC corrected arithmetically. No differences in AUC were observed for FVIII:C. Saline reconstitution seems most appropriate when adjusting for hemoconcentration effects on clotting time and activity. Stress-hemoconcentration accounted for the majority of coagulation changes.

Eccentric-exercise induced inflammation attenuates the vascular responses to mental stress

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.

Emotional triggers in myocardial infarction: do they matter?

Considerable excitement and interest have arisen recently concerning the role that acute emotional triggers may play in precipitating a myocardial infarction (MI). Observational studies have found repeatedly that patients report excessive anger, anxiety, sadness, grief, or acute stress immediately prior to onset of MI, and recent meta-analyses summarizing these findings reported strong associations between MI occurrence and many of these acute emotions. However, it is unclear whether and through what mechanisms acute emotional triggers might influence MI, and whether there is any clinical utility in knowing if or how emotions trigger MI. We debate whether emotional triggers matter by reviewing the recent evidence for the association between acute emotional triggers and MI and by describing the potential pathophysiological characteristics and mechanisms underlying this association and the preventive strategies that could be used to mitigate the risk of acute MI. We also examine whether the study of emotional triggers could influence clinical risk management or changes in clinical practice/management. We offer suggestions for research that might shed light on whether emotional triggers could initiate a paradigm shift in preventive cardiology, or whether acute emotional triggers are either intractable catalysts for, or merely an epiphenomenon of, some MIs.

Acute psychological stress as a precipitant of acute coronary syndromes in patients with undiagnosed ischemic heart disease: a case report and literature review

OBJECTIVES

Acute psychological stress causes a number of physiologic responses that can trigger acute coronary syndromes in individuals with silent coronary artery disease. The mechanisms behind this phenomena have been the subject of much speculation. The following is a case report and brief review of the literature.

METHOD

A PubMed search was undertaken using the key words stress and myocardial infarction, stress and ischemia, mental stress and coronary artery disease, psychological stress and acute coronary syndrome, and mental stress and plaque destabilization. Articles were restricted to the English language and those dating through December 2007.

RESULTS

Acute coronary syndrome is thought to be the end result of a complex mechanism involving platelet activation and endothelial dysfunction. Several studies have shown that acute mental stress leads to enhanced platelet activation and endothelial dysfunction. The mechanism behind this involves both the autonomic nervous system and the neuroendocrine response.

CONCLUSIONS

Acute psychological stress may lead to acute coronary syndromes in patients with previously silent disease. Physicians should inquire about cardiac symptoms in patients with cardiac risk factors who are experiencing psychological distress. Further research will hopefully lead to an improved understanding of the mechanism behind this process to improve therapeutic interventions.

Can triggers be cumulative in inducing heart attack in soccer game spectators?

Emotional stress and excitement associated with watching soccer matches has been suggested to act as an external trigger for the onset of acute coronary syndromes. We report about a patient of Italian nationality who developed acute coronary syndrome while watching the European football championship match Switzerland vs. Turkey in 2008. Although greater emotional intensity was possibly involved while watching his country play two days earlier (Italy vs Netherlands), he developed no symptoms. Hence, this case throws some interesting light on what can be considered as an acute trigger by discussing the assumption of a cumulative effect regarding to the potential trigger two days before and in which way psychological stress may have influence on the onset of acute coronary syndromes.