1
|
Sottmann L, Schmeling A. Philemon and Baucis death: a literature review. Int J Legal Med 2024; 138:1011-1021. [PMID: 37981585 PMCID: PMC11003922 DOI: 10.1007/s00414-023-03126-7] [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: 08/30/2023] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
Double death, i.e., two bodies at a scene, is relatively rare. The double death from natural causes of two close persons is called Philemon and Baucis death in the medicolegal literature. Despite being mentioned for the first time more than 50 years ago, all detailed case reports on this case constellation are from the last 15 years. A comprehensive review of the literature on this phenomenon has not yet been published. In this article, we review the available literature on Philemon and Baucis death. Pathophysiologically, it can be assumed that this phenomenon is a sub-form of so-called psychogenic death. Therefore, we equally review the literature on sudden cardiac death due to acute psychological stress.
Collapse
Affiliation(s)
- Lukas Sottmann
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany.
| | - Andreas Schmeling
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| |
Collapse
|
2
|
Chen YC, Chen HW, Huang TC, Chu TY, Juan YS, Long CY, Lee HY, Huang SP, Liu YP, Chen CJ, Wu MN, Chueh KS, Li CC, Lee CH, Tsai WC, Wu WJ. Skin sympathetic nerve activity as a potential biomarker for overactive bladder. World J Urol 2023; 41:1373-1379. [PMID: 36971826 DOI: 10.1007/s00345-023-04376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
PURPOSE Abnormalities in autonomic function are associated with an overactive bladder (OAB). Heart rate variability is generally used as the sole assessment of autonomic activity; however, we utilized neuECG, a novel method of recording skin electrical signals, to assess autonomic nervous function in healthy controls and patients with OAB before and after treatment. METHODS The prospective sample included 52 participants: 23 patients newly diagnosed with OAB and 29 controls. Autonomic function was assessed in all participants in the morning using neuECG, which analyzed the average skin sympathetic nerve activity (aSKNA) and electrocardiogram simultaneously. All patients with OAB were administered antimuscarinics; urodynamic parameters were assessed before treatments; autonomic and bladder functions using validated questionnaires for OAB symptoms were evaluated before and after OAB treatment. RESULTS Patients with OAB had significantly higher baseline aSKNA (p = 0.003), lower standard deviation of the normal-to-normal beat intervals, lower root mean square of the successive differences, lower high-frequency, and higher low-frequency than did controls. Baseline aSKNA had the highest value in predicting OAB (AUROC = 0.783, p < 0.001). The aSKNA was negatively correlated with first desire and normal desire in urodynamic studies (both p = 0.025) and was significantly decreased after treatment at rest, stress, and recovery phases, as compared to those before treatment (p = 0.046, 0.017, and 0.017, respectively). CONCLUSION Sympathetic activity increased significantly in patients with OAB compared to that in healthy controls, and decreased significantly post-treatment. Higher aSKNA is associated with decreased bladder volume at which voiding is desired. SKNA may be a potential biomarker for diagnosing OAB.
Collapse
|
3
|
Tang CL, Tsai WC, Lee JY, Wang YK, Chen YH, Liu YW, Lin MC, Fang PT, Huang YL, Wu IC. Higher pre-treatment skin sympathetic nerve activity and elevated resting heart rate after chemoradiotherapy predict worse esophageal cancer outcomes. BMC Cancer 2022; 22:1086. [PMID: 36271384 PMCID: PMC9587625 DOI: 10.1186/s12885-022-10180-8] [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: 08/05/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Chemoradiotherapy (CRT), which might affect the autonomic system, is the mainstay therapy for advanced esophageal squamous cell carcinoma (ESCC). Autonomic dysfunction has been found to possibly lead to cancer mortality in those with elevated resting heart rates (RHR). Skin sympathetic nerve activity (SKNA) is a new method of stimulating electrical signals in skin to evaluate autonomic function from sympathetic tone. In this study, we investigated the association between changes in RHR and autonomic function and ESCC mortality. Methods Thirty-nine stage II-IV ESCC patients receiving CRT between March 2019 and November 2020 were prospectively enrolled and carefully selected, followed up and received the same meticulous supportive care. Serial RHR was recorded every two weeks from before CRT to eight weeks after CRT and average SKNA were recorded before and four weeks after CRT. All-cause mortality was defined as primary outcome. Results We found the RHR of ESCC patients to be significantly elevated and peaking at four weeks after CRT (p < 0.001) and then to gradually decrease. Those with an elevated RHR above the cutoff level (18 beat-per-minute) at eight weeks after CRT had worse overall survival. In addition, those with higher baseline sympathetic tone (average SKNA ≥ 0.86 μV) also had poor outcome. Conclusions Increased pre-treatment sympathetic tone and elevated RHR after CRT are alarm signs of poor ESCC outcome. Further exploration of the mechanisms underlying these associations could potentially lead to intervention strategies for reducing mortality. Trial registration This study is registered with ClinicalTrials.gov, identifier: NCT03243448. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10180-8.
Collapse
Affiliation(s)
- Chen-Ling Tang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chung Tsai
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jui-Ying Lee
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Chest Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yao-Kuang Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Gastroenterology, Department of Internal Medicine, Sanmin Dist, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung City, 80756, Taiwan
| | - Yi-Hsun Chen
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Gastroenterology, Department of Internal Medicine, Sanmin Dist, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung City, 80756, Taiwan
| | - Yu-Wei Liu
- Division of Chest Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Chieh Lin
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pen-Tzu Fang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Ling Huang
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Chen Wu
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Division of Gastroenterology, Department of Internal Medicine, Sanmin Dist, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung City, 80756, Taiwan. .,Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan.
| |
Collapse
|
4
|
Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 883] [Impact Index Per Article: 441.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
5
|
Pang TD, Nearing BD, Schachter SC, Verrier RL. Epileptic seizures and Epilepsy Monitoring Unit admission disclose latent cardiac electrical instability. Epilepsy Behav 2022; 135:108881. [PMID: 36027867 DOI: 10.1016/j.yebeh.2022.108881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sudden cardiac arrest results from cardiac electrical instability and is 3-fold more frequent in patients with chronic epilepsy than in the general population. We hypothesized that focal to bilateral tonic-clonic seizures (FTBTCS) would acutely impact T-wave alternans (TWA), a marker of cardiac electrical instability linked to an elevated risk for sudden cardiac death, more than focal seizures (FS) [focal aware seizures (FAS) and focal with impaired awareness seizures (FIAS)], due to their greater sympathetic stimulation of the heart. Since stress has been shown to cause significant TWA elevations in patients with heart disease, we also hypothesized that the early days of an inpatient admission to an epilepsy monitoring unit (EMU) would be associated with higher TWA levels compared to later hospital days in patients with chronic epilepsy, presumably due to stress. DESIGN/METHODS We analyzed the acute effects of seizures [FAS, FIAS, FTBTCS, and nonepileptic seizures (NES)] and day of hospital stay on TWA in 18 patients admitted to the EMU using high-resolution wireless electrocardiographic (ECG) patch monitors. RESULTS A total of 5 patients had FTBTCS, 7 patients had FS (2 FAS, 5 FIAS), and 3 patients had NES only during the index hospital stay. Four patients did not have any electroclinical seizures or NES. FTBTCS resulted in marked acute increases in ictal TWA from baseline (2 ± 0.3 µV) to ictal maximum (70 ± 6.1 µV, p < 0.0001), the latter exceeding the 60 µV cut point defined as severely abnormal. By comparison, while FAS and FIAS also provoked significant increases in TWA (from 2 ± 0.5 µV to 30 ± 3.3 µV, p < 0.0001), maximum ictal TWA levels did not reach the 47 µV cut point defined as abnormal. Heart rate increases during FTBTCS from baseline (62 ± 5.8 beats/min) to ictal maximum (134 ± 8.6 beats/min, an increase of 72 ± 7.2 beats/min, p < 0.02) were also greater (p = 0.014) than heart rate increases during FS (from 70 ± 5.2 beats/min to 118 ± 6.2 beats/min, an increase of 48 ± 2.6 beats/min, p < 0.03). In 3 patients with NES, TWA rose mildly during the patients' typical episodes (from 2 ± 0.6 µV to 14 ± 2.6 µV, p < 0.0004), well below the cut point of abnormality, while heart rate increases were observed (from 75 ± 1.3 to 112 ± 8.7 beats/min, an increase of 37 ± 8.9 beats/min, p = 0.03). Patients with EEG-confirmed electroclinical seizures recorded while in the EMU exhibited significantly elevated interictal TWA maxima (61 ± 3.4 µV) on EMU admission day which were similar in magnitude to ictal maxima seen during FTBTCS (70 ± 6.1 µV, p = 0.21). During subsequent days of hospitalization, daily interictal TWA maxima showed gradual habituation in patients with both FS and FTBTCS but not in patients with NES only. CONCLUSIONS This is the first study to our knowledge demonstrating that FTBTCS acutely provoke highly significant increases in TWA to levels that have been associated with heightened risk for sudden cardiac death in other patient populations. We speculate that mortality temporally associated with FTBTCS may, in some cases, be due to sudden cardiac death rather than respiratory failure. In patients with EEG-confirmed epilepsy, hospital admission is associated with interictal TWA maxima that approach those seen during FTBTCS, presumably related to stress during the early phase of hospitalization compared to later in the hospitalization, indicating cardiac electrical instability and potential vulnerability to sudden cardiac death related to stress independent of temporal relationships to seizures. The elevated heart rates observed acutely with seizures and on hospital Day 1 are consistent with a hyperadrenergic state and the effect of elevated sympathetic output on a vulnerable cardiac substrate, a phenomenon termed "the Epileptic Heart."
Collapse
Affiliation(s)
- Trudy D Pang
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States.
| | - Bruce D Nearing
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States
| | - Steven C Schachter
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States; Departments of Neurology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States; Consortia for Improving Medicine with Innovation & Technology (CIMIT), Boston, MA, United States
| | - Richard L Verrier
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States
| |
Collapse
|
6
|
Huang TC, Lin SJ, Chen CJ, Jhuo SJ, Chang CW, Lin SC, Chi NY, Chou LF, Tai LH, Liu YH, Lin TH, Liao WS, Kao PH, Cheng MC, Hsu PC, Lee CS, Lin YH, Lee HC, Lu YH, Yen HW, Lin TH, Su HM, Lai WT, Dai CY, Lee CH, Chen PS, Lin SF, Tsai WC. Skin Sympathetic Nerve Activity and Ventricular Arrhythmias in Acute Coronary Syndrome. Heart Rhythm 2022; 19:1613-1619. [PMID: 35525422 DOI: 10.1016/j.hrthm.2022.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) is major cause of ventricular arrhythmias (VA) and sudden death. neuECG is a non-invasive method to simultaneously measure skin sympathetic nerve activity (SKNA) and electrocardiogram (ECG). OBJECTIVE To test the hypotheses that (1) ACS increases the average SKNA (aSKNA), (2) the magnitude of aSKNA elevation is associated with VA during ACS and (3) there is a gender difference of aSKNA in patients without and with ACS. METHODS We prospectively studied 128 ACS and 165 control participants. The neuECG was recorded with electrocardiogram (ECG) Lead I configuration at baseline, during mental math stress and during recovery (5-min each). All recordings were done in the morning. RESULTS In control group, women have higher aSKNA (μV) than men at baseline (0.82±0.25 vs 0.73±0.20, p=0.009) but not during mental stress (1.21±0.36 vs 1.16±0.36, p=0.394), suggesting women had lower sympathetic reserve. In comparison, ACS is associated with equally elevated aSKNA (μV) in women vs men at baseline (1.14±0.33 vs 1.04±0.35, p=0.531), during mental stress (1.46±0.32 vs 1.33 ±0.37, p=0.113) and during recovery (1.30±0.33 1.11±0.30, p=0.075). After adjusting for age and gender, the adjusted odds ratio for VA including ventricular tachycardia and fibrillation is 1.23 (95% confidence interval 1.05-1.44) for each 0.1 μV elevation of aSKNA. The aSKNA is positively correlated with plasma norepinephrine level. CONCLUSIONS ACS is associated with elevated aSKNA and the magnitude of aSKNA elevation is associated with occurrences of VA. Women have higher aSKNA and lower SKNA reserve than men in control but not in ACS patients.
Collapse
Affiliation(s)
- Tien-Chi Huang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shin-Jing Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chang-Jen Chen
- Division of Cardiology, Department of Internal Medicine, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Shih-Jie Jhuo
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chien-Wei Chang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Ching Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Nai-Yu Chi
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Fang Chou
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Hsin Tai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Hsueh Liu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Han Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Sheng Liao
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Heng Kao
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mu-Chun Cheng
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chee-Siong Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Hsiung Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Chun Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ye-Hsu Lu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ho-Ming Su
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Yen Dai
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chien-Hung Lee
- Department of Public Health, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan; Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shien-Fong Lin
- Department of Electrical and Computer Engineering, College of Electrical and Computer Engineering, National Chiao Tung University, Hsinchu, Taiwan
| | - Wei-Chung Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
| |
Collapse
|
7
|
Mind and body interventions in cardiology : The importance of the brain-heart connection. Herz 2022; 47:103-109. [PMID: 35292838 DOI: 10.1007/s00059-022-05104-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/04/2022]
Abstract
Mind and body interventions aim to harness the "relaxation response", reduce stress, and improve quality of life, which is important in the search for more holistic treatment approaches in cardiovascular medicine. This article describes the pertinent pathophysiological correlates building the mechanistic backbone for these interventions. They can be found in the complex connections of brain and heart (central and autonomic nervous system, hypothalamic-pituitary-adrenal axis), which play an important role in the development of various cardiovascular disease conditions and hold potential as therapeutic targets. The evidence regarding the effect of mind and body interventions in cardiology with a focus on arrhythmia and psychocardiology is reviewed systematically. To date, mostly small pilot studies prone to substantial bias and without adequate power have dominated the field and longer-term outcome data are lacking. Ultimately, integration of mind and body interventions could empower patients by strengthening their individual responsibility and mental power in addition to the benefits of stress reduction and improvement of quality of life. Whether this will translate into relevant longer-term clinical outcomes remains uncertain. Therefore, this field offers multifaceted opportunities for further research and practical applications.
Collapse
|
8
|
Shah AJ, Weeks V, Lampert R, Bremner JD, Kutner M, Raggi P, Sun YV, Lewis TT, Levantsevych O, Kim YJ, Hammadah M, Alkhoder A, Wittbrodt M, Pearce BD, Ward L, Sheps D, Quyyumi AA, Vaccarino V. Early Life Trauma Is Associated With Increased Microvolt T-Wave Alternans During Mental Stress Challenge: A Substudy of Mental Stress Ischemia: Prognosis and Genetic Influences. J Am Heart Assoc 2022; 11:e021582. [PMID: 35167312 PMCID: PMC9075061 DOI: 10.1161/jaha.121.021582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
Background Early life trauma has been associated with increased cardiovascular risk, but the arrhythmic implications are unclear. We hypothesized that in patients with coronary artery disease, early life trauma predicts increased arrhythmic risk during mental stress, measured by elevated microvolt T-wave alternans (TWA), a measure of repolarization heterogeneity and sudden cardiac death risk. Methods and Results In a cohort with stable coronary artery disease (NCT04123197), we examined early life trauma with the Early Trauma Inventory Self Report-Short Form. Participants underwent a laboratory-based mental stress speech task with Holter monitoring, as well as a structured psychiatric interview. We measured TWA during rest, mental stress, and recovery with ambulatory electrocardiographic monitoring. We adjusted for sociodemographic factors, cardiac history, psychiatric comorbidity, and hemodynamic stress reactivity with multivariable linear regression models. We examined 320 participants with noise- and arrhythmia-free ECGs. The mean (SD) age was 63.8 (8.7) years, 27% were women, and 27% reported significant childhood trauma (Early Trauma Inventory Self Report-Short Form ≥10). High childhood trauma was associated with a multivariable-adjusted 17% increase in TWA (P=0.04) during stress, and each unit increase in the Early Trauma Inventory Self Report-Short Form total score was associated with a 1.7% higher stress TWA (P=0.02). The largest effect sizes were found with the emotional trauma subtype. Conclusions In a cohort with stable coronary artery disease, early life trauma, and in particular emotional trauma, is associated with increased TWA, a marker of increased arrhythmic risk, during mental stress. This association suggests that early trauma exposures may affect long-term sudden cardiac death risk during emotional triggers, although more studies are warranted.
Collapse
Affiliation(s)
- Amit J. Shah
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
- Division of CardiologyDepartment of MedicineEmory UniversityAtlantaGA
- Atlanta Veterans Affairs Healthcare SystemDecaturGA
| | | | - Rachel Lampert
- Division of CardiologyDepartment of MedicineYale University School of MedicineNew HavenCT
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral SciencesSchool of MedicineEmory UniversityAtlantaGA
- Department of Psychiatry and Department of RadiologyEmory University, School of MedicineEmory UniversityAtlantaGA
| | - Michael Kutner
- Department of BiostatisticsRollins School of Public HealthEmory UniversityAtlantaGA
| | - Paolo Raggi
- Department of MedicineMazankowski Alberta Heart InstituteUniversity of AlbertaEdmontonAlbertaCanada
| | - Yan V. Sun
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Tené T. Lewis
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Oleksiy Levantsevych
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Ye Ji Kim
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Muhammad Hammadah
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
- Division of CardiologyDepartment of MedicineEmory UniversityAtlantaGA
| | - Ayman Alkhoder
- Division of CardiologyDepartment of MedicineEmory UniversityAtlantaGA
| | - Matthew Wittbrodt
- Department of Psychiatry and Behavioral SciencesSchool of MedicineEmory UniversityAtlantaGA
| | - Brad D. Pearce
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Laura Ward
- Department of BiostatisticsRollins School of Public HealthEmory UniversityAtlantaGA
| | - David Sheps
- Department of EpidemiologyUniversity of FloridaGainesvilleFL
| | - Arshed A. Quyyumi
- Division of CardiologyDepartment of MedicineEmory UniversityAtlantaGA
| | - Viola Vaccarino
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
- Division of CardiologyDepartment of MedicineEmory UniversityAtlantaGA
| |
Collapse
|
9
|
Krantz DS, Harris KM, Rogers HL, Whittaker KS, Haigney MCP, Kop WJ. Psychological factors and cardiac repolarization instability during anger in implantable cardioverter defibrillator patients. Ann Noninvasive Electrocardiol 2021; 26:e12848. [PMID: 33813750 PMCID: PMC8293621 DOI: 10.1111/anec.12848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background Evidence indicates that emotions such as anger are associated with increased incidence of sudden cardiac death, but the biological mechanisms remain unclear. We tested the hypothesis that, in patients with sudden death vulnerability, anger would be associated with arrhythmic vulnerability, indexed by cardiac repolarization instability. Methods Patients with coronary artery disease (CAD) and an implantable cardioverter defibrillator (ICD; n = 41) and healthy controls (n = 26) gave an anger‐inducing speech (anger recall), rated their current (state) anger, and completed measures of trait (chronic) levels of Anger and Hostility. Repolarization instability was measured using QT Variability Index (QTVI) at resting baseline and during anger recall using continuous ECG. Results ICD patients had significantly higher QTVI at baseline and during anger recall compared with controls, indicating greater arrhythmic vulnerability overall. QTVI increased from baseline to anger recall to a similar extent in both groups. In ICD patients but not controls, during anger recall, self‐rated anger was related to QTVI (r = .44, p = .007). Trait (chronic) Anger Expression (r = .26, p = .04), Anger Control (r = −.26, p = .04), and Hostility (r = .25, p = .05) were each associated with the change in QTVI from baseline to anger recall (ΔQTVI). Moderation analyses evaluated whether psychological trait associations with ΔQTVI were specific to the ICD group. Results indicated that Hostility scores predicted ΔQTVI from baseline to anger recall in ICD patients (β = 0.07, p = .01), but not in controls. Conclusions Anger increases repolarization lability, but in patients with CAD and arrhythmic vulnerability, chronic and acute anger interact to trigger cardiac repolarization lability associated with susceptibility to malignant arrhythmias.
Collapse
Affiliation(s)
- David S Krantz
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kristie M Harris
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Heather L Rogers
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Ikerbasque Basque Foundation for Science, Bilbao, Spain
| | - Kerry S Whittaker
- Research Facilitation Laboratory - Army Analytics Group, Monterey, CA, USA
| | - Mark C P Haigney
- Division of Cardiology, Department of Medicine, Military Cardiovascular Outcomes Research (MiCOR), Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Willem J Kop
- Department of Medical Psychology and Neuropsychology, Tilburg University, Tilburg, The Netherlands
| |
Collapse
|
10
|
Bremner JD, Wittbrodt MT, Shah AJ, Pearce BD, Gurel NZ, Inan OT, Raggi P, Lewis TT, Quyyumi AA, Vaccarino V. Confederates in the Attic: Posttraumatic Stress Disorder, Cardiovascular Disease, and the Return of Soldier's Heart. J Nerv Ment Dis 2020; 208:171-180. [PMID: 32091470 PMCID: PMC8214871 DOI: 10.1097/nmd.0000000000001100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Da Costa originally described Soldier's Heart in the 19th Century as a syndrome that occurred on the battlefield in soldiers of the American Civil War. Soldier's Heart involved symptoms similar to modern day posttraumatic stress disorder (PTSD) as well as exaggerated cardiovascular reactivity felt to be related to an abnormality of the heart. Interventions were appropriately focused on the cardiovascular system. With the advent of modern psychoanalysis, psychiatric symptoms became divorced from the body and were relegated to the unconscious. Later, the physiology of PTSD and other psychiatric disorders was conceived as solely residing in the brain. More recently, advances in psychosomatic medicine led to the recognition of mind-body relationships and the involvement of multiple physiological systems in the etiology of disorders, including stress, depression PTSD, and cardiovascular disease, has moved to the fore, and has renewed interest in the validity of the original model of the Soldier's Heart syndrome.
Collapse
Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta
- Department of Radiology, Emory University School of Medicine, Emory University, Atlanta
- Atlanta VA Medical Center, Decatur
| | - Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta
| | - Amit J. Shah
- Atlanta VA Medical Center, Decatur
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
| | - Bradley D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Nil Z. Gurel
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
- Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Arshed A. Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
| | - Viola Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
- Department of Epidemiology, Rollins School of Public Health, Emory University
| |
Collapse
|
11
|
Hashimoto K, Kasamaki Y, Soma M, Takase B. Diurnal variation of frequency domain T-wave alternans on 24-hour ambulatory electrocardiogram in subjects without heart disease: Significant effect of autonomic nervous activity of the heart. Ann Noninvasive Electrocardiol 2018; 24:e12620. [PMID: 30403436 DOI: 10.1111/anec.12620] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/09/2018] [Accepted: 09/18/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND T-wave alternans (TWA) is a risk stratification predictor for sudden cardiac death. However, little is known about the diurnal variation of TWA. Whether TWA are affected by heart rate (HR) or cardiac autonomic nervous activity in the subjects without significant structural heart disease in daily life is not fully understood. Thus, this study was aimed to clarify these issues. METHODS Frequency domain (FD)-TWA analysis was conducted in 47 subjects without significant structural heart disease using 24-hr ambulatory electrocardiogram (AECG). Measurement of heart rate variability (HRV) was performed in order to evaluate the autonomic activity of the heart. The maximum FD-TWA value in each period was measured four times per day (A, 00:00-6:00 hr; B, 06:00-12:00 hr; C, 12:00-18:00 hr; D, 18:00-24:00 hr). Correlations between FD-TWA and either HR or HRV parameters (LF/HF, LFnu, HFnu, SDNN, CVNN, pNN50) were analyzed in each period (A-D). RESULTS There was diurnal variation of FD-TWA (median, inter-quartile range [IQR]: A, 8.2 [6.5, 10.6] μV; B, 10.1 [8.4, 15.0] μV; C, 17.6 [12.3, 25.0] μV: D, 11.9 [9.1, 19.9] μV; p < 0.0001). Maximum FD-TWA had positive correlations with HR and LF/HF (HR, r = 0.496, p < 0.0001; LF/HF, r = 0.414, p = 0.004), while FD-TWA had a negative correlation with HFnu (r = -0.291, p = 0.048). On multiple linear regression analysis, HR had an independent effect on log FD-TWA amplitude (β = 0.461, p = 0.001). CONCLUSIONS FD-TWA has marked diurnal variation in the daily life of the subjects without significant structural heart disease. This variation could be more strongly affected by HR than the HRV indices.
Collapse
Affiliation(s)
- Kenichi Hashimoto
- Department of Intensive Care Medicine, National Defense Medical College, Saitama, Japan
| | - Yuji Kasamaki
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, Kanazawa, Japan
| | - Masayoshi Soma
- Division of General Medicine, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Bonpei Takase
- Department of Intensive Care Medicine, National Defense Medical College, Saitama, Japan
| |
Collapse
|
12
|
Fioranelli M, Bottaccioli AG, Bottaccioli F, Bianchi M, Rovesti M, Roccia MG. Stress and Inflammation in Coronary Artery Disease: A Review Psychoneuroendocrineimmunology-Based. Front Immunol 2018; 9:2031. [PMID: 30237802 PMCID: PMC6135895 DOI: 10.3389/fimmu.2018.02031] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/17/2018] [Indexed: 01/08/2023] Open
Abstract
Recent findings have deeply changed the current view of coronary heart disease, going beyond the simplistic model of atherosclerosis as a passive process involving cholesterol build-up in the subintimal space of the arteries until their final occlusion and/or thrombosis and instead focusing on the key roles of inflammation and the immune system in plaque formation and destabilization. Chronic inflammation is a typical hallmark of cardiac disease, worsening outcomes irrespective of serum cholesterol levels. Low-grade chronic inflammation correlates with higher incidence of several non-cardiac diseases, including depression, and chronic depression is now listed among the most important cardiovascular risk factors for poor prognosis among patients with myocardial infarction. In this review, we include recent evidence describing the immune and endocrine properties of the heart and their critical roles in acute ischaemic damage and in post-infarct myocardial remodeling. The importance of the central and autonomic regulation of cardiac functions, namely, the neuro-cardiac axis, is extensively explained, highlighting the roles of acute and chronic stress, circadian rhythms, emotions and the social environment in triggering acute cardiac events and worsening heart function and metabolism in chronic cardiovascular diseases. We have also included specific sections related to stress-induced myocardial ischaemia measurements and stress cardiomyopathy. The complex network of reciprocal interconnections between the heart and the main biological systems we have presented in this paper provides a new vision of cardiovascular science based on psychoneuroendocrineimmunology.
Collapse
Affiliation(s)
- Massimo Fioranelli
- Department of Nuclear Physics, Sub-Nuclear and Radiation, Guglielmo Marconi University, Rome, Italy
- Società Italiana di Psiconeuroendocrinoimmunologia, Rome, Italy
| | - Anna G. Bottaccioli
- Società Italiana di Psiconeuroendocrinoimmunologia, Rome, Italy
- Department of Internal Medicine, Sapienza University, Rome, Italy
| | - Francesco Bottaccioli
- Società Italiana di Psiconeuroendocrinoimmunologia, Rome, Italy
- Department of Clinical Medicine, University of l'Aquila, L'Aquila, Italy
- Department of Neurosciences “Rita Levi Montalcini”, University of Turin, Rome, Italy
| | - Maria Bianchi
- Department of Nuclear Physics, Sub-Nuclear and Radiation, Guglielmo Marconi University, Rome, Italy
| | - Miriam Rovesti
- Department of Dermatology, University of Parma, Parma, Italy
| | - Maria G. Roccia
- Department of Nuclear Physics, Sub-Nuclear and Radiation, Guglielmo Marconi University, Rome, Italy
| |
Collapse
|
13
|
Hallioglu O, Keceli M, Bozlu G, Delibas A, Karpuz D, Selvi H. Evaluation of T-wave alternans in pediatric patients with chronic renal failure. J Electrocardiol 2018; 51:622-627. [PMID: 29997001 DOI: 10.1016/j.jelectrocard.2018.04.013] [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: 12/15/2017] [Revised: 03/10/2018] [Accepted: 04/18/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Microvolt T-wave alternans (TWA) is known to be useful in prediction of ischemia and sudden death in high-risk populations and there are no studies in children with chronic renal failure (CRF). Cardiac problems seem to be responsible for an important part of death in children and young adults with CRF. The aim of this study is to evaluate Holter microvolts TWA measurements in children with CRF comparing to the control group. METHODS This prospective study included 40 patients with CRF and 48 healthy controls. The history, echocardiography and microvolt TWA values based on 24-hour ECG recordings of the patients were evaluated. Analysis of microvolt TWA was considered on the basis of three leads (V5, V1 and AVF). RESULTS Compared with the controls, the mean systolic and diastolic blood pressure values and average heart rates were significantly higher in the children with CRF (p = 0.001 and p = 0.026, respectively). Also, the values of left ventricular internal dimensions at end diastole and end-diastolic volume were significantly higher in CRF group (p = 0.01 and p = 0.049, respectively) and couplet ventricular extrasystole was detected in 2 patients with CRF. Consequently, all TWA values in three leads were increased in CRF group than the control group but the only increase in V5 lead was statistically significant (p = 0.028). CONCLUSIONS This study has demonstrated that microvolt TWA values increased in pediatric patients with CRF. TWA might be used for early risk assessment in pediatric patients with CRF in the future.
Collapse
Affiliation(s)
- Olgu Hallioglu
- Department of Pediatrics, University of Mersin Faculty of Medicine, Mersin, Turkey; Division of Pediatric Cardiology, University of Mersin Faculty of Medicine, Mersin, Turkey.
| | - Meryem Keceli
- Department of Pediatrics, University of Mersin Faculty of Medicine, Mersin, Turkey
| | - Gulcin Bozlu
- Department of Pediatrics, University of Mersin Faculty of Medicine, Mersin, Turkey
| | - Ali Delibas
- Department of Pediatrics, University of Mersin Faculty of Medicine, Mersin, Turkey; Division of Pediatric Nephrology, University of Mersin Faculty of Medicine, Mersin, Turkey
| | - Derya Karpuz
- Department of Pediatrics, University of Mersin Faculty of Medicine, Mersin, Turkey; Division of Pediatric Cardiology, University of Mersin Faculty of Medicine, Mersin, Turkey
| | - Hüseyin Selvi
- Department of Medical Education, University of Mersin Faculty of Medicine, Mersin, Turkey
| |
Collapse
|
14
|
Etienne P, Huchet F, Gaborit N, Barc J, Thollet A, Kyndt F, Guyomarch B, Le Marec H, Charpentier F, Schott JJ, Redon R, Probst V, Gourraud JB. Mental stress test: a rapid, simple, and efficient test to unmask long QT syndrome. Europace 2018; 20:2014-2020. [DOI: 10.1093/europace/euy078] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 03/20/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pauline Etienne
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - François Huchet
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | | | - Julien Barc
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, Nantes, France
| | - Aurélie Thollet
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Florence Kyndt
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Béatrice Guyomarch
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Hervé Le Marec
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Flavien Charpentier
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Jean-Jacques Schott
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Richard Redon
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Vincent Probst
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| | - Jean-Baptiste Gourraud
- l’institut du thorax, INSERM, CNRS, UNIV Nantes, CHU de Nantes, Boulevard Jacques Monod, Nantes, France
| |
Collapse
|
15
|
Tse G, Yan BP. Traditional and novel electrocardiographic conduction and repolarization markers of sudden cardiac death. Europace 2018; 19:712-721. [PMID: 27702850 DOI: 10.1093/europace/euw280] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/11/2016] [Indexed: 12/20/2022] Open
Abstract
Sudden cardiac death, frequently due to ventricular arrhythmias, is a significant problem globally. Most affected individuals do not arrive at hospital in time for medical treatment. Therefore, there is an urgent need to identify the most-at-risk patients for insertion of prophylactic implantable cardioverter defibrillators. Clinical risk markers derived from electrocardiography are important for this purpose. They can be based on repolarization, including corrected QT (QTc) interval, QT dispersion (QTD), interval from the peak to the end of the T-wave (Tpeak - Tend), (Tpeak - Tend)/QT, T-wave alternans (TWA), and microvolt TWA. Abnormal repolarization properties can increase the risk of triggered activity and re-entrant arrhythmias. Other risk markers are based solely on conduction, such as QRS duration (QRSd), which is a surrogate marker of conduction velocity (CV) and QRS dispersion (QRSD) reflecting CV dispersion. Conduction abnormalities in the form of reduced CV, unidirectional block, together with a functional or a structural obstacle, are conditions required for circus-type or spiral wave re-entry. Conduction and repolarization can be represented by a single parameter, excitation wavelength (λ = CV × effective refractory period). λ is an important determinant of arrhythmogenesis in different settings. Novel conduction-repolarization markers incorporating λ include Lu et al.' index of cardiac electrophysiological balance (iCEB: QT/QRSd), [QRSD× (Tpeak - Tend)/QRSd] and [QRSD × (Tpeak - Tend)/(QRSd × QT)] recently proposed by Tse and Yan. The aim of this review is to provide up to date information on traditional and novel markers and discuss their utility and downfalls for risk stratification.
Collapse
Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, SAR, P.R. China
| | - Bryan P Yan
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, SAR, P.R. China.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, Australia
| |
Collapse
|
16
|
Mehta PK, Hermel M, Nelson MD, Cook-Wiens G, Martin EA, Alkhoder AA, Wei J, Minissian M, Shufelt CL, Marpuri S, Hermel D, Shah A, Irwin MR, Krantz DS, Lerman A, Noel Bairey Merz C. Mental stress peripheral vascular reactivity is elevated in women with coronary vascular dysfunction: Results from the NHLBI-sponsored Cardiac Autonomic Nervous System (CANS) study. Int J Cardiol 2018; 251:8-13. [PMID: 29103858 PMCID: PMC5870901 DOI: 10.1016/j.ijcard.2017.10.061] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/26/2017] [Accepted: 10/17/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Women with chest pain, ischemia, and no obstructive coronary artery disease often have coronary vascular dysfunction (CVaD). Peripheral vascular reactivity to mental stress may contribute mechanistic understanding of stress-induced ischemia in women with CVaD. METHODS 62 women (41 CVaD and 21 controls) underwent mental stress testing (MST) with anger recall, mental arithmetic, and forehead cold pressor (COP) challenge. Emotional arousal was measured (Likert scale). Reactive hyperemia index (RHI) was calculated before and after MST by peripheral arterial tonometry (PAT). Stress PAT ratio (SPR) of pulse amplitude during stress to rest was obtained to measure vasoconstriction. Wilcoxson rank sum test was used for analysis. RESULTS Mean age of CVaD and control groups was 58±9 and 55±10years (p=0.73). Baseline RHI correlated with coronary endothelial function (r=0.36, p=0.03) and inversely with RHI change post-MST (r=-0.51, p<0.001). During MST, 10% of controls reported chest pain vs. 41% of CVaD subjects (p=0.01). RHI did not change significantly after MST in either group. CVaD subjects had lower SPR vs. controls during mental arithmetic (0.54 [0.15, 1.46] vs. 0.67 [0.36, 1.8], p=0.039), not evident in the other tasks. Vasoconstriction inversely correlated with anxiety (r=-3.4, p=0.03), frustration (r=-0.37, p=0.02), and feeling challenged (r=-0.37, p=0.02) in CVaD but not controls. CONCLUSIONS Mental stress peripheral vascular reactivity is elevated in women with CVaD compared to controls. Elevated vascular reactivity may be one contributor to stress-induced chest pain in CVaD. Interventions that modulate vasoconstrictive responses may be of benefit and should be tested in clinical trials in women with CVaD.
Collapse
Affiliation(s)
- Puja K Mehta
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States.
| | - Melody Hermel
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Michael D Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Galen Cook-Wiens
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Elizabeth A Martin
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Ayman A Alkhoder
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Margo Minissian
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Chrisandra L Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Sailaja Marpuri
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - David Hermel
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| | - Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, United States
| | - Michael R Irwin
- Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience, David Geffen SOM at UCLA, United States
| | - David S Krantz
- Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD, United States
| | - Amir Lerman
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, United States
| |
Collapse
|
17
|
Abstract
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.
Collapse
|
18
|
Finlay M, Harmer SC, Tinker A. The control of cardiac ventricular excitability by autonomic pathways. Pharmacol Ther 2017; 174:97-111. [PMID: 28223225 DOI: 10.1016/j.pharmthera.2017.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Central to the genesis of ventricular cardiac arrhythmia are variations in determinants of excitability. These involve individual ionic channels and transporters in cardiac myocytes but also tissue factors such as variable conduction of the excitation wave, fibrosis and source-sink mismatch. It is also known that in certain diseases and particularly the channelopathies critical events occur with specific stressors. For example, in hereditary long QT syndrome due to mutations in KCNQ1 arrhythmic episodes are provoked by exercise and in particular swimming. Thus not only is the static substrate important but also how this is modified by dynamic signalling events associated with common physiological responses. In this review, we examine the regulation of ventricular excitability by signalling pathways from a cellular and tissue perspective in an effort to identify key processes, effectors and potential therapeutic approaches. We specifically focus on the autonomic nervous system and related signalling pathways.
Collapse
Affiliation(s)
- Malcolm Finlay
- The Heart Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London EC1M6BQ, UK
| | - Stephen C Harmer
- The Heart Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London EC1M6BQ, UK
| | - Andrew Tinker
- The Heart Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London EC1M6BQ, UK.
| |
Collapse
|
19
|
Taggart P, Critchley H, van Duijvendoden S, Lambiase PD. Significance of neuro-cardiac control mechanisms governed by higher regions of the brain. Auton Neurosci 2016; 199:54-65. [DOI: 10.1016/j.autneu.2016.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 12/24/2022]
|
20
|
Quantitative T-wave alternans analysis for sudden cardiac death risk assessment and guiding therapy: answered and unanswered questions. J Electrocardiol 2016; 49:429-38. [DOI: 10.1016/j.jelectrocard.2016.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Indexed: 11/23/2022]
|
21
|
Living with an implantable cardioverter defibrillator: The patients' experience. Heart Lung 2016; 45:34-40. [DOI: 10.1016/j.hrtlng.2015.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/09/2015] [Accepted: 10/11/2015] [Indexed: 11/24/2022]
|
22
|
Eisenmann ED, Rorabaugh BR, Zoladz PR. Acute Stress Decreases but Chronic Stress Increases Myocardial Sensitivity to Ischemic Injury in Rodents. Front Psychiatry 2016; 7:71. [PMID: 27199778 PMCID: PMC4843048 DOI: 10.3389/fpsyt.2016.00071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/08/2016] [Indexed: 12/18/2022] Open
Abstract
Cardiovascular disease (CVD) is the largest cause of mortality worldwide, and stress is a significant contributor to the development of CVD. The relationship between acute and chronic stress and CVD is well evidenced. Acute stress can lead to arrhythmias and ischemic injury. However, recent evidence in rodent models suggests that acute stress can decrease sensitivity to myocardial ischemia-reperfusion injury (IRI). Conversely, chronic stress is arrhythmogenic and increases sensitivity to myocardial IRI. Few studies have examined the impact of validated animal models of stress-related psychological disorders on the ischemic heart. This review examines the work that has been completed using rat models to study the effects of stress on myocardial sensitivity to ischemic injury. Utilization of animal models of stress-related psychological disorders is critical in the prevention and treatment of cardiovascular disorders in patients experiencing stress-related psychiatric conditions.
Collapse
Affiliation(s)
- Eric D Eisenmann
- Department of Psychology, Sociology and Criminal Justice, Ohio Northern University , Ada, OH , USA
| | - Boyd R Rorabaugh
- Department of Pharmaceutical and Biomedical Sciences, Ohio Northern University , Ada, OH , USA
| | - Phillip R Zoladz
- Department of Psychology, Sociology and Criminal Justice, Ohio Northern University , Ada, OH , USA
| |
Collapse
|
23
|
Brindle RC, Ginty AT, Phillips AC, Fisher JP, McIntyre D, Carroll D. Heart rate complexity: A novel approach to assessing cardiac stress reactivity. Psychophysiology 2015; 53:465-72. [PMID: 26585809 DOI: 10.1111/psyp.12576] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 10/08/2015] [Indexed: 02/04/2023]
Abstract
Correlation dimension (D2), a measure of heart rate (HR) complexity, has been shown to decrease in response to acute mental stress and relate to adverse cardiovascular health. However, the relationship between stress-induced changes in D2 and HR has yet to be established. The present studies aimed to assess this relationship systematically while controlling for changes in respiration and autonomic activity. In Study 1 (N = 25) D2 decreased during stress and predicted HR reactivity even after adjusting for changes in respiration rate, and cardiac vagal tone. This result was replicated in Study 2 (N = 162) and extended by including a measure of cardiac sympathetic activity; correlation dimension remained an independent predictor of HR reactivity in a hierarchical linear model containing measures of cardiac parasympathetic and sympathetic activity and their interaction. These results suggest that correlation dimension may provide additional information regarding cardiac stress reactivity above that provided by traditional measures of cardiac autonomic function.
Collapse
Affiliation(s)
- Ryan C Brindle
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Annie T Ginty
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anna C Phillips
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - James P Fisher
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - David McIntyre
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Douglas Carroll
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
24
|
Abstract
Psychological stress can lead to atrial and ventricular arrhythmias, but the physiological pathways have not been fully elucidated. Signal processing techniques can provide insight into electrophysiological mechanisms of stress-induced arrhythmia. T-wave alternans, as well as other ECG measures of heterogeneity of repolarization, increases with emotional and cognitive stress in the laboratory setting, and may also in "real life" settings. In the atrium, stress impacts components of the signal-averaged ECG. These changes suggest mechanisms by which everyday stressors can lead to arrhythmia.
Collapse
|
25
|
Shlyakhto EV, Treshkur TV, Tulintseva TE, Zhdanova ON, Tikhonenko VM, Tsurinova EA, Ilyina DY, Los MM. [Algorithm for the management of patients with ventricular arrhythmias]. TERAPEVT ARKH 2015; 87:106-112. [PMID: 26155628 DOI: 10.17116/terarkh2015875106-112] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- E V Shlyakhto
- Federal North-West Medical Research Center, Ministry of Health of the Russian Federation, Saint Petersburg
| | - T V Treshkur
- Federal North-West Medical Research Center, Ministry of Health of the Russian Federation, Saint Petersburg
| | - T E Tulintseva
- Federal North-West Medical Research Center, Ministry of Health of the Russian Federation, Saint Petersburg
| | - O N Zhdanova
- Acad. I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - V M Tikhonenko
- Federal North-West Medical Research Center, Ministry of Health of the Russian Federation, Saint Petersburg
| | - E A Tsurinova
- Federal North-West Medical Research Center, Ministry of Health of the Russian Federation, Saint Petersburg
| | - D Yu Ilyina
- Federal North-West Medical Research Center, Ministry of Health of the Russian Federation, Saint Petersburg
| | - M M Los
- Federal North-West Medical Research Center, Ministry of Health of the Russian Federation, Saint Petersburg
| |
Collapse
|
26
|
Emotional, neurohormonal, and hemodynamic responses to mental stress in Tako-Tsubo cardiomyopathy. Am J Cardiol 2015; 115:1580-6. [PMID: 25910524 DOI: 10.1016/j.amjcard.2015.02.064] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/11/2015] [Accepted: 02/11/2015] [Indexed: 11/21/2022]
Abstract
Tako-Tsubo cardiomyopathy (TTC) is characterized by apical ballooning of the left ventricle and symptoms and signs mimicking acute myocardial infarction. The high catecholamine levels in the acute phase of TTC and common emotional triggers suggest a dysregulated stress response system. This study examined whether patients with TTC show exaggerated emotional, neurohormonal, and hemodynamic responses to mental stress. Patients with TTC (n = 18; mean age 68.3 ± 11.7, 78% women) and 2 comparison groups (healthy controls, n = 19; mean age 60.0 ± 7.6, 68% women; chronic heart failure, n = 19; mean age 68.8 ± 10.1, 68% women) performed a structured mental stress task (anger recall and mental arithmetic) and low-grade exercise with repeated assessments of negative emotions, neurohormones (catecholamines: norepinephrine, epinephrine, dopamine, hypothalamic-pituitary-adrenal axis hormones: adrenocorticotropic hormone [ACTH], cortisol), echocardiography, blood pressure, and heart rate. TTC was associated with higher norepinephrine (520.7 ± 125.5 vs 407.9 ± 155.3 pg/ml, p = 0.021) and dopamine (16.2 ± 10.3 vs 10.3 ± 3.9 pg/ml, p = 0.027) levels during mental stress and relatively low emotional arousal (p <0.05) compared with healthy controls. During exercise, norepinephrine (511.3 ± 167.1 vs 394.4 ± 124.3 pg/ml, p = 0.037) and dopamine (17.3 ± 10.0 vs 10.8 ± 4.1 pg/ml, p = 0.017) levels were also significantly higher in patients with TTC compared with healthy controls. In conclusion, catecholamine levels during mental stress and exercise were elevated in TTC compared with healthy controls. No evidence was found for a dysregulated hypothalamic-pituitary-adrenal axis or hemodynamic responses. Patients with TTC showed blunted emotional arousal to mental stress. This study suggests that catecholamine hyper-reactivity and not emotional hyper-reactivity to stress is likely to play a role in myocardial vulnerability in TTC.
Collapse
|
27
|
Lampert R. Behavioral influences on cardiac arrhythmias. Trends Cardiovasc Med 2015; 26:68-77. [PMID: 25983071 DOI: 10.1016/j.tcm.2015.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 04/12/2015] [Accepted: 04/13/2015] [Indexed: 01/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Rachel Lampert
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT.
| |
Collapse
|
28
|
Whitfield V, Havyatt J, Buckley T, Bartrop R, McKinley S, Roche D, Spinaze M, Bramwell M, Tofler G. The complexities of recruiting bereaved family members into a research study in the critical care environment: a discussion paper. Aust Crit Care 2014; 28:77-81. [PMID: 25554542 DOI: 10.1016/j.aucc.2014.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 11/26/2014] [Accepted: 11/27/2014] [Indexed: 11/17/2022] Open
Abstract
Research on the effects of stressful events on human health and wellbeing has progressed in recent years. One such stress, bereavement, is considered one of life's greatest stresses, requiring significant readjustment. The Cardiovascular Risk in Bereavement study (CARBER) investigated in detail cardiovascular risk factors during the first weeks following the death of a partner or adult child in the critical care environment. The purpose of this paper is to explore the once held perception that the bereaved population should not be involved in research, using an actual illustrative project. The paper specifically focuses on the challenges regarding acceptability and feasibility of recruitment of recently bereaved individuals from the critical care environment. The question of whether bereaved individuals have capacity to consent to involvement in research immediately after loss is considered. The appropriateness of asking newly bereaved individuals to participate in research immediately after the death of their relative is also discussed. The work of the research team demonstrates that early recruitment of bereaved family members into a research project is feasible and acceptable to participants, especially when a multidisciplinary collaborative approach is employed and a personal mode of recruitment used.
Collapse
Affiliation(s)
| | | | - Thomas Buckley
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Australia
| | - Roger Bartrop
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Australia
| | | | - Diane Roche
- Royal North Shore Hospital, Sydney, Australia
| | | | | | - Geoffrey Tofler
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Australia
| |
Collapse
|
29
|
Verrier RL, Malik M. Quantitative T-wave alternans analysis for guiding medical therapy: an underexploited opportunity. Trends Cardiovasc Med 2014; 25:201-13. [PMID: 25541329 DOI: 10.1016/j.tcm.2014.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/09/2014] [Accepted: 10/09/2014] [Indexed: 11/18/2022]
Abstract
Reducing the toll of sudden cardiac death (SCD) remains a major challenge in cardiology, as it is the leading cause of adult mortality in the industrially developed world, claiming 310,000 lives annually in the United States alone. The main contemporary noninvasive index of cardiovascular risk, left ventricular ejection fraction (LVEF), has not proved adequately reliable, as the majority of individuals who die suddenly have relatively preserved cardiac mechanical function. Monitoring of T-wave alternans (TWA), a beat-to-beat fluctuation in ST-segment or T-wave morphology, is an attractive approach to risk stratification on both scientific and clinical grounds, as this ECG phenomenon has been shown using the FDA-cleared Spectral and Modified Moving Average methods to assess risk for cardiovascular mortality including SCD in studies enrolling >12,000 individuals with depressed or preserved LVEF. The evidence supporting TWA as a therapeutic target is reviewed.
Collapse
Affiliation(s)
- Richard L Verrier
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.
| | - Marek Malik
- St. Paul׳s Cardiac Electrophysiology, University of London, and Imperial College, London, United Kingdom
| |
Collapse
|
30
|
Wei J, Rooks C, Ramadan R, Shah AJ, Bremner JD, Quyyumi AA, Kutner M, Vaccarino V. Meta-analysis of mental stress-induced myocardial ischemia and subsequent cardiac events in patients with coronary artery disease. Am J Cardiol 2014; 114:187-92. [PMID: 24856319 PMCID: PMC4126399 DOI: 10.1016/j.amjcard.2014.04.022] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 04/23/2014] [Accepted: 04/23/2014] [Indexed: 02/02/2023]
Abstract
Mental stress-induced myocardial ischemia (MSIMI) has been associated with adverse prognosis in patients with coronary artery disease (CAD), but whether this is a uniform finding across different studies has not been described. We conducted a systematic review and meta-analysis of prospective studies examining the association between MSIMI and adverse outcome events in patients with stable CAD. We searched PubMed, EMBASE, Web of Science, and PsycINFO databases for English language prospective studies of patients with CAD who underwent standardized mental stress testing to determine presence of MSIMI and were followed up for subsequent cardiac events or total mortality. Our outcomes of interest were CAD recurrence, CAD mortality, or total mortality. A summary effect estimate was derived using a fixed-effects meta-analysis model. Only 5 studies, each with a sample size of <200 patients and fewer than 50 outcome events, met the inclusion criteria. The pooled samples comprised 555 patients with CAD (85% male) and 117 events with a range of follow-up from 35 days to 8.8 years. Pooled analysis showed that MSIMI was associated with a twofold increased risk of a combined end point of cardiac events or total mortality (relative risk 2.24, 95% confidence interval 1.59 to 3.15). No heterogeneity was detected among the studies (Q=0.39, I2=0.0%, p=0.98). In conclusion, although few selected studies have examined the association between MSIMI and adverse events in patients with CAD, all existing investigations point to approximately a doubling of risk. Whether this increased risk is generalizable to the CAD population at large and varies in patient subgroups warrant further investigation.
Collapse
Affiliation(s)
- Jingkai Wei
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Cherie Rooks
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ronnie Ramadan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Kutner
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| |
Collapse
|
31
|
Child N, Hanson B, Bishop M, Rinaldi CA, Bostock J, Western D, Cooklin M, O'Neil M, Wright M, Razavi R, Gill J, Taggart P. Effect of mental challenge induced by movie clips on action potential duration in normal human subjects independent of heart rate. Circ Arrhythm Electrophysiol 2014; 7:518-23. [PMID: 24833641 DOI: 10.1161/circep.113.000909] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mental stress and emotion have long been associated with ventricular arrhythmias and sudden death in animal models and humans. The effect of mental challenge on ventricular action potential duration (APD) in conscious healthy humans has not been reported. METHODS AND RESULTS Activation recovery intervals measured from unipolar electrograms as a surrogate for APD (n=19) were recorded from right and left ventricular endocardium during steady-state pacing, whilst subjects watched an emotionally charged film clip. To assess the possible modulating role of altered respiration on APD, the subjects then repeated the same breathing pattern they had during the stress, but without the movie clip. Hemodynamic parameters (mean, systolic, and diastolic blood pressure, and rate of pressure increase) and respiration rate increased during the stressful part of the film clip (P=0.001). APD decreased during the stressful parts of the film clip, for example, for global right ventricular activation recovery interval at end of film clip 193.8 ms (SD, 14) versus 198.0 ms (SD, 13) during the matched breathing control (end film left ventricle 199.8 ms [SD, 16] versus control 201.6 ms [SD, 15]; P=0.004). Respiration rate increased during the stressful part of the film clip (by 2 breaths per minute) and was well matched in the respective control period without any hemodynamic or activation recovery interval changes. CONCLUSIONS Our results document for the first time direct recordings of the effect of a mental challenge protocol on ventricular APD in conscious humans. The effect of mental challenge on APD was not secondary to emotionally induced altered respiration or heart rate.
Collapse
Affiliation(s)
- Nicholas Child
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Ben Hanson
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Martin Bishop
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Christopher A Rinaldi
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Julian Bostock
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - David Western
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Michael Cooklin
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Mark O'Neil
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Matthew Wright
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Reza Razavi
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Jaswinder Gill
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.)
| | - Peter Taggart
- From the Department of Cardiology, Guy's and St. Thomas's Hospital, London, United Kingdom (N.C., C.A.R., J.B., M.C., M.O., M.W., R.R., J.G.); Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom (N.C., M.B., R.R.); Department of Mechanical Engineering, University College London, London, United Kingdom (B.H., D.W.); and Neurocardiology Unit, University College London Hospitals, London, United Kingdom (P.T.).
| |
Collapse
|
32
|
Prognostic importance of distressed (Type D) personality and shocks in patients with an implantable cardioverter defibrillator. Int J Cardiol 2013; 167:2705-9. [DOI: 10.1016/j.ijcard.2012.06.114] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/08/2012] [Accepted: 06/24/2012] [Indexed: 11/19/2022]
|
33
|
Peacock J, Whang W. Psychological distress and arrhythmia: risk prediction and potential modifiers. Prog Cardiovasc Dis 2013; 55:582-9. [PMID: 23621968 DOI: 10.1016/j.pcad.2013.03.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- James Peacock
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
| | | |
Collapse
|
34
|
Synowski SJ, Kop WJ, Warwick ZS, Waldstein SR. Effects of glucose ingestion on autonomic and cardiovascular measures during rest and mental challenge. J Psychosom Res 2013; 74:149-54. [PMID: 23332530 DOI: 10.1016/j.jpsychores.2012.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 09/29/2012] [Accepted: 10/21/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND High levels of dietary sugar consumption may result in dysregulated glucose metabolism and lead to elevated cardiovascular disease risk via autonomic nervous system and cardiovascular dysfunction. Altered cardiovascular function can be examined using perturbation tasks such as mental challenge. This study examined the effects of controlled glucose intake on cardiovascular measures at rest and in responses to mental challenge in a laboratory setting. METHOD Using a double blind within-subjects design, participants were monitored at baseline, following ingestion of a glucose or taste-control solution, during structured speech (SS), anger recall (AR) and recovery (N=24, 288 repeated measures; age = 21±2 years). Pre-ejection period (PEP), heart rate (HR), stroke index (SI), cardiac index (CI), blood pressure and total peripheral resistance (TPR) were measured throughout the protocol. RESULTS Glucose resulted in sustained decreased PEP levels compared to control condition (Δ=11.98±9.52 vs. 3.27±7.65 m·s, P<.001) and transient increases in resting HR (P=.011), CI (P=.040) and systolic blood pressure (P=.009). Glucose did not result in increased cardiovascular reactivity to mental challenge tasks, but was associated with a delayed HR recovery following AR (P=.032). CONCLUSION Glucose intake resulted in a drop in PEP indicating increased sympathetic nervous system activity. No evidence was found for glucose-related exaggerated cardiovascular responses to mental challenge. Dysregulated glucose metabolism may result in elevated cardiovascular disease risk as a result of repeated glucose-induced elevations of sympathetic nervous system activity.
Collapse
Affiliation(s)
- Stephen J Synowski
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | |
Collapse
|
35
|
de Morree HM, Szabó BM, Rutten GJ, Kop WJ. Central nervous system involvement in the autonomic responses to psychological distress. Neth Heart J 2013. [PMID: 23184602 DOI: 10.1007/s12471-012-0351-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Psychological distress can trigger acute coronary syndromes and sudden cardiac death in vulnerable patients. The primary pathophysiological mechanism that plays a role in stress-induced cardiac events involves the autonomic nervous system, particularly disproportional sympathetic activation and parasympathetic withdrawal. This article describes the relation between psychological distress and autonomic nervous system function, with a focus on subsequent adverse cardiovascular outcomes. The role of the central nervous system in these associations is addressed, and a systematic review is presented of studies examining the association between stress-induced central nervous system responses measured by neuroimaging techniques and autonomic nervous system activation. Results of the systematic review indicate that the primary brain areas involved in the autonomic component of the brain-heart association are the insula, medial prefrontal cortex, and cerebellum (based on 121 participants across three studies that fitted the inclusion criteria). Other areas involved in stress-induced autonomic modulation are the (anterior) cingulate cortex, parietal cortex, somatomotor cortex/precentral gyrus, and temporal cortex. The interaction between central and autonomic nervous system responses may have implications for further investigations of the brain-heart associations and mechanisms by which acute and chronic psychological distress increase the risk of myocardial infarction, cardiac arrhythmias, and sudden cardiac death.
Collapse
Affiliation(s)
- H M de Morree
- Department of Medical Psychology and Neuropsychology, Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, Warandelaan 2, PO Box 90153, 5000 LE, Tilburg, the Netherlands,
| | | | | | | |
Collapse
|
36
|
Tan AY, Verrier RL. The role of the autonomic nervous system in cardiac arrhythmias. HANDBOOK OF CLINICAL NEUROLOGY 2013; 117:135-45. [PMID: 24095122 DOI: 10.1016/b978-0-444-53491-0.00012-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Autonomic nervous system activity exerts potent and diverse effects on cardiac rhythm through elaborate neurocircuitry that is integrated at multiple levels. Adrenergic activity such as is associated with mental or physical stress or as a reflex response to myocardial ischemia is capable of generating significant rhythm abnormalities including ventricular fibrillation, the arrhythmia responsible for sudden cardiac death. With respect to the ventricles, vagus nerve activity is generally antiarrhythmic as it inhibits the profibrillatory effects of sympathetic nerve activation, whereas atrial arrhythmias generally derive from heightened levels of both vagus and sympathetic nerve activity. Containment of neural influences by pharmacological and electrical targeted neuromodulation is being pursued as an antiarrhythmic modality.
Collapse
Affiliation(s)
- Alex Y Tan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | |
Collapse
|
37
|
Maury P, Extramiana F, Giustetto C, Cardin C, Rollin A, Duparc A, Mondoly P, Denjoy I, Delay M, Messali A, Leenhardt A, Marangoni D. Microvolt T-wave alternans in short QT syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1413-9. [PMID: 22897428 DOI: 10.1111/j.1540-8159.2012.03491.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND T-wave alternans (TWA) is an accepted marker of risk for malignant ventricular arrhythmias, for which prognosis value has been established in different populations. Short QT syndrome (SQTS) is a very rare primary electrical disease carrying the risk of ventricular fibrillation. TWA in SQTS has not been evaluated yet. METHODS Thirteen patients with SQTS (QT = 308 ± 16 ms, QTc = 329 ± 10 ms, heart rate = 69 ± 8 beats/min) underwent microvolt TWA measurement using spectral analysis. TWA testing was performed using Heartwave II (Cambridge Heart™, Inc., Bedford, MA, USA) during bicycle exercice and classified as negative, positive, or indeterminate according to the published standards for clinical interpretation. RESULTS Twelve patients were male (mean age 23 ± 5 years). Five were asymptomatic, three presented with aborted sudden cardiac death, and five with unexplained syncope. Six patients belonged to two unrelated families, while familial cases of SQTS were present for two other patients. A familial history of sudden death (SD) was present for seven patients. Ventricular fibrillation was inducible in three patients. Four patients were implanted with an implantable cardioverter-defibrillator and one presented with polymorphic ventricular tachycardia during follow-up. TWA was negative in each but one patient (indeterminate). Maximal negative heart rate was 118 ± 12 beats/min. Patients with previous SD displayed significant shorter QT and higher resting heart rate compared to the remaining cases. CONCLUSIONS TWA testing is negative in 12 of 13 SQTS patients, even in the symptomatic or inducible ones. Measurement of TWA using conventional protocol and criteria for risk stratification in SQTS seems therefore useless.
Collapse
Affiliation(s)
- Philippe Maury
- University Hospital Rangueil, Toulouse, France University Hospital Bichat Paris, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Kusha M, Masse S, Farid T, Urch B, Silverman F, Brook RD, Gold DR, Mangat I, Speck M, Nair K, Poku K, Meyer C, Mittleman MA, Wellenius GA, Nanthakumar K. Controlled exposure study of air pollution and T-wave alternans in volunteers without cardiovascular disease. ENVIRONMENTAL HEALTH PERSPECTIVES 2012; 120:1157-1161. [PMID: 22552907 PMCID: PMC3440072 DOI: 10.1289/ehp.1104171] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 05/02/2012] [Indexed: 05/31/2023]
Abstract
BACKGROUND Epidemiological studies have assessed T-wave alternans (TWA) as a possible mechanism of cardiac arrhythmias related to air pollution in high-risk subjects and have reported associations with increased TWA magnitude. OBJECTIVE In this controlled human exposure study, we assessed the impact of exposure to concentrated ambient particulate matter (CAP) and ozone (O3) on T-wave alternans in resting volunteers without preexisting cardiovascular disease. METHODS Seventeen participants without preexisting cardiovascular disease were randomized to filtered air (FA), CAP (150 μg/m3), O3 (120 ppb), or combined CAP + O3 exposures for 2 hr. Continuous electrocardiograms (ECGs) were recorded at rest and T-wave alternans (TWA) was computed by modified moving average analysis with QRS alignment for the artifact-free intervals of 20 beats along the V2 and V5 leads. Exposure-induced changes in the highest TWA magnitude (TWAMax) were estimated for the first and last 5 min of each exposure (TWAMax_Early and TWAMax_Late respectively). ΔTWAMax (Late-Early) were compared among exposure groups using analysis of variance. RESULTS Mean ± SD values for ΔTWAMax were -2.1 ± 0.4, -2.7 ± 1.1, -1.9 ± 1.5, and -1.2 ± 1.5 in FA, CAP, O3, and CAP + O3 exposure groups, respectively. No significant differences were observed between pollutant exposures and FA. CONCLUSION In our study of 17 volunteers who had no preexisting cardiovascular disease, we did not observe significant changes in T-wave alternans after 2-hr exposures to CAP, O3, or combined CAP + O3. This finding, however, does not preclude the possibility of pollution-related effects on TWA at elevated heart rates, such as during exercise, or the possibility of delayed responses.
Collapse
Affiliation(s)
- Marjan Kusha
- Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Magrì D, Piccirillo G, Quaglione R, Dell'armi A, Mitra M, Velitti S, Di Barba D, Lizio A, Maisto D, Barillà F. Effect of Acute Mental Stress on Heart Rate and QT Variability in Postmyocardial Infarction Patients. ISRN CARDIOLOGY 2012; 2012:912672. [PMID: 22844616 PMCID: PMC3403409 DOI: 10.5402/2012/912672] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 05/16/2012] [Indexed: 01/08/2023]
Abstract
Emotionally charged events are associated with an increased risk of sudden cardiac death (SCD). In this study we assessed RR and QT variability index (QTVI) at baseline during anger recall test (AR). We calculated QTVI from a 5-min ECG recording and from a 10-beats segment around the presumed maximum sympathetic activation in thirty post-myocardial infarction patients under β-blocker therapy and 10 controls underwent. In all groups, the low-frequency component of RR and SBP increased during AR. In all recordings, the QTVI calculated on a 5-min ECG recording and the QTVI10 beats were higher in patients than in controls (P < 0.05). The QTVI during AR remained unchanged from baseline within each group. Conversely, during AR, the QTVI10 beats in controls diminished significantly (P < 0.05) from baseline whereas in patients remained unchanged. The inability to buffer an acute stress-induced increase in sympathetic activity could explain why events charged with acute stress are associated with an increased risk of ventricular arrhythmias in this setting of patients and support the role of cognitive behavior stress management strategies.
Collapse
Affiliation(s)
- Damiano Magrì
- Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera S. Andrea, "Sapienza" Università degli Studi di Roma, 00185 Rome, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
GREEN DARREN, BATCHVAROV VELISLAV, WIJESEKARA CHANDRAKUMARA, KALRA PHILIPA, CAMM ALANJ. Dialysis-Dependent Changes in Ventricular Repolarization. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:703-10. [DOI: 10.1111/j.1540-8159.2012.03364.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
41
|
Taggart P, Boyett MR, Logantha SJRJ, Lambiase PD. Anger, emotion, and arrhythmias: from brain to heart. Front Physiol 2011; 2:67. [PMID: 22022314 PMCID: PMC3196868 DOI: 10.3389/fphys.2011.00067] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 09/14/2011] [Indexed: 01/01/2023] Open
Abstract
Strong emotion and mental stress are now recognized as playing a significant role in severe and fatal ventricular arrhythmias. The mechanisms, although incompletely understood, include central processing at the cortical and brain stem level, the autonomic nerves and the electrophysiology of the myocardium. Each of these is usually studied separately by investigators from different disciplines. However, many are regulatory processes which incorporate interactive feedforward and feedback mechanisms. In this review we consider the whole as an integrated interactive brain-heart system.
Collapse
Affiliation(s)
- Peter Taggart
- Neurocardiology Research Unit, Department of Medicine, University College LondonLondon, UK
| | - Mark R. Boyett
- Cardiovascular Medicine, University of ManchesterManchester, UK
| | | | - Pier D. Lambiase
- Department of Cardiology, University College London HospitalsLondon, UK
| |
Collapse
|
42
|
Abisse SS, Lampert R, Burg M, Soufer R, Shusterman V. Cardiac repolarization instability during psychological stress in patients with ventricular arrhythmias. J Electrocardiol 2011; 44:678-83. [PMID: 21920534 DOI: 10.1016/j.jelectrocard.2011.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Changes in the autonomic nervous system activity are a major trigger of life-threatening ventricular tachyarrhythmias (VTAs). Mental arithmetic, a condition administered in a laboratory setting, can provide insight into the autonomic nervous system activity effects on cardiac physiology. We examined the responses of cardiac repolarization to laboratory-induced psychological stressors in patients with implantable cardioverter-defibrillators (ICDs) with the objective of identifying the indices that differentiate patients with and without subsequent VTA in follow-up. METHODS Continuous electrocardiographic signals were recorded using 3 standard bipolar (Holter) leads in 56 patients (age, 63.6 ± 11.9; female, 12%; left ventricular ejection fraction, 32.3 ± 11) with ICDs during mental arithmetic. The patients were separated into those with subsequent VTA during 3 to 4 years of follow-up (group 1: n = 9) and those without VTA (group 2: n = 47). Changes in repolarization (QT interval, mean T wave amplitude [Tamp], and T wave area) were analyzed during 5 minutes at baseline, stress, and recovery. The temporal instability of Tamp and T wave area was examined using the range (Δ) and variance (σ(2)) of beat-to-beat variations of the corresponding parameters. RESULTS There were no significant differences in heart rate between the 2 groups at baseline (61 vs 63 beats per minute, P = .97), stress (64 vs 65 beats per minute, P = .40), and recovery (62 vs 61 beats per minute, P = .88). However, during mental stress and poststress recovery, ΔTamp was almost 2-fold greater in group 1 compared with group 2 (111 [57-203] vs 68 [44-94] μV, P = .04, respectively). Changes in QT intervals were also greater in group 1 compared with group 2 (P = .02). CONCLUSION Among patients with ICDs, changes of Tamp after psychological stress were greater in those with subsequent arrhythmic events. This might signal proarrhythmic repolarization response and help identify patients who would benefit the most from ICD implantation and proactive management.
Collapse
Affiliation(s)
- Saddam S Abisse
- Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | |
Collapse
|
43
|
Skinner JE, Anchin JM, Weiss DN. Nonlinear analysis of the heartbeats in public patient ECGs using an automated PD2i algorithm for risk stratification of arrhythmic death. Ther Clin Risk Manag 2011; 4:549-57. [PMID: 18728829 PMCID: PMC2504053 DOI: 10.2147/tcrm.s2521] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Heart rate variability (HRV) reflects both cardiac autonomic function and risk of arrhythmic death (AD). Reduced indices of HRV based on linear stochastic models are independent risk factors for AD in post-myocardial infarct cohorts. Indices based on nonlinear deterministic models have a significantly higher sensitivity and specificity for predicting AD in retrospective data. A need exists for nonlinear analytic software easily used by a medical technician. In the current study, an automated nonlinear algorithm, the time-dependent point correlation dimension (PD2i), was evaluated. The electrocardiogram (ECG) data were provided through an National Institutes of Health-sponsored internet archive (PhysioBank) and consisted of all 22 malignant arrhythmia ECG files (VF/VT) and 22 randomly selected arrhythmia files as the controls. The results were blindly calculated by automated software (Vicor 2.0, Vicor Technologies, Inc., Boca Raton, FL) and showed all analyzable VF/VT files had PD2i < 1.4 and all analyzable controls had PD2i > 1.4. Five VF/VT and six controls were excluded because surrogate testing showed the RR-intervals to contain noise, possibly resulting from the low digitization rate of the ECGs. The sensitivity was 100%, specificity 85%, relative risk > 100; p < 0.01, power > 90%. Thus, automated heartbeat analysis by the time-dependent nonlinear PD2i-algorithm can accurately stratify risk of AD in public data made available for competitive testing of algorithms.
Collapse
|
44
|
Lampert R, Salberg L, Burg M. Emotional stress triggers symptoms in hypertrophic cardiomyopathy: a survey of the Hypertrophic Cardiomyopathy Association. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 33:1047-53. [PMID: 20487360 DOI: 10.1111/j.1540-8159.2010.02770.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Symptoms are among the most important factors impacting quality of life (QOL) in hypertrophic cardiomyopathy (HCM) patients, and reflect a poor prognosis. Whether emotional stress can trigger symptoms of chest pain, dyspnea, palpitations, and lightheadedness has not been described. METHODS Members of the Hypertrophic Cardiomyopathy Association (HCMA) received an electronic link via e-mail to an ongoing online survey, also accessed via links on the HCMA message-board and homepage. Between May 2007 and November 2008, there were 1,297 respondents. The survey queried demographic and self-reported clinical information, and types and triggers of symptoms. Respondents reported physical and emotional QOL on a 1-10 Likert scale. RESULTS Symptoms reported included chest pain (49%), dyspnea (70%), palpitations (61%), and syncope/lightheadedness (59%). The most common symptom trigger was exertion, 64% describing symptoms while climbing stairs or hills. Forty-nine percent described experiencing symptoms during emotional stress. Those reporting chest pain were more likely to report emotion triggering (60%) than those reporting palpitations, syncope/lightheadedness, or dyspnea (50-54% each). Both physical and emotional QOL were significantly decreased in those describing emotion-triggered symptoms. Women were more likely than men to report symptoms overall, as well as emotion-triggered symptoms (50% vs 35%, P < 0.001) and exertion-triggered symptoms (79% vs 58%, P < 0.001). After controlling for presence of symptoms, both emotion- and exertion-triggered symptoms remained significantly more common in women. CONCLUSIONS Triggering of symptoms by emotion is common in individuals with HCM. Further studies will determine pathways linking emotional stressors with chest pain, dyspnea, palpitations, and lightheadedness in these patients.
Collapse
Affiliation(s)
- Rachel Lampert
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA.
| | | | | |
Collapse
|
45
|
Leino J, Verrier RL, Minkkinen M, Lehtimäki T, Viik J, Lehtinen R, Nikus K, Kööbi T, Turjanmaa V, Kähönen M, Nieminen T. Importance of regional specificity of T-wave alternans in assessing risk for cardiovascular mortality and sudden cardiac death during routine exercise testing. Heart Rhythm 2010; 8:385-90. [PMID: 21056698 DOI: 10.1016/j.hrthm.2010.11.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 11/01/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND T-wave alternans (TWA) indicates increased risk for life-threatening arrhythmias. However, the regional distribution and predictivity of TWA among precordial leads remain unknown. OBJECTIVE We analyzed the magnitude and prognostic power of TWA in precordial leads separately and in combination during routine exercise stress testing in the largest TWA study conducted to date. METHODS The Finnish Cardiovascular Study (FINCAVAS) enrolled consecutive patients (n = 3,598, 56 ± 13 [mean ± standard deviation] years old, 2,164 men, 1,434 women) with a clinically indicated exercise test with bicycle ergometer. TWA was analyzed with the time-domain modified moving average method. RESULTS During a follow-up of 55 months (interquartile range of 35-78 months), 231 patients died; 97 deaths were cardiovascular, and 46 were classified as sudden cardiac deaths (SCDs). In Cox analysis after adjustment for common coronary risk factors, each 20-μV increase in TWA in leads V1-V6 multiplied the hazard ratio for cardiovascular mortality by 1.486-fold (95% confidence interval [CI] 1.127-1.952; P = .005). Each 20-μV increase in TWA in lead V5 amplified the hazard ratio for cardiovascular mortality by 1.545 (95% CI 1.150-2.108; P = .004) and for SCD by 1.576 (95% CI 1.041-2.412; P = .033). CONCLUSIONS Maximum TWA monitored from anterolateral precordial lead V5 is the strongest predictor of cardiovascular mortality and SCD during routine exercise testing in our analysis. Higher TWA values indicate greater cardiovascular mortality and SCD risk, supporting the concept that quantification of TWA should receive more attention.
Collapse
|
46
|
Denollet J, Gidron Y, Vrints CJ, Conraads VM. Anger, suppressed anger, and risk of adverse events in patients with coronary artery disease. Am J Cardiol 2010; 105:1555-60. [PMID: 20494661 DOI: 10.1016/j.amjcard.2010.01.015] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 01/13/2010] [Accepted: 01/13/2010] [Indexed: 11/24/2022]
Abstract
Anger is associated with cardiovascular stress reactivity; however, little is known about the effect of suppressed anger in patients with coronary artery disease (CAD). We examined whether patients with CAD who suppress their anger are at risk of adverse events. At baseline, 644 patients with CAD completed measures of anger, anger-in (reluctance to express anger), and Type D personality (tendency to experience distress and to be inhibited). The combination of high anger and anger-in scores was used to identify the presence of suppressed anger. The end points were major adverse cardiac events (a composite of death, myocardial infarction, and revascularization) and cardiac death/myocardial infarction. After an average follow-up of 6.3 years (range 5 to 10), 126 patients (20%) had experienced a major adverse cardiac event, and 59 (9%) had experienced cardiac death or myocardial infarction. Anger (p = 0.009) and suppressed anger (p = 0.011) were associated with future major adverse cardiac events, but these associations were no longer significant after adjustment for clinical characteristics. However, suppressed anger remained associated with the more rigorous end point of cardiac death or myocardial infarction (odds ratio 2.87, 95% confidence interval 1.15 to 7.15, p = 0.024) after controlling for decreased systolic function, poor exercise tolerance, extent of CAD, and revascularization. Anger alone was not independently associated with this end point. Patients with a Type D personality had a fourfold rate of suppressed anger, and an adjustment for a Type D personality attenuated the observed association between suppressed anger and adverse cardiac events. In conclusion, patients with CAD who suppress their anger were at increased risk of adverse cardiac events, and this was accounted for by individual differences in Type D personality.
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW Although anecdotal evidence has long suggested links between emotion and ventricular arrhythmia, more recent studies have prospectively demonstrated the arrhythmogenic effects of anger, as well as mechanisms underlying these effects. RECENT FINDINGS Epidemiological studies reveal that psychological stress increases sudden death, as well as arrhythmias, in patients with implantable cardioverter-defibrillators, in populations during emotionally devastating disasters such as earthquake or war. Diary-based studies confirm that anger and other negative emotions can trigger potentially lethal ventricular arrhythmias. Anger alters electrophysiological properties of the myocardium, including T-wave alternans, a measure of heterogeneity of repolarization, suggesting one mechanistic link between emotion and arrhythmia. Pilot studies of behavioral interventions have shown promise in decreasing arrhythmias in patients with implantable cardioverter-defibrillators. SUMMARY Anger and other strong emotions can trigger polymorphic, potentially life-threatening ventricular arrhythmias in vulnerable patients. Through autonomic changes including increased sympathetic activity and vagal withdrawal, anger leads to increases in heterogeneity of repolarization as measured by T-wave alternans, known to be associated with arrhythmogenesis, as well as increasing inducibility of arrhythmia. Further delineation of mechanisms linking anger and arrhythmia, and of approaches to decrease the detrimental effects of anger and other negative emotions on arrhythmogenesis, are important areas of future investigation.
Collapse
|
48
|
Combined assessment of heart rate recovery and T-wave alternans during routine exercise testing improves prediction of total and cardiovascular mortality: The Finnish Cardiovascular Study. Heart Rhythm 2009; 6:1765-71. [DOI: 10.1016/j.hrthm.2009.08.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 08/12/2009] [Indexed: 11/21/2022]
|
49
|
Shusterman V, McTiernan CF, Goldberg A, Saba S, Salama G, London B. Adrenergic stimulation promotes T-wave alternans and arrhythmia inducibility in a TNF-alpha genetic mouse model of congestive heart failure. Am J Physiol Heart Circ Physiol 2009; 298:H440-50. [PMID: 19940073 DOI: 10.1152/ajpheart.01024.2008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
T-wave alternans (TWA) is a proarrhythmic repolarization instability that is common in congestive heart failure (CHF). Although transgenic mice are commonly used to study the mechanisms of arrhythmogenesis in CHF, little is known about the dynamics of TWA in these species. We hypothesized that TWA is present in a TNF-alpha model of CHF and can be further promoted by adrenergic stimulation. We studied 16 TNF-alpha mice and 12 FVB controls using 1) in vivo intracardiac electrophysiological testing and 2) ambulatory telemetry during 30 min before and after an intraperitoneal injection of isoproterenol. TWA was examined using both linear and nonlinear filtering applied in the time domain. In addition, changes in the mean amplitude of the T wave and area under the T wave were computed. During intracardiac electrophysiological testing, none of the animals had TWA or inducible arrhythmias before the injection of isoproterenol. After the injection, sustained TWA and inducible ventricular tachyarrhythmias were observed in TNF-alpha mice but not in FVB mice. In ambulatory telemetry, before the isoproterenol injection, the cardiac cycle length (CL) was longer in TNF-alpha mice than in FVB mice (98 +/- 9 and 88 +/- 3 ms, P = 0.04). After the injection of isoproterenol, the CL became 8% and 6% shorter in TNF-alpha and FVB mice (P < 10(-4)); however, the 2% difference between the groups in the magnitude of CL changes was not significant. In TNF-alpha mice, the magnitude of TWA was 1.5-2 times greater than in FVB mice both before and after the isoproterenol injection. The magnitude of TWA increased significantly after the isoproterenol injection compared with the baseline in TNF-alpha mice (P = 0.003) but not in FVB mice. The mean amplitude of the T wave and area under the T wave increased 60% and 80% in FVB mice (P = 0.006 and 0.009) but not in TNF-alpha mice. In conclusion, TWA is present in a TNF-alpha model of CHF and can be further promoted by adrenergic stimulation, along with the enhanced susceptibility for ventricular arrhythmias.
Collapse
Affiliation(s)
- Vladimir Shusterman
- Cardiovascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | |
Collapse
|
50
|
Hassan M, Mela A, Li Q, Brumback B, Fillingim RB, Conti JB, Sheps DS. The effect of acute psychological stress on QT dispersion in patients with coronary artery disease. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1178-83. [PMID: 19719496 DOI: 10.1111/j.1540-8159.2009.02462.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND An acute psychological stress can precipitate ventricular arrhythmias and sudden cardiac death in patients with coronary artery disease (CAD). However, the physiologic mechanisms by which these effects occur are not entirely clear. Mental stress-induced myocardial ischemia occurs in a significant percentage of the CAD population. It is unknown if the proarrhythmic effects of psychological stress are mediated through the development of myocardial ischemia. OBJECTIVES To examine the effects of psychological stress on QT dispersion (QTd) among CAD patients and whether these effects are mediated via the development of myocardial ischemia. METHODS Psychological stress was induced using a public speaking task. Twelve-lead electrocardiograms (ECG) were recorded at rest, during mental stress, and during recovery. QTd was calculated as the difference between the longest and the shortest QT interval in the 12-lead ECG. Rest-stress myocardial perfusion imaging was also performed to detect mental stress-induced myocardial ischemia. RESULTS Mental stress induced a significant increase in QTd compared to the resting condition (P < 0.001). This effect persisted beyond the first 10 minutes of recovery (P < 0.001). QTd was significantly associated with the development of mental stress ischemia with ischemic patients having significantly higher QTd during mental stress than nonischemic patients (P = 0.006). This finding remained significant after controlling for possible confounding factors (P = 0.01). CONCLUSION An acute psychological stress induces a significant increase in QTd, which persists for more than 10 minutes after the cessation of the stressor. This effect seems to be, at least partially, mediated by the development of mental stress-induced myocardial ischemia.
Collapse
Affiliation(s)
- Mustafa Hassan
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida, USA.
| | | | | | | | | | | | | |
Collapse
|