Happiness and stress alter susceptibility to cardiac events in Long QT Syndrome

How Patient Perceptions Shape Responses and Outcomes in Inherited Cardiac Conditions

At least one-third of adults living with an inherited cardiac condition report clinically-significant levels of psychological distress. Poorer health-related quality of life compared with population norms is also consistently reported. These outcomes are associated with younger patient age, having an implantable cardioverter defibrillator, and receipt of uncertain clinical test results, and can influence self-management behaviours, such as adherence to potentially critical life-preserving medications. According to the Common Sense Model of Illness, people use information from multiple sources to 'make sense' of their health condition, and how they conceptualise the condition can strongly influence adaptation and coping responses. Previous studies with people with inherited cardiac conditions show that illness perceptions, such as greater perceived consequences and a poorer understanding of the condition, are associated with greater psychological distress and poorer adherence to medication. The Common Sense Model provides one potential framework for identifying patients who may be more vulnerable to adverse health outcomes, and for developing early interventions to reduce the physical and psychosocial burden of these conditions. Interventions based on the Common Sense Model have successfully improved physical and psychosocial outcomes associated with other cardiac conditions, and could be tailored for use with patients with an inherited cardiac condition (ICC).

Mental Stress and Ventricular Arrhythmias

Anger and other negative emotions can precipitate sudden death, as shown in studies of population stressors. Clinical studies of patients with implantable defibrillators demonstrate that anger can trigger ventricular arrhythmias. Long-term negative emotions also increase vulnerability to arrhythmias. Mechanisms linking anger and arrhythmias include autonomic changes, which alter repolarization, possibly enhanced in patients with sympathetic denervation, which in turn trigger potentially lethal polymorphic ventricular tachycardias. Interventions which decrease negative emotions and resultant autonomic responses may be therapeutic in patients with implantable cardioverter defibrillators.

Cataplexy and Its Mimics: Clinical Recognition and Management

OPINION STATEMENT

This review describes the diagnosis and management of cataplexy: attacks of bilateral loss of muscle tone, triggered by emotions and with preserved consciousness. Although cataplexy is rare, its recognition is important as in most cases, it leads to a diagnosis of narcolepsy, a disorder that still takes a median of 9 years to be diagnosed. The expression of cataplexy varies widely, from partial episodes affecting only the neck muscles to generalized attacks leading to falls. Moreover, childhood cataplexy differs from the presentation in adults, with a prominent facial involvement, already evident without clear emotional triggers ('cataplectic facies') and 'active' motor phenomena especially of the tongue and perioral muscles. Next to narcolepsy, cataplexy can sometimes be caused by other diseases, such as Niemann-Pick type C, Prader Willi Syndrome, or lesions in the hypothalamic or pontomedullary region. Cataplexy mimics include syncope, epilepsy, hyperekplexia, drop attacks and pseudocataplexy. They can be differentiated from cataplexy using thorough history taking, supplemented with (home)video recordings whenever possible. Childhood narcolepsy, with its profound facial hypotonia, can be confused with neuromuscular disorders, and the active motor phenomenona resemble those found in childhood movement disorders such as Sydenham's chorea. Currently, the diagnosis of cataplexy is made almost solely on clinical grounds, based on history taking and (home) videos. Cataplexy shows remarkable differences in childhood compared to adults, with profound facial hypotonia and complex active motor phenomena. Over time, these severe symptoms evolve to the milder adult phenotype, and this pattern is crucial to recognize when assessing the outcome of uncontrolled case series with potential treatments such as immunomodulation. Symptomatic treatment is possible with antidepressants and sodium oxybate. Importantly, management also needs to involve sleep hygiene advice, safety measures whenever applicable and guidance with regard to the social sequelae of cataplexy.

Positive Psychotherapy to Improve Autonomic Function and Mood in ICD Patients (PAM-ICD): Rationale and Design of an RCT Currently Underway

BACKGROUND

Improving mental and physical health of patients with implantable cardioverter defibrillators (ICD) is critical because this group is at high risk for ventricular arrhythmias and sudden death and depressed or anxious cardiovascular disease (CVD) patients appear to be at even higher risk for mortality compared to nondepressed or nonanxious CVD patients. Further, autonomic dysfunction is present in these patients, and negative emotions and arrhythmias form a downward spiral further worsening mood, well-being, and cardiovascular health. Much research demonstrates that positive emotion is related to health benefits, improved physiology, and increased survival.

METHODS AND RESULTS

This is a two-arm randomized controlled trial aiming to recruit 60 adult ICD patients comparing 12 individually delivered, weekly sessions of: (1) a positive emotion-focused cognitive-behavioral therapy (Quality of Life Therapy [QOLT]), and (2) Heart Healthy Education. Autonomic functioning, heart rhythm indices, and psychosocial health are measured at baseline, 3 months, and 9 months. The first goal is feasibility and acceptability, with the primary outcome being arrhythmic event frequency data.

CONCLUSION

This study is designed to test whether QOLT produces changes in mood, quality of life/well-being, autonomic function, and arrhythmic and ICD therapy event rates. This feasibility trial is a foundational step for the next trial of QOLT to help determine whether a 3-month QOLT trial can reduce arrhythmias occurrences among ICD patients, and examine a mechanism of autonomic functioning. This study may help to develop and implement new medical or psychological therapies for ICD patients.

Behavioral influences on cardiac arrhythmias

Stress can trigger both ventricular and atrial arrhythmias, as evidenced by epidemiological, clinical, and laboratory studies, through its impact on autonomic activity. Chronic stress also increases vulnerability to arrhythmias. Novel therapies aimed at decreasing the psychological and physiological response to stress may decrease arrhythmia frequency and improve quality of life.

Association of depression with coronary artery disease and QTc interval prolongation in women with chest pain: data from the KoRean wOmen'S chest pain rEgistry (KoROSE) study

The presence of depression is reportedly related with cardiovascular diseases, including coronary artery disease (CAD), but little is known concerning the association between depressive symptoms reflecting the cultural constructions of female patients with chest pain as well as coronary artery stenosis, coronary vasospasm, and the corrected QT (QTc) interval. In a multicenter prospective cross-sectional survey of 163 Korean women with chest pain, the presence of depression was evaluated using the Beck Depression Inventory (BDI) and Lee and Rhee Depression (LRD) scales. The differences in the QTc interval and the presence of CAD (defined as ≥ 50% coronary artery stenosis on coronary angiography) and coronary vasospasm were compared between depressed and non-depressed women. Significant CAD was present in 83 of 163 female patients (mean age, 61 years), and coronary vasospasm was present in 11 of 80 patients. The mean BDI and LRD scores were significantly higher in patients with significant CAD (BDI: 13.4 ± 9.6 vs. 6.9 ± 5.6, p < 0.001; LRD: 46.9 ± 21.4 vs. 39.8 ± 15.2, p = 0.027) and coronary vasospasm (BDI: 12.3 ± 6.4 vs. 4.6 ± 2.8; and LRD: 49.8 ± 12.3 vs. 30.5 ± 13.9; both p < 0.05). On multivariate analysis, BDI scores were important risk factors for the presence of CAD (odds ratio [OR] = 1.138; 95% confidence interval [CI] = 1.071-1.210; p=0.021) and coronary vasospasm (OR = 2.534; 95% CI = 1.161-2.028; p = 0.003), with similar findings obtained for LRD scores (CAD: OR = 1.034; 95% CI = 1.013-1.056; p = 0.001; coronary vasospasm: OR = 1.125; 95% CI = 1.050-1.206; p = 0.001). The mean QTc interval was also significantly higher in the depressed group than in the non-depressed group (440.1 ± 32.0 ms vs. 408.2 ± 26.4ms; p < 0.001). The QTc interval displayed significant positive with the BDI (r = 0.595; p < 0.001) and LRD scores (r = 0.467; p< 0.001). This study demonstrated that depression is associated with a prolonged QTc interval, CAD, and coronary vasospasm in female patients with chest pain, suggesting a possible mechanism by which depressive mood may be linked with coronary endothelial dysfunction and atherosclerosis.

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.

Psychological distress and arrhythmia: risk prediction and potential modifiers

The connection between the heart and the brain has long been anecdotally recognized but has systematically been studied only relatively recently. Cardiac arrhythmias, especially ventricular arrhythmias that can lead to sudden cardiac death, remain a major public health concern and there is mounting evidence that psychological distress plays a critical role both as a predictor of high-risk cardiac substrate and as an inciting trigger. The transient, unpredictable nature of emotions and cardiac arrhythmias has made their study challenging, but evolving technologies in monitoring and imaging along with larger epidemiological data sets have encouraged more sophisticated studies examining this relationship. Here we review the research on psychological distress including anger, depression and anxiety on cardiac arrhythmias, insights into proposed mechanisms, and potential avenues for future research.

Cloninger's temperament traits and inherited long QT syndrome

OBJECTIVE

The long QT syndrome (LQTS) is an inherited cardiac disorder which predisposes the mutation carrier to ventricular arrhythmias that can lead to sudden death. The objective of the present study was to examine the association between the symptom status of congenital long QT syndrome mutation carriers and their temperament.

METHODS

The study subjects included 587 LQTS mutation carriers from the Finnish LQTS registry, and 2056 individuals from a database study, the Young Finns Study (YFS), representing general population and serving as control subjects. The LQTS subjects were divided into symptomatic (n=259) and asymptomatic (n=328) groups, according to their history of arrhythmic events. Temperament was assessed using the Cloninger's Temperament and Character Inventory (TCI), assessing novelty seeking, harm avoidance and reward dependence.

RESULTS

Congenital long QT syndrome mutation carriers had a higher harm avoidance (HA) than those representing the general population (2.77 vs. 2.61, p<.001, η²=0.011). Symptomatic and asymptomatic LQTS mutation carriers did not differ from one another in any of the three Cloninger's temperament traits. HA was significantly higher in women (2.72 vs. 2.54, p<0.001 η²=0.017).

CONCLUSIONS

LQTS mutation carriers may have higher stress proneness because of their high HA, which in turn may predispose them to the effects of environmental loading and thus increase the risk of arrhythmias.

Women, but not men, have prolonged QT interval if depressed after an acute coronary syndrome

AIMS

Depression is a mortality risk marker for acute coronary syndrome (ACS) patients. We hypothesized that the QT interval, a predictor for risk of sudden cardiac death, was related to depressive symptoms in ACS.

METHODS AND RESULTS

We performed an analysis of admission electrocardiograms from hospitalized patients with unstable angina or non-ST elevation myocardial infarction from two prospective observational studies of depression in ACS. Depressive symptoms were assessed with the Beck Depression Inventory (BDI), and depression was defined as BDI score ≥10, compared with <5. Patients with QRS duration ≥120 ms and/or who were prescribed antidepressants were excluded. QT intervals were adjusted for heart rate by two methods. Our analyses included 243 men (40.0% with BDI ≥10) and 139 women (62.0% with BDI ≥ 10). Among women, average QT corrected by Fridericia's method (QTcF) was 435.4 ± 26.6 ms in the depressed group, vs. 408.6 ± 24.3 ms in the non-depressed group (P< 0.01). However, among men, average QTcF was not significantly different between the depressed and non-depressed groups (415.4 ± 23.6 vs. 412.0 ± 25.8 ms, P= 0.29). In multivariable analyses that included hypertension, diabetes, ACS type, left ventricular ejection fraction <0.40, and use of QT-prolonging medication, there was a statistically significant interaction between depressive symptoms and gender (P< 0.001).

CONCLUSIONS

In this ACS sample, prolongation of the QT interval was associated with depressive symptoms in women, but not in men. Further investigation of the mechanism of the relationship between depression and abnormal cardiac repolarization, particularly in women, is warranted to develop treatment strategies.

Changes in ventricular repolarization duration during typical daily emotion in patients with Long QT syndrome

OBJECTIVE

Intense emotions are known triggers of sudden cardiac death. However, the effect of typical daily emotion on repolarization has not been examined. We examined whether QT interval changes as a function of typical daily emotion in patients at risk for cardiac events in the context of emotion.

METHODS

We studied 161 patients (n = 114 females; mean age, 35 years) with the congenital form of the Long QT Syndrome during daily activities. Each day for 3 days, a 12-hour Holter recording was completed. Patients were paged ten times per day at random times and rated the intensity of 16 prespecified emotions during the preceding 5 minutes. Measurements of QT interval and interbeat intervals were synchronized with emotion ratings.

RESULTS

Low Arousal Positive Affect was associated with significant increases in QT interval corrected for heart rate (using Fridericia's QTc) (p < .001), whereas higher arousal Activated Positive Affect (p < .001) and Activated Negative Affect (p < .01) were associated with significant decreases in QTc. Changes in QTc as a function of daily emotion ranged from 5-ms increases to 11-ms decreases. High-frequency heart rate variability (vagal tone) was positively correlated with QTc (p < .001). The effects of each positive emotion variable on QTc were greater in LQT2 than LQT1 patients (p < .001).

CONCLUSION

Ventricular repolarization duration (QTc) changes dynamically as a function of daily emotion. These changes are relatively small and do not constitute a risk in themselves. In the context of other risk factors, however, they may contribute to ventricular arrhythmias in vulnerable populations.