Anger and ventricular arrhythmias

The Role of Major Biomarkers of Stress in Atrial Fibrillation: A Literature Review

Numerous studies have reported that physical or emotional stress can provoke atrial fibrillation (AF) or vice versa, which suggests a potential link between exposure to external stressors and AF. This review article sought to describe in detail the relationship between major stress biomarkers and the pathogenesis of AF and presents up-to-date knowledge on the role of physiological and psychological stress in AF patients. For this purpose, this review article contends that plasma cortisol is linked to a greater risk of AF. A previous study has investigated the association between increased copeptin levels and paroxysmal AF (PAF) in rheumatic mitral stenosis and reported that copeptin concentration was not independently associated with AF duration. Reduced levels of chromogranin were measured in patients with AF. Furthermore, the dynamic activity of antioxidant enzymes, including catalase as well as superoxide dismutase, was examined in PAF patients during a period of <48 h. Malondialdehyde activity, serum high-sensitivity C-reactive protein, and high mobility group box 1 protein concentrations were significantly greater in patients with persistent AF or PAF compared to controls. Pooled data from 13 studies confirmed a significant reduction in the risk of AF related to the administration of vasopressin. Other studies have revealed the mechanism of action of heat shock proteins (HSPs) in preventing AF and also discussed the therapeutic potential of HSP-inducing compounds in clinical AF. More research is required to detect other biomarkers of stress, which have not been reported in the pathogenesis of AF. Further studies are required to identify their mechanism of action and drugs to manage these biomarkers of stress in AF patients, which might help to reduce the prevalence of AF globally.

Hostility, Anger, Psycho-emotional Factors and Cardiovascular Disease

The review presents the main aspects of the relationship between psychoemotional factors, hostility, anger and cardiovascular diseases. The first chapter describes the main historical stages in the study of this problem, starting from the Middle Ages and ending with fundamental research of the 19-20 centuries. In the second part, the authors demonstrated that hostility/anger are a risk factor for the CVD development and affect the prognosis and course of CVD (hypertension, ischemic heart disease, various cardiac arrhythmias, etc.). In the third chapter, there were studies that found that high rates of hostility/ anger reduced the effectiveness of cardiovascular therapy. In the fourth part, there are the main correlation mechanisms of negative emotions, hostility/anger and the cardiovascular system, carried out through the relationships with the activation of the hypothalamic-pituitary-adrenal, autonomic nervous system, platelet activation, with the changes in the risk factors characteristics etc. In the final chapter, the authors suggested prospects for further study of the problem, probably associated with the assessment of behavioral interventions, pharmacological or complex effects on the severity of hostility/anger to reduce CVD mortality in individuals with high rates of hostility / anger.

Stress, the autonomic nervous system, and sudden death

The existence of an important relationship between stress, the autonomic nervous system, and sudden cardiac death (SCD) has been long recognized. In the present essay we review the large number of conditions, acting at individual or at population level, that have been causally associated to SCD and discuss the mechanistic and translational value of the studies exploring such associations. These conditions include external stressors (earthquakes, wars) and internal stressors (anger, fear, loss of a loved one) and emotions of even opposite sign. Most situations confirm the time-honored view that increases in sympathetic activity are proarrhythmic whereas increases in vagal activity are protective; however, we will also show and discuss a condition in which the culprit appears to be the excess of vagal activity. The physiologic rationale underlying the most typical situations is on one hand the profibrillatory effect of the increase in the heterogeneity of repolarization secondary to the release of norepinephrine, and on the other the combined effect of acetylcholine to lower heart rate and to antagonize the cardiac effects of norepinephrine at ventricular level. An interesting facet of this potentially lethal relationship is that the elements involved are by no means always exceptional, and they can actually represent part of our everyday life.

[Electrical storm : Recognition and management]

The electrical storm (ES) defined as ≥3 sustained episodes of ventricular tachycardia within a 24 h period comprises a wide spectrum of clinical entities. Mostly patients suffer from severe heart insufficiency and comorbidities making an immediate transfer into a heart center with multidisciplinary expertise in the treatment of ES mandatory. As these patients are often traumatized by ongoing tachycardia despite multiple cardioversions, early deep sedation and β‑blockade to break the vicious circle of sympathico-adrenergic hyperactivation is very effective. Multiple ICD discharges suggesting the diagnosis of ES are inadequate in one third of cases. Pharmacological suppression, frequency control or ablation of supraventricular tachycardias (SVT) help in most cases. In some cases "oversensing" demands optimization of ICD programming. Even so not all adequate ICD discharges, however, are necessary. Since every ICD discharge worsens the patient's prognosis, any kind of ICD discharge should be prevented as far as hemodynamically feasible. After clinical stabilization of the patient with simultaneous acquisition of ECG and testing for reversible causes of ES, ES should be terminated by external or internal cardioversion followed by urgent but elective therapy. Some cases of ES, however, may require immediate escalation of therapy with emergency ablation or revascularization sometimes with circulatory support systems. If ES still persists, a further step in escalation may be taken by cardiac sympathetic denervation. Due to the poor prognosis of patients after ES, close monitoring of the patient, preferably with telemedicine, is indicated.

A time to fight: Circadian control of aggression and associated autonomic support

The central circadian clock, located in the suprachiasmatic nucleus of the mammalian hypothalamus (SCN), regulates daily behavioral rhythms including the temporal propensity for aggressive behavior. Such aggression propensity rhythms are regulated by a functional circuit from the SCN to neurons that drive attack behavior in the ventromedial hypothalamus (VMH), via a relay in the subparaventricular zone (SPZ). In addition to this pathway, the SCN also regulates sleep-wake and locomotor activity rhythms, via the SPZ, in a circuit to the dorsomedial hypothalamus (DMH), a structure that is also known to play a key role in autonomic function and the sympathetic "fight-or-flight" response (which prepares the body for action in stressful situations such as an agonistic encounter). While the autonomic nervous system is known to be under pronounced circadian control, it is less apparent how such autonomic rhythms and their underlying circuitry may support the temporal propensity for aggressive behavior. Additionally, it is unclear how circadian and autonomic dysfunction may contribute to aberrant social and emotional behavior, such as agitation and aggression. Here we review the literature concerning interactions between the circadian and autonomic systems and aggression, and we discuss the implications of these relationships for human neural and behavioral pathologies.

[Algorithm for the management of patients with ventricular arrhythmias]

The paper proposes an original algorithm for the management of patients with ventricular arrhythmia from its first registration to choice of treatment policy. Using modern diagnostic methods, much attention is paid to the identification of myocardial structural and ischemic changes and also to the involvement of the autonomic and central nervous systems in ventricular arrhythmogenesis. The diagnostic problems are solved step-by-step. The role of psychological diagnosis is accentuated. Longitudinal electrocardiogram monitoring with telemetric data transmission can promptly initiate treatment of patients in an outpatient setting and, in a number of cases, without discontinuing work. The key point of the algorithm proposed is to prevent sudden cardiac death.

Chronic stress impacts the cardiovascular system: animal models and clinical outcomes

Psychological stresses are associated with cardiovascular diseases to the extent that cardiovascular diseases are among the most important group of psychosomatic diseases. The longstanding association between stress and cardiovascular disease exists despite a large ambiguity about the underlying mechanisms. An array of possibilities have been proposed including overactivity of the autonomic nervous system and humoral changes, which then converge on endothelial dysfunction that initiates unwanted cardiovascular consequences. We review some of the features of the two most important stress-activated systems, i.e., the humoral and nervous systems, and focus on alterations in endothelial function that could ensue as a result of these changes. Cardiac and hematologic consequences of stress are also addressed briefly. It is likely that activation of the inflammatory cascade in association with oxidative imbalance represents key pathophysiological components of stress-induced cardiovascular changes. We also review some of the commonly used animal models of stress and discuss the cardiovascular outcomes reported in these models of stress. The unique ability of animals for adaptation under stressful conditions lessens the extrapolation of laboratory findings to conditions of human stress. An animal model of unpredictable chronic stress, which applies various stress modules in a random fashion, might be a useful solution to this predicament. The use of stress markers as indicators of stress intensity is also discussed in various models of animal stress and in clinical studies.

Impaired IKs channel activation by Ca(2+)-dependent PKC shows correlation with emotion/arousal-triggered events in LQT1

BACKGROUND

The most common inherited cardiac arrhythmia, LQT1, is due to IKs potassium channel mutations and is linked to high risk of adrenergic-triggered cardiac events. We recently showed that although exercise-triggered events are very well treated by ß-blockers for these patients, acute arousal-triggered event rate were not significantly reduced after beta-blocker treatment, suggesting that the mechanisms underlying arousal-triggered arrhythmias may be different from those during exercise. IKs is strongly regulated by β-adrenergic receptor (β-AR) signaling, but little is known about the role of α1-AR-mediated regulation.

METHODS AND RESULTS

Here we show, using a combination of cellular electrophysiology and computational modeling, that IKs phosphorylation and α1-AR regulation via activation of calcium-dependent PKC isoforms (cPKC) may be a key mechanism to control channel voltage-dependent activation and consequently action potential duration (APD) in response to adrenergic-stimulus. We show that simulated mutation-specific combined adrenergic effects (β+α) on APD were strongly correlated to acute stress-triggered cardiac event rate for patients while β-AR effects alone were not.

CONCLUSION

We were able to show that calcium-dependent PKC signaling is key to normal QT shortening during acute arousal and when impaired, correlates with increased rate of sudden arousal-triggered cardiac events. Our study suggests that the acute α1-AR-cPKC regulation of IKs is important for QT shortening in "fight-or-flight" response and is linked to decreased risk of sudden emotion/arousal-triggered cardiac events in LQT1 patients.

Investigation of Deaths Temporally Associated with Law Enforcement Apprehension

The investigation of a death that occurs in custody requires a careful and methodical approach since concerns of police or institutional misconduct may be raised. The medicolegal official charged with the investigation and ultimate certification of death bears heavy responsibility to the decedent's family, the public, law enforcement and other institutions. A wide variety of causes of death and manners of death are seen in these deaths. This paper reviews causes, mechanisms, manners, findings, and evaluation of persons who have died in temporal relation to legal apprehension.

[Electrical storm in ICD patients: prevention and treatment]

Medical progress and demographic changes cause a continuous increase in patients with implantable cardioverter-defibrillators (ICD). Up to one third of patients with ICDs for secondary prevention and half of the patients with previous electrical storm (ES) will suffer from (further) ESs. When multiple ICD shocks are reported by patients (ICD storm), appropriate, inappropriate and phantom shocks have to be distinguished. Reported shocks without clinical correlates (phantom) often affect patients suffering from posttraumatic stress syndrome after an ICD storm. Approximately one third of all ICD shocks are inappropriate, most often due to supraventricular tachycardia with fast atrioventricular (AV) nodal conduction or lead failure. Within 10 years after implantation lead failure can be detected in up to 20 % of cases and approximately one third of these failures are only seen after inappropriate ICD shocks. Furthermore, inappropriate shocks are due to oversensing of far field atrial electrograms, T-waves, diaphragmatic potentials and electrical noise.Appropriate ICD shocks can rarely also be stimulated by the proarrhythmogenicity of lead implantation or ICD programming. Modifications of the waiting period to therapy, time to detection, detection window, antitachycardia pacing (ATP) stimulation and supraventricular discrimination algorithms may minimize ICD shocks. Some stimulation algorithms may improve the hemodynamic stability during ES. In addition to ventricular ablation, blockade of the sympathetic autonomic nervous system and antiarrhythmic treatment are the main pillars of ES treatment. The best ES prevention, however, is optimized heart failure treatment, especially when a cardiac resynchronization with defibrillator (CRT-D) system is implanted.

Psychosocial correlates of atrial natriuretic peptide: a marker of vascular health

BACKGROUND

Psychosocial factors have been associated with cardiovascular outcomes, but few studies have examined the association between psychosocial function and natriuretic peptides.

PURPOSE

The purpose of this study is to determine the predictive value of hostility, anger, and social support in relation to atrial natriuretic peptide (ANP), a marker of vascular health, among middle-aged men.

METHODS

One hundred twenty-one men (mean age = 39.8 years, SD = 4.1) underwent assessments of ANP and completed the Cook-Medley Hostility Scale, the Spielberger State-Trait Anger Scale, and the Interview Schedule for Social Interaction.

RESULTS

Higher levels of hostility (β = 0.22 [95 % CI 0.04, 0.40], P = 0.032) and trait anger (β = 0.18 [95 % CI 0.01, 0.37], P = 0.044) were associated with greater ANP levels. In contrast, higher perceived social support was also associated with lower ANP levels, (β = -0.19 [95 % CI -0.05, -0.41], P = 0.010).

CONCLUSIONS

Psychosocial factors, including hostility, anger, and social support, are associated with varying ANP levels among middle-aged men, independent of cardiovascular and behavioral risk factors.

Relation of outbursts of anger and risk of acute myocardial infarction

The aim of the present study was to explore the association between outbursts of anger and acute myocardial infarction (AMI) risk. Outbursts of anger are associated with an abrupt increase in cardiovascular events; however, it remains unknown whether greater levels of anger intensity are associated with greater levels of AMI risk or whether potentially modifiable factors can mitigate the short-term risk of AMI. We conducted a case-crossover analysis of 3,886 participants from the multicenter Determinants of Myocardial Infarction Onset Study, who were interviewed during the index hospitalization for AMI from 1989 to 1996. We compared the observed number and intensity of anger outbursts in the 2 hours preceding AMI symptom onset with its expected frequency according to each patient's control information, defined as the number of anger outbursts in the previous year. Of the 3,886 participants in the Determinants of Myocardial Infarction Onset Study, 1,484 (38%) reported outbursts of anger in the previous year. The incidence rate of AMI onset was elevated 2.43-fold (95% confidence interval 2.01 to 2.90) within 2 hours of an outburst of anger. The association was consistently stronger with increasing anger intensities (p trend <0.001). In conclusion, the risk of experiencing AMI was more than twofold greater after outbursts of anger compared with at other times, and greater intensities of anger were associated with greater relative risks. Compared with nonusers, regular β-blocker users had a lower susceptibility to heart attacks triggered by anger, suggesting that some drugs might lower the risk from each anger episode.

Role of Stress in Cardiac Arrhythmias

Stress is a major trigger of cardiac arrhythmias; it exerts profound effects on electrophysiology of the cardiomyocytes and the cardiac rhythm. Psychological and physiological stressors impact the cardiovascular system through the autonomic nervous system (ANS). While stressors vary, properties of the stress response at the level of cardiovascular system (collectively referred to as the autonomic cardiovascular responses) are similar and can be studied independently from the properties of specific stressors. Here, we will review the clinical and experimental evidence linking common stressors and atrial arrhythmias. Specifically, we will describe the impact of psychological and circadian stressors on ANS activity and arrhythmogenesis. We will also review studies examining relationships between autonomic cardiovascular responses and cardiac arrhythmias in ambulatory and laboratory settings.

Anxiety, panic disorder and coronary artery disease: issues concerning physical exercise and cognitive behavioral therapy

Psychological factors such as stress and depression have already been established as primary and secondary cardiovascular risk factors. More recently, the role of anxiety in increasing cardiac risk has also been studied. The underlying mechanisms of increased cardiac risk in panic disorder patients seem to reflect the direct and indirect effects of autonomic dysfunction, as well as behavioral risk factors associated with an unhealthy lifestyle. Implications of the comorbidity between panic and cardiovascular disease include higher morbidity, functional deficits, increased cardiovascular risk, and poor adherence to cardiac rehabilitation or exercise programs. This article probes the most recent evidence on the association between coronary artery disease, anxiety and panic disorder, and discusses the potential role of incorporating regular physical exercise and cognitive behavioral therapy in the treatment of this condition.