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Ebong IA, Quesada O, Fonkoue IT, Mattina D, Sullivan S, Oliveira GMMD, Spikes T, Sharma J, Commodore Y, Ogunniyi MO, Aggarwal NR, Vaccarino V. The Role of Psychosocial Stress on Cardiovascular Disease in Women: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 84:298-314. [PMID: 38986672 DOI: 10.1016/j.jacc.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/18/2024] [Accepted: 05/03/2024] [Indexed: 07/12/2024]
Abstract
Psychosocial stress can affect cardiovascular health through multiple pathways. Certain stressors, such as socioeconomic disadvantage, childhood adversity, intimate partner violence, and caregiving stress, are especially common among women. The consequences of stress begin at a young age and persist throughout the life course. This is especially true for women, among whom the burden of negative psychosocial experiences tends to be larger in young age and midlife. Menarche, pregnancy, and menopause can further exacerbate stress in vulnerable women. Not only is psychosocial adversity prevalent in women, but it could have more pronounced consequences for cardiovascular risk among women than among men. These differential effects could reside in sex differences in responses to stress, combined with women's propensity toward vasomotor reactivity, microvascular dysfunction, and inflammation. The bulk of evidence suggests that targeting stress could be an important strategy for cardiovascular risk reduction in women.
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Affiliation(s)
- Imo A Ebong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California Davis, Sacramento, California, USA.
| | - Odayme Quesada
- Women's Heart Center, Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA; Carl and Edyth Lindner Center for Research and Education, Christ Hospital, Cincinnati, Ohio, USA
| | - Ida T Fonkoue
- Divisions of Physical Therapy and Rehabilitation Science, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Deirdre Mattina
- Division of Regional Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samaah Sullivan
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center-Houston, Houston, Texas, USA
| | | | - Telisa Spikes
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Jyoti Sharma
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Yvonne Commodore
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Modele O Ogunniyi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Grady Health System, Atlanta, Georgia, USA
| | - Niti R Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Viola Vaccarino
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
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Osei J, Vaccarino V, Wang M, Shah AS, Lampert RJ, Li LY, Ko YA, Pearce BD, Kutner M, Garcia E, Piccinelli M, Raggi P, Bremner JD, Quyyumi AA, Sun YV, Ahmed H, Haddad G, Daaboul O, Roberts T, Stefanos L, Correia L, Shah AJ. Stress-Induced Autonomic Dysfunction is Associated With Mental Stress-Induced Myocardial Ischemia in Patients With Coronary Artery Disease. Circ Cardiovasc Imaging 2024; 17:e016596. [PMID: 38868952 PMCID: PMC11187646 DOI: 10.1161/circimaging.124.016596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/30/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) is associated with adverse cardiovascular outcomes in individuals with coronary artery disease, but the mechanisms underlying this phenomenon are unknown. We examined the relationship between stress-induced autonomic dysfunction, measured by low heart rate variability (HRV) in response to stress, and MSIMI in patients with stable coronary artery disease. We hypothesized that stress-induced autonomic dysfunction is associated with higher odds of MSIMI. METHODS In 735 participants with stable coronary artery disease, we measured high- and low-frequency HRV in 5-minute intervals before and during a standardized laboratory-based speech stressor using Holter monitoring. HRV at rest and stress were categorized into low HRV (first quartile) versus high HRV (second to fourth quartiles); the low category was used as an indicator of autonomic dysfunction. Multivariable logistic regression models were used to examine the association of autonomic dysfunction with MSIMI. RESULTS The mean age was 58 (SD, ±10) years, 35% were women, 44% were Black participants, and 16% developed MSIMI. Compared with high HRV during stress, low HRV during stress (both high and low frequencies) was associated with higher odds of MSIMI after adjusting for demographic and clinical factors (odds ratio for high-frequency HRV, 2.1 [95% CI, 1.3-3.3]; odds ratio for low-frequency HRV, 2.1 [95% CI, 1.3-3.3]). Low-frequency HRV at rest was also associated with MSIMI but with slightly reduced effect estimates. CONCLUSIONS In individuals with coronary artery disease, mental stress-induced autonomic dysfunction may be a mechanism implicated in the causal pathway of MSIMI.
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Affiliation(s)
- Jeffery Osei
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maggie Wang
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anish S. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel J. Lampert
- Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Louis Y. Li
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ernest Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marina Piccinelli
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Hashir Ahmed
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George Haddad
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Obada Daaboul
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tatum Roberts
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lewam Stefanos
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Luis Correia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Vaccarino V, Bremner JD. Stress and cardiovascular disease: an update. Nat Rev Cardiol 2024:10.1038/s41569-024-01024-y. [PMID: 38698183 DOI: 10.1038/s41569-024-01024-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/05/2024]
Abstract
Psychological stress is generally accepted to be associated with an increased risk of cardiovascular disease (CVD), but results have varied in terms of how stress is measured and the strength of the association. Additionally, the mechanisms and potential causal links have remained speculative despite decades of research. The physiological responses to stress are well characterized, but their contribution to the development and progression of CVD has received little attention in empirical studies. Evidence suggests that physiological responses to stress have a fundamental role in the risk of CVD and that haemodynamic, vascular and immune perturbations triggered by stress are especially implicated. Stress response physiology is regulated by the corticolimbic regions of the brain, which have outputs to the autonomic nervous system. Variation in these regulatory pathways might explain interindividual differences in vulnerability to stress. Dynamic perturbations in autonomic, immune and vascular functions are probably also implicated as CVD risk mechanisms of chronic, recurring and cumulative stressful exposures, but more data are needed from prospective studies and from assessments in real-life situations. Psychological assessment remains insufficiently recognized in clinical care and prevention. Although stress-reduction interventions might mitigate perceived stress levels and potentially reduce cardiovascular risk, more data from randomized trials are needed.
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Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Department of Radiology and Diagnostic Imaging, Emory University School of Medicine, Atlanta, GA, USA
- Veterans Administration Medical Center, Decatur, GA, USA
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Kim HL. Differences in Risk Factors for Coronary Atherosclerosis According to Sex. J Lipid Atheroscler 2024; 13:97-110. [PMID: 38826179 PMCID: PMC11140242 DOI: 10.12997/jla.2024.13.2.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 06/04/2024] Open
Abstract
Interest in sex differences related to coronary artery disease (CAD) has steadily increased, and the risk factors for CAD show distinct sex differences. For women, cardiovascular risk increases significantly after menopause due to a decrease in estrogen levels. In older individuals, increased arterial stiffness results in a higher pulse pressure, leading to a more common occurrence of isolated systolic hypertension; these changes are more noticeable in women. While the incidence of diabetes is similar in both sexes, women with diabetes face a 50% higher relative risk of fatal coronary heart disease compared to men. Smoking significantly increases the risk of ischemic heart disease in women, particularly those who are younger. The decrease in estrogen in women leads to a redistribution of fat, resulting in increased abdominal obesity and, consequently, an elevated cardiovascular risk. Pregnancy and reproductive factors also have a significant impact on CAD risks in women. Additionally, disparities exist in medical practice. Women are less likely to be prescribed cardioprotective drugs, referred for interventional or surgical treatments, or included in clinical research than men. By increasing awareness of these sex differences and addressing the disparities, we can progress toward more personalized treatment strategies, ultimately improving patient outcomes.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Kim HL, Kim MA. Sex Differences in Coronary Artery Disease: Insights From the KoRean wOmen'S chest pain rEgistry (KoROSE). Korean Circ J 2023; 53:655-676. [PMID: 37880830 PMCID: PMC10625849 DOI: 10.4070/kcj.2023.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 10/27/2023] Open
Abstract
Interest in sex differences in coronary artery disease (CAD) has been steadily increasing. Concurrently, most of the data on these differences have primarily been Western-oriented. The KoRean wOmen'S chest pain rEgistry (KoROSE), started in 2011, has since published numerous research findings. This review aims to summarize the reported differences between men and women in CAD, integrating data from KoROSE. Cardiovascular risk in postmenopausal women escalates dramatically due to the decrease in estrogen levels, which normally offer cardiovascular protective effects. Lower estrogen levels can lead to abdominal obesity, insulin resistance, increased blood pressure, and endothelial dysfunction in older women. Upon analyzing patients with CAD, women are typically older and exhibit more cardiovascular risk factors than men. Diagnosing CAD in women tends to be delayed due to their symptoms being more atypical than men's. While in-hospital outcome was similar between sexes, bleeding complications after percutaneous coronary intervention occur more frequently in women. The differences in long-term prognosis for CAD patients between men and women are still a subject of ongoing debate. Pregnancy and reproductive factors also play a significant role as risk factors for cardiovascular disease in women. A notable sex disparity exists, with women found to use fewer cardiovascular protective drugs and undergo fewer interventional or surgical procedures than men. Additionally, women participate less frequently than men in clinical research. Through concerted efforts to increase awareness of sex differences and mitigate sex disparity, personalized treatment can be provided. This approach can ultimately improve patient prognosis.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Myung-A Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea.
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Almuwaqqat Z, Garcia EV, Cooke CD, Garcia M, Shah AJ, Elon L, Ko YA, Sullivan S, Nye J, Van Assen M, De Cecco C, Raggi P, Bremner JD, Quyyumi AA, Vaccarino V. Quantitation of diffuse myocardial ischemia with mental stress and its association with cardiovascular events in individuals with recent myocardial infarction. J Nucl Cardiol 2023; 30:2029-2038. [PMID: 36991249 PMCID: PMC11057358 DOI: 10.1007/s12350-023-03212-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/22/2022] [Indexed: 03/31/2023]
Abstract
Microcirculatory dysfunction during psychological stress may lead to diffuse myocardial ischemia. We developed a novel quantification method for diffuse ischemia during mental stress (dMSI) and examined its relationship with outcomes after a myocardial infarction (MI). We studied 300 patients ≤ 61 years of age (50% women) with a recent MI. Patients underwent myocardial perfusion imaging with mental stress and were followed for 5 years. dMSI was quantified from cumulative count distributions of rest and stress perfusion. Focal ischemia was defined in a conventional fashion. The main outcome was a composite outcome of recurrent MI, heart failure hospitalizations, and cardiovascular death. A dMSI increment of 1 standard deviation was associated with a 40% higher risk for adverse events (HR 1.4, 95% CI 1.2-1.5). Results were similar after adjustment for viability, demographic and clinical factors and focal ischemia. In sex-specific analysis, higher levels of dMSI (per standard deviation increment) were associated with 53% higher risk of adverse events in women (HR 1.5, 95% CI 1.2-2.0) but not in men (HR 0.9, 95% CI 0.5-1.4), P 0.001. A novel index of diffuse ischemia with mental stress was associated with recurrent events in women but not in men after MI.
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Affiliation(s)
- Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA.
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA.
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - C David Cooke
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Mariana Garcia
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Jonathon Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Marly Van Assen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Carlo De Cecco
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - J Douglas Bremner
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
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Rossi A, Mikail N, Giannopoulos A. Contribution of coronary CT angiography to identify sex-specific phenotypes of atherosclerosis. Eur Heart J Cardiovasc Imaging 2023; 24:1190-1191. [PMID: 37395674 DOI: 10.1093/ehjci/jead150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/04/2023] Open
Affiliation(s)
- Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Andreas Giannopoulos
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
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8
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Nan N, Feng L, Dong W, Gao B, Zuo H, Mi H, Wang G, Song X, Zhang H. The prognostic study of mental stress-induced myocardial ischemia in coronary revascularization patients with depression/anxiety: rationale and design. BMC Cardiovasc Disord 2023; 23:235. [PMID: 37142999 PMCID: PMC10157980 DOI: 10.1186/s12872-023-03246-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) frequently occurs in patients with coronary artery disease (CAD), and is even more common in patients with co-occurring CAD and depression/anxiety. MSIMI appears to be a poor prognostic factor for CAD, but existing data on depression/anxiety patients are limited. METHODS This cohort study will consecutively screen 2,647 CAD patients between 2023 and 2025. Included subjects will need to have received coronary revascularization and also have depression and/or anxiety at baseline. This study will enroll 360 subjects who meet the criteria. Two mental stress tests will be carried out in each patient at 1 month and 1 year timelines after coronary revascularization, using Stroop color word tests. MSIMI will be assessed by 99 m-Tc-sestamibi myocardial perfusion imaging. The endothelial function will be assessed by EndoPAT. Furthermore, we will dynamically monitor patients' health and mental conditions every 3 months. The mean follow-up time will be 1 year. The primary endpoint is the major adverse cardiac events, a composite of all-cause death, cardiac death, myocardial infarction, stroke, or unplanned revascularization. Secondary endpoints will include overall health and mental conditions. The reproducibility of mental stress combined with myocardial perfusion for detecting MSIMI and comparisons between coronary stenosis and ischemic segments will also be included. CONCLUSIONS This cohort study will provide information on MSIMI outcomes in CAD patients who also have comorbid depression/anxiety after revascularization. In addition, understanding the long-term dynamics of MSIMI and the match between coronary stenosis and ischemia will provide insight into MSIMI mechanisms. TRAIL REGISTRATION ChiCTR2200055792, 2022.1.20, www.medresman.org.cn.
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Affiliation(s)
- Nan Nan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Lei Feng
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital, Advanced Innovation Center for Human Brain Protection, Capital Medical University, NO.5 DeWai AnKang Hutong Xicheng District, Beijing, 100088, China
| | - Wei Dong
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Bingyu Gao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Huijuan Zuo
- Department of Community Health Research, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Hongzhi Mi
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital, Advanced Innovation Center for Human Brain Protection, Capital Medical University, NO.5 DeWai AnKang Hutong Xicheng District, Beijing, 100088, China
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China.
| | - Hongjia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University; Beijing Lab for Cardiovascular Precision Medicine; Key Laboratory of Medical Engineering for Cardiovascular Disease, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
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9
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Helman TJ, Headrick JP, Vider J, Peart JN, Stapelberg NJC. Sex-specific behavioral, neurobiological, and cardiovascular responses to chronic social stress in mice. J Neurosci Res 2022; 100:2004-2027. [PMID: 36059192 DOI: 10.1002/jnr.25115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Psychosocial stress promotes and links mood and cardiovascular disorders in a sex-specific manner. However, findings in animal models are equivocal, in some cases opposing human dimorphisms. We examined central nervous system (CNS), behavioral, endocrine, cardiac, and hepatic outcomes in male or female C57Bl/6 mice subjected to chronic social stress (56 days of social isolation, with intermittent social confrontation encounters twice daily throughout the final 20 days). Females exhibited distinct physiological and behavioral changes, including relative weight loss, and increases in coronary resistance, hepatic inflammation, and thigmotaxic behavior in the open field. Males evidence reductions in coronary resistance and cardiac ischemic tolerance, with increased circulating and hippocampal monoamine levels and emerging anhedonia. Shared CNS gene responses include reduced hippocampal Maoa and increased Htr1b expression, while unique responses include repression of hypothalamic Ntrk1 and upregulation of cortical Nrf2 and Htr1b in females; and repression of hippocampal Drd1 and hypothalamic Gabra1 and Oprm in males. Declining cardiac stress resistance in males was associated with repression of cardiac leptin levels and metabolic, mitochondrial biogenesis, and anti-inflammatory gene expression. These integrated data reveal distinct biological responses to social stress in males and females, and collectively evidence greater biological disruption or allostatic load in females (consistent with propensities to stress-related mood and cardiovascular disorders in humans). Distinct stress biology, and molecular to organ responses, emphasize the importance of sex-specific mechanisms and potential approaches to stress-dependent disease.
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Affiliation(s)
- Tessa J Helman
- School of Pharmacy and Medical Sciences, Griffith University, Southport, Queensland, Australia
| | - John P Headrick
- School of Pharmacy and Medical Sciences, Griffith University, Southport, Queensland, Australia
| | - Jelena Vider
- School of Pharmacy and Medical Sciences, Griffith University, Southport, Queensland, Australia
| | - Jason N Peart
- School of Pharmacy and Medical Sciences, Griffith University, Southport, Queensland, Australia
| | - Nicolas J C Stapelberg
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia.,Gold Coast Hospital and Health Service, Southport, Queensland, Australia
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Rogalewski A, Beyer A, Friedrich A, Zuhorn F, Klingebiel R, Woermann FG, Oertelt-Prigione S, Schäbitz WR. Transient Global Amnesia (TGA): Sex-Specific Differences in Blood Pressure and Cerebral Microangiopathy in Patients with TGA. J Clin Med 2022; 11:jcm11195803. [PMID: 36233669 PMCID: PMC9571788 DOI: 10.3390/jcm11195803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/09/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
Transient global amnesia (TGA) is defined by an acute memory disturbance of unclear aetiology for a period of less than 24 h. Observed psychological, neuroanatomical and hormonal differences between the sexes in episodic memory suggest sex-specific differences in memory disorders such as TGA. The aim of this study was to determine sex-specific differences in cardiovascular risk profiles, recurrences and magnetic resonance imaging (MRI). In total, 372 hospitalised TGA patients between 01/2011 and 10/2021 were retrospectively analysed. Comparisons were made between female and male TGA patients and compared to 216 patients with acute stroke. In our sample, women were overrepresented (61.8%), especially compared to the general population in the 65−74 age category (χ2 = 10.6, p < 0.02). On admission, female TGA patients had significantly higher systolic blood pressure values and a higher degree of cerebral microangiopathy compared to male TGA patients, whereas acute stroke patients did not. No sex-specific differences were observed with respect to recurrences or hippocampal DWI lesions. Our data demonstrate sex-specific differences in TGA. The higher blood pressure on admission and different degree of cerebral microangiopathy in female TGA patients supports the theory of blood pressure dysregulation as a disease trigger. Distinct precipitating events in female and male patients could lead to differences in the severity and duration of blood pressure abnormalities, possibly explaining the higher incidence in female patients.
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Affiliation(s)
- Andreas Rogalewski
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL, University Bielefeld, 33611 Bielefeld, Germany
- Correspondence: ; Tel.: +49-521-772-78301; Fax: +49-521-772-78302
| | - Anne Beyer
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL, University Bielefeld, 33611 Bielefeld, Germany
| | - Anja Friedrich
- Department of Psychology, Bielefeld University, 33615 Bielefeld, Germany
| | - Frédéric Zuhorn
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL, University Bielefeld, 33611 Bielefeld, Germany
| | - Randolf Klingebiel
- Department of Neuroradiology, Evangelisches Klinikum Bethel EvKB, University Hospital OWL, University Bielefeld, 33617 Bielefeld, Germany
| | - Friedrich G. Woermann
- Department of Epileptology (Krankenhaus Mara), University Hospital OWL, University Bielefeld, 33617 Bielefeld, Germany
| | | | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL, University Bielefeld, 33611 Bielefeld, Germany
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11
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Kuhail M, Djafarian K, Shab-Bidar S, Khadoura KJ. Association of Perceived Stress and Physical Activity Level with Severity of Coronary Artery Disease in Gaza Strip, Palestine: A Cross-Sectional Study. Korean J Fam Med 2022; 43:261-270. [PMID: 35903050 PMCID: PMC9334714 DOI: 10.4082/kjfm.21.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/15/2021] [Indexed: 11/08/2022] Open
Abstract
Background The association between life-event stressors and low physical activity linked to the severity of coronary artery disease (CAD) is poorly understood. Therefore, this study aimed to determine the perceived stress status and physical activity level associated with the severity of CAD. Methods The study was conducted among 423 patients with newly discovered CAD (both sexes, aged 35–65 years) confirmed by coronary angiography results. CAD severity was classified according to the Gensini score as severe or non-severe. The fasting blood glucose and lipid profiles were also investigated. Anthropometric and brachial blood pressure measurements were obtained. A structured questionnaire including participants’ characteristics, the Perceived Stress Scale (PSS-14), and the International Physical Activity Questionnaire were used via face-to-face interviews. Multivariable binary logistic regression was used to assess the predictors of CAD severity using IBM SPSS ver. 24.0 (IBM Corp., Armonk, NY, USA). Results Most participants were classified as having severe CAD (63.8%). Adjusting for age, sex, smoking status, systolic blood pressure, body mass index, and history of hypertension, the severity of CAD increased by 9% for a onescore increase in the PSS (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.01–1.14; P=0.030). Moreover, sufficiently active (600–1,500 metabolic equivalents [METs]/wk) patients had lower odds of severe CAD (OR, 0.43; 95% CI, 0.23–0.72; P=0.027) than those with insufficient activity. However, no significant association was found between physical activity (≥1,500 METs/wk) and CAD severity. Conclusion The odds of CAD severity significantly increased with increasing perceived stress score but decreased with sufficient physical activity.
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Affiliation(s)
- Mohamed Kuhail
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences International Campus, Tehran, Iran
| | - Kurosh Djafarian
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Kurosh Djafarian Tel: +98-216465405, Fax: +98-2188974462, E-mail:
| | - Sakineh Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences International College, Tehran, Iran
| | - Khalid Jamal Khadoura
- Department of Nursing, Faculty of Medical Sciences, Israa University-Gaza, Gaza, Palestine
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12
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Cattaneo M, Halasz G, Cattaneo MM, Younes A, Gallino C, Sudano I, Gallino A. The Central Nervous System and Psychosocial Factors in Primary Microvascular Angina. Front Cardiovasc Med 2022; 9:896042. [PMID: 35647077 PMCID: PMC9136057 DOI: 10.3389/fcvm.2022.896042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/14/2022] [Indexed: 01/09/2023] Open
Abstract
Patients diagnosed with ischemia without obstructive coronary artery disease (INOCA) comprise the group of patients with primary microvascular angina (MVA). The pathophysiology underlying ischemia and angina is multifaceted. Differences in vascular tone, collateralization, environmental and psychosocial factors, pain thresholds, and cardiac innervation seem to contribute to clinical manifestations. There is evidence suggesting potential interactions between the clinical manifestations of MVA and non-cardiac conditions such as abnormal function of the central autonomic network (CAN) in the central nervous system (CNS), pain modulation pathways, and psychological, psychiatric, and social conditions. A few unconventional non-pharmacological and pharmacological techniques targeting these psychosocial conditions and modulating the CNS pathways have been proposed to improve symptoms and quality of life. Most of these unconventional approaches have shown encouraging results. However, these results are overall characterized by low levels of evidence both in observational studies and interventional trials. Awareness of the importance of microvascular dysfunction and MVA is gradually growing in the scientific community. Nonetheless, therapeutic success remains frustratingly low in clinical practice so far. This should promote basic and clinical research in this relevant cardiovascular field investigating, both pharmacological and non-pharmacological interventions. Standardization of definitions, clear pathophysiological-directed inclusion criteria, crossover design, adequate sample size, and mid-term follow-up through multicenter randomized trials are mandatory for future study in this field.
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Affiliation(s)
- Mattia Cattaneo
- Cardiology Department, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
- *Correspondence: Mattia Cattaneo ;
| | - Geza Halasz
- Heart Failure Unit, Guglielmo da Saliceto Hospital, Azienda unità sanitaria locale (AUSL) Piacenza, University of Parma, Parma, Italy
| | - Magdalena Maria Cattaneo
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
| | - Adel Younes
- Cardiology Department, Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Camilla Gallino
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
| | - Isabella Sudano
- Human Medicine Department, University of Zurich, Zurich, Switzerland
- Cardiology Department, University Hospital, University Heart Center Zurich, Zurich, Switzerland
| | - Augusto Gallino
- Human Medicine Department, Università della Svizzera italiana, Lugano, Switzerland
- Cardiovascular Research Unit, Hospital of San Giovanni, Bellinzona, Switzerland
- Human Medicine Department, University of Zurich, Zurich, Switzerland
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13
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Mehta PK, Sharma A, Bremner JD, Vaccarino V. Mental Stress-Induced Myocardial Ischemia. Curr Cardiol Rep 2022; 24:2109-2120. [PMID: 36322365 PMCID: PMC9628301 DOI: 10.1007/s11886-022-01821-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To summarize recent evidence on mental stress-induced myocardial ischemia (MSIMI), its mechanisms, and clinical significance. RECENT FINDINGS MSIMI can occur in patients with normal cardiac stress testing, is only weakly related to severity of coronary artery disease (CAD), and it is often silent. Among patients with CAD, MSIMI is associated with a twofold increased risk of major adverse cardiovascular events compared to those who do not have MSIMI. Certain groups such as young women with myocardial infarction and those with psychological comorbidities are more susceptible to MSIMI. Abnormal microvascular vasoreactivity and inflammation are implicated mechanisms in MSIMI. Increased brain activity in regions that modulate autonomic reactivity to emotional stress and fear is associated with MSIMI. MSIMI has important prognostic implications in patients with CAD. Stress can no longer be ignored as a risk factor in cardiology care. Clinical trials testing effective strategies to target MSIMI are needed.
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Affiliation(s)
- Puja K. Mehta
- grid.189967.80000 0001 0941 6502Division of Cardiology, Emory Women’s Heart Center and Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA 30322 USA
| | - Ashish Sharma
- grid.259906.10000 0001 2162 9738Internal Medicine Residency Program, Mercer University School of Medicine, Macon, GA USA
| | - J. Douglas Bremner
- grid.189967.80000 0001 0941 6502Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA USA ,grid.414026.50000 0004 0419 4084Atlanta VA Medical Center, Decatur, GA USA
| | - Viola Vaccarino
- grid.189967.80000 0001 0941 6502Division of Cardiology, Emory Women’s Heart Center and Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA 30322 USA ,grid.189967.80000 0001 0941 6502Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
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14
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van der Meer RE, Maas AH. The Role of Mental Stress in Ischaemia with No Obstructive Coronary Artery Disease and Coronary Vasomotor Disorders. Eur Cardiol 2021; 16:e37. [PMID: 34721671 PMCID: PMC8532004 DOI: 10.15420/ecr.2021.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/12/2021] [Indexed: 01/22/2023] Open
Abstract
Ischaemic heart disease has been estimated to affect 126.5 million people globally. Approximately 70% of patients with angina and suspected myocardial ischaemia show no signs of obstructed coronary arteries after coronary angiography, but may still demonstrate ischaemia. Ischaemia with no obstructive coronary artery disease (INOCA) is increasingly acknowledged as a serious condition because of its association with poor quality of life and elevated risk for cardiovascular events. The negative effects of psychological stress on INOCA are gaining more attention. Psychological stress is associated with adverse cardiovascular outcomes such as mental stress-induced myocardial ischaemia. Psychological stress includes anxiety, depression, anger and personality disturbances. Coronary microvascular dysfunction and coronary arterial spasm are phenotypes of coronary vasomotor disorders that are triggered by psychological distress and depression, thereby increasing cardiovascular disease risk. Coronary vasomotor disorders are often co-existent in INOCA patients and might be considered as a contributing factor to mental stress-associated adverse cardiovascular outcomes. Additionally, psychological stress induces endothelial dysfunction more often in (young) women with INOCA than in men. Overall, many studies demonstrate an association between mental stress, coronary microvascular dysfunction and coronary vasospasm in patients with INOCA - especially women. Future research on stress-reducing therapies that target coronary vasomotor disorders in patients with INOCA is needed. This is particularly the case in young adolescents, in whom this type of ischaemic heart disease is increasing.
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Affiliation(s)
| | - Angela Hem Maas
- Department of Cardiology, Radboud University Medical Center Nijmegen, the Netherlands
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15
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McKinnon II, Shah AJ, Lima B, Moazzami K, Young A, Sullivan S, Almuwaqqat Z, Garcia M, Elon L, Bremner JD, Raggi P, Quyyumi AA, Vaccarino V, Lewis TT. Everyday Discrimination and Mental Stress-Induced Myocardial Ischemia. Psychosom Med 2021; 83:432-439. [PMID: 34080584 PMCID: PMC8225242 DOI: 10.1097/psy.0000000000000941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Mental stress-induced myocardial ischemia (MSIMI), a transient myocardial ischemic response to mental stress, is associated with poorer outcomes among patients with coronary heart disease and is more likely to occur among women. However, predictors of MSIMI are not well explored. The current study investigated the association between experiences of everyday discrimination and MSIMI among patients with recent myocardial ischemia and contrasted the results with conventional stress-induced myocardial ischemia (CSIMI). We examined sex differences in associations. METHODS We studied 295 post-MI patients (145 women, 150 men). Provocation of myocardial ischemia with mental stress (speech task) and conventional stress (exercise or pharmacologic) was assessed by myocardial perfusion imaging. Frequency of exposure to everyday discrimination was assessed via questionnaire using the Everyday Discrimination Scale (EDS). RESULTS The mean age was 51 years in both women and men, and the EDS score ranged from 10 to 38 (mean [standard deviation] = 17 [6] years). After multivariable analysis, each standard deviation increase in the EDS score (more frequent exposure) was associated with an increased odds of MSIMI (odds ratio [OR] = 1.57 [1.10-2.23]). The EDS score was not associated with CSIMI (OR = 0.86 [0.64-1.17]). Women demonstrated a twofold increase (OR = 1.96 [1.13-3.38], p = .02) in the adjusted odds of MSIMI, with each standard deviation increase in the EDS score compared with a 1.4-fold increase (OR = 1.40 [0.80-2.44], p = .24) among men; however, interaction was not statistically significant. CONCLUSIONS Among post-MI patients, everyday discrimination was positively associated with occurrence of MSIMI, but not with CSIMI; associations were more pronounced among women.
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Affiliation(s)
- Izraelle I. McKinnon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur, Georgia
| | - Bruno Lima
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - An Young
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zakaria Almuwaqqat
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Mariana Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Lisa Elon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Paolo Raggi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Arshed A. Quyyumi
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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16
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Brain-heart connections in stress and cardiovascular disease: Implications for the cardiac patient. Atherosclerosis 2021; 328:74-82. [PMID: 34102426 PMCID: PMC8254768 DOI: 10.1016/j.atherosclerosis.2021.05.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/05/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022]
Abstract
The influence of psychological stress on the physiology of the cardiovascular system, and on the etiology and outcomes of cardiovascular disease (CVD) has been the object of intense investigation. As a whole, current knowledge points to a "brain-heart axis" that is especially important in individuals with pre-existing CVD. The use of acute psychological stress provocation in the laboratory has been useful to clarify the effects of psychological stress on cardiovascular physiology, immune function, vascular reactivity, myocardial ischemia, neurobiology and cardiovascular outcomes. An emerging paradigm is that dynamic perturbations of physiological and molecular pathways during stress or negative emotions are important in influencing cardiovascular outcomes, and that some patient subgroups, such as women, patients with an early-onset myocardial infarction, and patients with adverse psychosocial exposures, may be at especially high risk for these effects. This review summarizes recent knowledge on mind-body connections in CVD among cardiac patients and highlights important pathways of risk which could become the object of future intervention efforts. As a whole, this research suggests that an integrated study of mind and body is necessary to fully understand the determinants and consequences of CVD.
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17
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Sullivan S, Young A, Hammadah M, Lima BB, Levantsevych O, Ko YA, Pearce BD, Shah AJ, Kim JH, Moazzami K, Driggers EG, Haffar A, Ward L, Herring I, Hankus A, Lewis TT, Mehta PK, Bremner JD, Raggi P, Quyyumi A, Vaccarino V. Sex differences in the inflammatory response to stress and risk of adverse cardiovascular outcomes among patients with coronary heart disease. Brain Behav Immun 2020; 90:294-302. [PMID: 32916271 PMCID: PMC7872132 DOI: 10.1016/j.bbi.2020.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 12/18/2022] Open
Abstract
Stress may contribute to progression of coronary heart disease (CHD) through inflammation, especially among women. Thus, we sought to examine whether increased inflammatory response to stress among patients with CHD is associated with a greater risk of cardiovascular events and whether this risk is higher in women. We examined inflammatory biomarkers known to increase with mental stress (speech task), including interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and matrix metallopeptidase-9 (MMP-9) among 562 patients with stable CHD. Inflammatory response, the difference between post-stress and resting values, was examined as a predictor of major adverse cardiovascular events (MACE) using subdistribution hazards models for competing risks adjusting for demographics, cardiovascular risk factors, and medications. MACE was defined as a composite endpoint of cardiovascular death, myocardial infarction, unstable angina with revascularization, and heart failure. All biomarkers were standardized. The mean age was 63 years (range 34-79) and 24% were women. During a median follow-up of 3 years, 71 patients experienced MACE. Overall, there was no significant association between inflammatory response to stress and risk of MACE, but there were sex-based interactions for IL-6 (p = 0.001) and MCP-1 (p = 0.01). The risk of MACE increased 56% (HR: 1.56; 95% CI: 1.21, 2.01; p = 0.001) and 30% (HR: 1.30; 95% 1.09, 1.55; p = 0.004) for each standard deviation increase in IL-6 and MCP-1 response to mental stress for women, respectively, while there was no association among men. Increased inflammation in response to stress is associated with future adverse cardiovascular outcomes among women with CHD.
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Affiliation(s)
- Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
| | - An Young
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Oleksiy Levantsevych
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States,Atlanta VA Medical Center, Decatur, Georgia, 30322, United States
| | - Jeong Hwan Kim
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Emily G. Driggers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Ammer Haffar
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | | | - Allison Hankus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Puja K. Mehta
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia, 30322, United States,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Arshed Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
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18
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Research progress regarding the diagnosis and treatment of mental stress-induced myocardial ischemia. Anatol J Cardiol 2020; 24:126-136. [PMID: 32870175 PMCID: PMC7585978 DOI: 10.14744/anatoljcardiol.2020.69447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myocardial ischemia resulting from psychological stress [mental stress-induced myocardial ischemia (MSIMI)] refers to the condition wherein psychosocial and psychological stimulations cause myocardial ischemia in patients with coronary heart disease, which is different from drug-induced myocardial ischemia. Therefore, this condition often escapes diagnosis, portends clinical risk, and affects the quality of life of MSIMI survivors. MSIMI is closely related to the poor prognosis of cardiovascular diseases, especially in young women, according to recent randomized, controlled trials (RCTs) on MSIMI. These RCTs involved different sample sizes, interventional measures, and detection techniques. Moreover, differences exist regarding the prevalence rate, distribution characteristics, possible pathogenesis, and clinical significance. Nevertheless, currently, the diagnostic criteria, pathogenesis, and treatment of MSIMI are still in the clinical exploration stage. Hence, considering recent RCTs, this paper summarizes the research status of MSIMI from the aspects of pathogenesis, diagnosis, and treatment strategies to provide a theoretical basis for the follow-up diagnostic methods and treatment guidelines for MSIMI.
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19
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Reynolds HR, Shaw LJ, Min JK, Spertus JA, Chaitman BR, Berman DS, Picard MH, Kwong RY, Bairey-Merz CN, Cyr DD, Lopes RD, Lopez-Sendon JL, Held C, Szwed H, Senior R, Gosselin G, Nair RG, Elghamaz A, Bockeria O, Chen J, Chernyavskiy AM, Bhargava B, Newman JD, Hinic SB, Jaroch J, Hoye A, Berger J, Boden WE, O’Brien SM, Maron DJ, Hochman JS. Association of Sex With Severity of Coronary Artery Disease, Ischemia, and Symptom Burden in Patients With Moderate or Severe Ischemia: Secondary Analysis of the ISCHEMIA Randomized Clinical Trial. JAMA Cardiol 2020; 5:773-786. [PMID: 32227128 PMCID: PMC7105951 DOI: 10.1001/jamacardio.2020.0822] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
Importance While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. Objective To describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants. Design, Setting, and Participants This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. Interventions CCTA and angina assessment. Main Outcomes and Measures Sex differences in stress test, CCTA findings, and symptom severity. Results Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA) (353 of 1022 [34.4%] vs 378 of 3353 [11.3%]). Of individuals who were randomized, women had more angina at baseline than men (median [interquartile range] Seattle Angina Questionnaire Angina Frequency score: 80 [70-100] vs 90 [70-100]). Women had less severe ischemia on stress imaging (383 of 919 [41.7%] vs 1361 of 2972 [45.9%] with severe ischemia; 386 of 919 [42.0%] vs 1215 of 2972 [40.9%] with moderate ischemia; and 150 of 919 [16.4%] vs 394 of 2972 [13.3%] with mild or no ischemia). Ischemia was similar by sex on exercise tolerance testing. Women had less extensive CAD on CCTA (205 of 568 women [36%] vs 1142 of 2418 men [47%] with 3-vessel disease; 184 of 568 women [32%] vs 754 of 2418 men [31%] with 2-vessel disease; and 178 of 568 women [31%] vs 519 of 2418 men [22%] with 1-vessel disease). Female sex was independently associated with greater angina frequency (odds ratio, 1.41; 95% CI, 1.13-1.76). Conclusions and Relevance Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease. Trial Registration ClinicalTrials.gov Identifier: NCT01471522.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Derek D. Cyr
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Hanna Szwed
- National Institute of Cardiology, Warsaw, Poland
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | | | | | - Ahmed Elghamaz
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Olga Bockeria
- National Research Center for Cardiovascular Surgery, Moscow, Russia
| | - Jiyan Chen
- Guangdong General Hospital, Guangzhou, China
| | - Alexander M. Chernyavskiy
- E.Meshalkin National medical research center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Moscow, Russia
| | | | | | | | - Joanna Jaroch
- Wroclaw Medical University, T. Marciniak Hospital, Wroclaw, Poland
| | - Angela Hoye
- The University of Hull/Castle Hill Hospital, Cottingham, United Kingdom
| | | | | | | | - David J. Maron
- Department of Medicine, Stanford University, Stanford, California
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20
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Abstract
Symptomatic individuals suspected of having myocardial ischemia often have no obstructive atherosclerotic narrowing of epicardial coronary arteries. Abnormal coronary vascular reactivity and, in particular, coronary artery vasospasm (CAS) may be an explanation in a subset of these patients. Psychological factors play an important role in ischemic heart disease, but their role in CAS is not clear; autonomic dysfunction and increased inflammation are two prevailing pathophysiological mechanisms implicated in abnormal coronary reactivity resulting from mental health conditions. Interrelationships between psychological factors, abnormal coronary reactivity, and sex/gender differences are poorly defined in the etiology of CAS. In this issue of Psychosomatic Medicine (2019;81:237-245), Hung et al. report a frequency of less than 0.1% of new-onset CAS in the Taiwanese population, with higher occurrence in women and younger individuals. Patients with CAS had a higher prevalence of previous anxiety and depression compared with those with coronary artery disease and controls, with no sex differences. In this editorial comment, we discuss the potential reasons for underreporting of CAS and the challenges regarding the use of administrative health records for psychosomatic research. In this editorial, a model is presented to explain the association between emotional stressors and mental health factors with CAS, including the role of sympathetic nervous system activation, inflammation, oxidative stress, endothelial dysfunction, and smooth muscle cell dysregulation.
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