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Peng X, Li D, Quan J, Wu C, Li H, Liu E, Hu L, Huang S, Kong L, Chen X, Yang H, Liang H, Wang S, Ma H, Geng Q. A multimodal physiological and psychological dataset for human with mental stress induced myocardial ischemia. Sci Data 2024; 11:704. [PMID: 38937514 PMCID: PMC11211436 DOI: 10.1038/s41597-024-03462-2] [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: 04/14/2023] [Accepted: 06/03/2024] [Indexed: 06/29/2024] Open
Abstract
Accurate differentiation between angina with no obstructive coronary arteries (ANOCA) and mental stress-induced myocardial ischemia (MSIMI) is crucial for tailored treatment strategies, yet public data scarcity hampers understanding. Given the higher incidence of both conditions in women, this study prospectively enrolled 80 female ANOCA and 39 age-matched female controls, subjecting them to three types of mental stress tasks. ECGs were continuously monitored across Rest, Stress, and Recover stages of the mental stress tasks, with PET/CT imaging during the Stress stage to evaluate myocardial perfusion. With PET/CT serving as the gold standard for MSIMI diagnosis, 35 of the 80 ANOCA patients were diagnosed as MSIMI. Using ECG variables from different stages of mental stress tasks, we developed five machine learning models to diagnose MSIMI. The results showed that ECG data from different stages provide valuable information for MSIMI classification. Additionally, the dataset encompassed demographic details, physiological, and blood sample test results of the patients. We anticipate this new dataset will significantly push further progress in ANOCA and MSIMI research.
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Affiliation(s)
- Xiaoting Peng
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Dantong Li
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Jun Quan
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
| | - Chao Wu
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
| | - Huixian Li
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Entao Liu
- Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lianting Hu
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Shuai Huang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Lingcong Kong
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Xuanhui Chen
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Huan Yang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China
| | - Huiying Liang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China.
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China.
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Province, 510080, China.
| | - Shuxia Wang
- Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Huan Ma
- Guangdong Provincial Cardiovascular Institute, Guangzhou, Guangdong Province, 510080, China.
| | - Qingshan Geng
- Department of Cardiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.
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2
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Osei J, Vaccarino V, Wang M, Shah AS, Lampert RJ, Li LY, Ko YA, Pearce BD, Kutner M, Garcia E, Piccinelli M, Raggi P, Bremner JD, Quyyumi AA, Sun YV, Ahmed H, Haddad G, Daaboul O, Roberts T, Stefanos L, Correia L, Shah AJ. Stress-Induced Autonomic Dysfunction is Associated With Mental Stress-Induced Myocardial Ischemia in Patients With Coronary Artery Disease. Circ Cardiovasc Imaging 2024; 17:e016596. [PMID: 38868952 PMCID: PMC11187646 DOI: 10.1161/circimaging.124.016596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/30/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) is associated with adverse cardiovascular outcomes in individuals with coronary artery disease, but the mechanisms underlying this phenomenon are unknown. We examined the relationship between stress-induced autonomic dysfunction, measured by low heart rate variability (HRV) in response to stress, and MSIMI in patients with stable coronary artery disease. We hypothesized that stress-induced autonomic dysfunction is associated with higher odds of MSIMI. METHODS In 735 participants with stable coronary artery disease, we measured high- and low-frequency HRV in 5-minute intervals before and during a standardized laboratory-based speech stressor using Holter monitoring. HRV at rest and stress were categorized into low HRV (first quartile) versus high HRV (second to fourth quartiles); the low category was used as an indicator of autonomic dysfunction. Multivariable logistic regression models were used to examine the association of autonomic dysfunction with MSIMI. RESULTS The mean age was 58 (SD, ±10) years, 35% were women, 44% were Black participants, and 16% developed MSIMI. Compared with high HRV during stress, low HRV during stress (both high and low frequencies) was associated with higher odds of MSIMI after adjusting for demographic and clinical factors (odds ratio for high-frequency HRV, 2.1 [95% CI, 1.3-3.3]; odds ratio for low-frequency HRV, 2.1 [95% CI, 1.3-3.3]). Low-frequency HRV at rest was also associated with MSIMI but with slightly reduced effect estimates. CONCLUSIONS In individuals with coronary artery disease, mental stress-induced autonomic dysfunction may be a mechanism implicated in the causal pathway of MSIMI.
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Affiliation(s)
- Jeffery Osei
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maggie Wang
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anish S. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel J. Lampert
- Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Louis Y. Li
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ernest Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marina Piccinelli
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Hashir Ahmed
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George Haddad
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Obada Daaboul
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tatum Roberts
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lewam Stefanos
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Luis Correia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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3
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Khalil M, Lau HC, Thackeray JT, Mikail N, Gebhard C, Quyyumi AA, Bengel FM, Bremner JD, Vaccarino V, Tawakol A, Osborne MT. Heart-brain axis: Pushing the boundaries of cardiovascular molecular imaging. J Nucl Cardiol 2024; 36:101870. [PMID: 38685398 PMCID: PMC11180568 DOI: 10.1016/j.nuclcard.2024.101870] [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: 02/18/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
Despite decades of research, the heart-brain axis continues to challenge investigators seeking to unravel its complex pathobiology. Strong epidemiologic evidence supports a link by which insult or injury to one of the organs increases the risk of pathology in the other. The putative pathways have important differences between sexes and include alterations in autonomic function, metabolism, inflammation, and neurohormonal mechanisms that participate in crosstalk between the heart and brain and contribute to vascular changes, the development of shared risk factors, and oxidative stress. Recently, given its unique ability to characterize biological processes in multiple tissues simultaneously, molecular imaging has yielded important insights into the interplay of these organ systems under conditions of stress and disease. Yet, additional research is needed to probe further into the mechanisms underlying the heart-brain axis and to evaluate the impact of targeted interventions.
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Affiliation(s)
- Maria Khalil
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Chong Lau
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - James T Thackeray
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland; Center for Molecular Cardiology, University Hospital Zurich, Schlieren, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland; Center for Molecular Cardiology, University Hospital Zurich, Schlieren, Switzerland; Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arshed A Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA, USA
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - J Douglas Bremner
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA, USA; Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Ahmed Tawakol
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael T Osborne
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
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4
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Vaccarino V, Bremner JD. Stress and cardiovascular disease: an update. Nat Rev Cardiol 2024:10.1038/s41569-024-01024-y. [PMID: 38698183 DOI: 10.1038/s41569-024-01024-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/05/2024]
Abstract
Psychological stress is generally accepted to be associated with an increased risk of cardiovascular disease (CVD), but results have varied in terms of how stress is measured and the strength of the association. Additionally, the mechanisms and potential causal links have remained speculative despite decades of research. The physiological responses to stress are well characterized, but their contribution to the development and progression of CVD has received little attention in empirical studies. Evidence suggests that physiological responses to stress have a fundamental role in the risk of CVD and that haemodynamic, vascular and immune perturbations triggered by stress are especially implicated. Stress response physiology is regulated by the corticolimbic regions of the brain, which have outputs to the autonomic nervous system. Variation in these regulatory pathways might explain interindividual differences in vulnerability to stress. Dynamic perturbations in autonomic, immune and vascular functions are probably also implicated as CVD risk mechanisms of chronic, recurring and cumulative stressful exposures, but more data are needed from prospective studies and from assessments in real-life situations. Psychological assessment remains insufficiently recognized in clinical care and prevention. Although stress-reduction interventions might mitigate perceived stress levels and potentially reduce cardiovascular risk, more data from randomized trials are needed.
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Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Department of Radiology and Diagnostic Imaging, Emory University School of Medicine, Atlanta, GA, USA
- Veterans Administration Medical Center, Decatur, GA, USA
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5
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Moazzami K, Garcia M, Sullivan S, Lewis TT, Bremner JD, Razavi AC, Shallenberger L, Sun YV, Raggi P, Shah AJ, Quyyumi AA, Vaccarino V. Association Between Symptoms of Chronic Psychological Distress and Myocardial Ischemia Induced by Mental Stress in Patients With Coronary Artery Disease. J Am Heart Assoc 2023; 12:e030305. [PMID: 37929719 PMCID: PMC10727402 DOI: 10.1161/jaha.123.030305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/15/2023] [Indexed: 11/07/2023]
Abstract
Background Mental stress-induced myocardial ischemia is a frequent phenomenon in patients with coronary artery disease and is associated with a greater risk of future cardiovascular events. The association between chronic symptoms of psychological distress and mental stress-induced ischemia is not clear. Methods and Results We used a composite score of psychological distress derived from symptoms of depression, posttraumatic stress disorder, anxiety, anger, and perceived general stress. Participants underwent myocardial perfusion imaging with both mental (public speaking task) and conventional (exercise or pharmacological) stress testing. Overall, 142 (15.9%) patients experienced mental stress-induced myocardial ischemia. After adjusting for demographic factors, medical history, and medication use, patients in the highest tertile of psychological distress score had 35% higher odds of having mental stress-induced ischemia compared to those in the lowest tertile (odds ratio [OR], 1.35 [95% CI, 1.06-2.22]). Stratified analyses showed that the association between psychological distress score and mental stress-induced myocardial ischemia was significantly associated only within the subgroup of patients with a prior myocardial infraction, with patients with a prior myocardial infarction in the highest tertile having a 93% higher odds of developing myocardial ischemia with mental stress (95% CI, 1.07-3.60). There was no significant association between psychological distress and conventional stress-induced ischemia (OR, 1.19 [95% CI, 0.87-1.63]). Conclusions Among patients with a history of myocardial infarction, a higher level of psychosocial distress is associated with mental stress-induced myocardial ischemia but not with ischemia induced by a conventional stress test.
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Affiliation(s)
- Kasra Moazzami
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Grady Health SystemAtlantaGA
| | - Mariana Garcia
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
| | - Samaah Sullivan
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public HealthThe University of Texas Health Science CenterHoustonTX
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - J. Douglas Bremner
- Atlanta VA Medical CenterDecaturGA
- Department of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaGA
| | - Alexander C. Razavi
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Lucy Shallenberger
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Paolo Raggi
- Mazankowski Alberta Heart InstituteUniversity of AlbertaEdmontonAlbertaCanada
| | - Amit J. Shah
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
- Atlanta VA Medical CenterDecaturGA
| | - Arshed A. Quyyumi
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
| | - Viola Vaccarino
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
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6
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Almuwaqqat Z, Garcia EV, Cooke CD, Garcia M, Shah AJ, Elon L, Ko YA, Sullivan S, Nye J, Van Assen M, De Cecco C, Raggi P, Bremner JD, Quyyumi AA, Vaccarino V. Quantitation of diffuse myocardial ischemia with mental stress and its association with cardiovascular events in individuals with recent myocardial infarction. J Nucl Cardiol 2023; 30:2029-2038. [PMID: 36991249 PMCID: PMC11057358 DOI: 10.1007/s12350-023-03212-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/22/2022] [Indexed: 03/31/2023]
Abstract
Microcirculatory dysfunction during psychological stress may lead to diffuse myocardial ischemia. We developed a novel quantification method for diffuse ischemia during mental stress (dMSI) and examined its relationship with outcomes after a myocardial infarction (MI). We studied 300 patients ≤ 61 years of age (50% women) with a recent MI. Patients underwent myocardial perfusion imaging with mental stress and were followed for 5 years. dMSI was quantified from cumulative count distributions of rest and stress perfusion. Focal ischemia was defined in a conventional fashion. The main outcome was a composite outcome of recurrent MI, heart failure hospitalizations, and cardiovascular death. A dMSI increment of 1 standard deviation was associated with a 40% higher risk for adverse events (HR 1.4, 95% CI 1.2-1.5). Results were similar after adjustment for viability, demographic and clinical factors and focal ischemia. In sex-specific analysis, higher levels of dMSI (per standard deviation increment) were associated with 53% higher risk of adverse events in women (HR 1.5, 95% CI 1.2-2.0) but not in men (HR 0.9, 95% CI 0.5-1.4), P 0.001. A novel index of diffuse ischemia with mental stress was associated with recurrent events in women but not in men after MI.
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Affiliation(s)
- Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA.
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA.
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - C David Cooke
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Mariana Garcia
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Jonathon Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Marly Van Assen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Carlo De Cecco
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - J Douglas Bremner
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
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7
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Bremner JD, Piccinelli M, Garcia EV, Moncayo VM, Elon L, Nye JA, Cooke CD, Washington BP, Ortega RA, Desai SR, Okoh AK, Cheung B, Soyebo BO, Shallenberger LH, Raggi P, Shah AJ, Daaboul O, Jajeh MN, Ziegler C, Driggers EG, Murrah N, De Cecco CN, van Assen M, Krafty RT, Quyyumi AA, Vaccarino V. A Pilot Study of Neurobiological Mechanisms of Stress and Cardiovascular Risk. MEDICAL RESEARCH ARCHIVES 2023; 11:3787. [PMID: 37484871 PMCID: PMC10361343 DOI: 10.18103/mra.v11i4.3787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Objective Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk. Methods Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [18F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain, heart, adipose tissue and aorta with mental stress. Results Patients with mental stress-induced ischemia showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group as a whole, activity increase with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (r=0.69, p=0.038; and r=0.69, p=0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (r=0.71, p=0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Activity in other brain areas not implicated in stress did not show similar correlations. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (r=0.85, p=0.004). Conclusions These findings suggest a link between brain response to stress in key areas mediating emotion and peripheral organs involved in inflammation and hematopoietic activity, as well as myocardial ischemia, in Coronary Heart Disease patients.
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Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Marina Piccinelli
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Ernest V. Garcia
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Valeria M. Moncayo
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Lisa Elon
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Jonathon A. Nye
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - C. David Cooke
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Brianna P. Washington
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Rebeca Alvarado Ortega
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Shivang R. Desai
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Alexis K. Okoh
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Brian Cheung
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Britt O. Soyebo
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | | | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Amit J. Shah
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Obada Daaboul
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | | | - Carrie Ziegler
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | | | - Nancy Murrah
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Carlo N. De Cecco
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
- Department Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
| | - Marly van Assen
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Robert T. Krafty
- Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Arshed A. Quyyumi
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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8
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Sullivan S, Young A, Garcia M, Almuwaqqat Z, Moazzami K, Hammadah M, Lima BB, Hu Y, Jajeh MN, Alkhoder A, Elon L, Lewis TT, Shah AJ, Mehta PK, Bremner JD, Quyyumi AA, Vaccarino V. Sex Differences in Vascular Response to Mental Stress and Adverse Cardiovascular Events Among Patients With Ischemic Heart Disease. Arterioscler Thromb Vasc Biol 2023; 43:e112-e120. [PMID: 36857628 PMCID: PMC10164352 DOI: 10.1161/atvbaha.122.318576] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Microvascular measures of vascular dysfunction during acute mental stress may be important determinants of major adverse cardiovascular events (MACE), especially among younger and middle-aged women survivors of an acute myocardial infarction. METHODS In the MIMS2 study (Myocardial Infarction and Mental Stress 2), individuals who had been hospitalized for a myocardial infarction in the past 8 months were prospectively followed for 5 years. MACE was defined as a composite index of cardiovascular death and first/recurring events for nonfatal myocardial infarction and hospitalizations for heart failure. Reactive hyperemia index and flow-mediated dilation were used to measure microvascular and endothelial function, respectively, before and 30 minutes after a public-speaking mental stress task. Survival models for recurrent events were used to examine the association between vascular response to stress (difference between poststress and resting values) and MACE. Reactive hyperemia index and flow-mediated dilation were standardized in analyses. RESULTS Of 263 patients (the mean age was 51 years; range, 25-61), 48% were women, and 65% were Black. During a median follow-up of 4.3 years, 64 patients had 141 adverse cardiovascular events (first and repeated). Worse microvascular response to stress (for each SD decrease in the reactive hyperemia index) was associated with 50% greater risk of MACE (hazard ratio, 1.50 [95% CI, 1.05-2.13]; P=0.03) among women only (sex interaction: P=0.03). Worse transient endothelial dysfunction in response to stress (for each SD decrease in flow-mediated dilation) was associated with a 35% greater risk of MACE (hazard ratio, 1.35 [95% CI, 1.07-1.71]; P=0.01), and the association was similar in women and men. CONCLUSIONS Peripheral microvascular dysfunction with mental stress was associated with adverse events among women but not men. In contrast, endothelial dysfunction was similarly related to MACE among both men and women. These results suggest a female-specific mechanism linking psychological stress to adverse outcomes.
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Affiliation(s)
- Samaah Sullivan
- Department of Epidemiology, Human Genetics and
Environmental Sciences, The University of Texas Health Science Center at Houston,
Dallas, TX
- Department of Epidemiology, Emory University, Atlanta,
GA
| | - An Young
- Department of Epidemiology, Emory University, Atlanta,
GA
- Department of Medicine, Emory University, Atlanta, GA
| | - Mariana Garcia
- Department of Epidemiology, Emory University, Atlanta,
GA
- Department of Medicine, Emory University, Atlanta, GA
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Emory University, Atlanta,
GA
- Department of Medicine, Emory University, Atlanta, GA
| | - Kasra Moazzami
- Department of Epidemiology, Emory University, Atlanta,
GA
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Bruno B. Lima
- Department of Medicine, Emory University, Atlanta, GA
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Emory
University, Atlanta, GA
| | | | | | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Emory
University, Atlanta, GA
| | - Tené T. Lewis
- Department of Epidemiology, Emory University, Atlanta,
GA
| | - Amit J. Shah
- Department of Epidemiology, Emory University, Atlanta,
GA
- Department of Medicine, Emory University, Atlanta, GA
- Atlanta VA Medical Center, Atlanta, GA
| | - Puja K. Mehta
- Department of Medicine, Emory University, Atlanta, GA
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory
University, Atlanta, GA
- Atlanta VA Medical Center, Atlanta, GA
| | | | - Viola Vaccarino
- Department of Epidemiology, Emory University, Atlanta,
GA
- Department of Medicine, Emory University, Atlanta, GA
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9
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Laou E, Tsitsanoudi E, Alexandrou C, Goupou D, Papanastasiou E, Mermiri M, Chalkias A. Sublingual microcirculatory shock and loss of haemodynamic coherence during subarachnoid anaesthesia. Anaesthesiol Intensive Ther 2023; 55:126-130. [PMID: 37409837 PMCID: PMC10415601 DOI: 10.5114/ait.2023.128707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Affiliation(s)
- Eleni Laou
- Department of Anesthesiology, Agia Sophia Children’s Hospital, Athens, Greece
| | | | | | - Dimitra Goupou
- Faculty of Medicine, University of Thessaly, Larisa, Greece
| | | | - Maria Mermiri
- Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Athanasios Chalkias
- Faculty of Medicine, University of Thessaly, Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, United States
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10
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Henein MY, Vancheri S, Longo G, Vancheri F. The Impact of Mental Stress on Cardiovascular Health—Part II. J Clin Med 2022; 11:jcm11154405. [PMID: 35956022 PMCID: PMC9369438 DOI: 10.3390/jcm11154405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 12/03/2022] Open
Abstract
Endothelial dysfunction is one of the earliest manifestations of atherosclerosis, contributing to its development and progression. Mental stress induces endothelial dysfunction through increased activity of the sympathetic nervous system, release of corticotropin-releasing hormone from the hypothalamus, inhibition of nitric oxide (NO) synthesis by cortisol, and increased levels of pro-inflammatory cytokines. Mental-stress-induced increased output of the sympathetic nervous system and concomitant withdrawal of the parasympathetic inflammatory reflex results in systemic inflammation and activation of a neural–hematopoietic–arterial axis. This includes the brainstem and subcortical regions network, bone marrow activation, release of leukocytes into the circulation and their migration to the arterial wall and atherosclerotic plaques. Low-grade, sterile inflammation is involved in all steps of atherogenesis, from coronary plaque formation to destabilisation and rupture. Increased sympathetic tone may cause arterial smooth-muscle-cell proliferation, resulting in vascular hypertrophy, thus contributing to the development of hypertension. Emotional events also cause instability of cardiac repolarisation due to brain lateralised imbalance of cardiac autonomic nervous stimulation, which may lead to asymmetric repolarisation and arrhythmia. Acute emotional stress can also provoke severe catecholamine release, leading to direct myocyte injury due to calcium overload, known as myocytolysis, coronary microvascular vasoconstriction, and an increase in left ventricular afterload. These changes can trigger a heart failure syndrome mimicking acute myocardial infarction, characterised by transient left ventricular dysfunction and apical ballooning, known as stress (Takotsubo) cardiomyopathy. Women are more prone than men to develop mental-stress-induced myocardial ischemia (MSIMI), probably reflecting gender differences in brain activation patterns during mental stress. Although guidelines on CV prevention recognise psychosocial factors as risk modifiers to improve risk prediction and decision making, the evidence that their assessment and treatment will prevent CAD needs further evaluation.
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Affiliation(s)
- Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden;
- Brunel University, Middlesex, London UB8 3PH, UK
- St. George’s University, London SW17 0RE, UK
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S. Elia Hospital, 93100 Caltanissetta, Italy;
| | - Federico Vancheri
- Department of Internal Medicine, S. Elia Hospital, 93100 Caltanissetta, Italy
- Correspondence:
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11
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It Takes a Village: Expanding Women's Cardiovascular Care to Include the Community as well as Cardiovascular and Primary Care Teams. Curr Cardiol Rep 2022; 24:785-792. [PMID: 35608721 PMCID: PMC9127819 DOI: 10.1007/s11886-022-01700-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 11/12/2022]
Abstract
Purpose of Review Our aim is to highlight some of the current issues that prevent women from getting sex-specific and gender-specific cardiovascular care and provide recommendations for new approaches and delivery models to improve cardiovascular care for all women. Recent Findings Cardiovascular disease remains the number one cause of death for women in the US. Many women remain unaware of cardiovascular risk factors and many healthcare providers who care for women are also poorly informed and feel ill prepared to assess women for cardiovascular risk. Women’s Heart Centers have tried to bridge the gaps in women’s care between primary care and cardiology. Many of the impediments to care in the current models are lack of comprehensive care and socioeconomic societal limitations. Summary New models of care and delivery are essential to change cardiovascular outcomes for all women, especially women at high risk.
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12
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Sara JDS, Toya T, Ahmad A, Clark MM, Gilliam WP, Lerman LO, Lerman A. Mental Stress and Its Effects on Vascular Health. Mayo Clin Proc 2022; 97:951-990. [PMID: 35512885 PMCID: PMC9058928 DOI: 10.1016/j.mayocp.2022.02.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 01/13/2023]
Abstract
Coronary artery disease continues to be a major cause of morbidity and mortality despite significant advances in risk stratification and management. This has prompted the search for alternative nonconventional risk factors that may provide novel therapeutic targets. Psychosocial stress, or mental stress, has emerged as an important risk factor implicated in a higher incidence of cardiovascular events, and although our understanding of this far ranging and interesting phenomenon has developed greatly over recent times, there is still much to be learned regarding how to measure mental stress and how it may impact physical health. With the current coronavirus disease 2019 global pandemic and its incumbent lockdowns and social distancing, understanding the potentially harmful biological effects of stress related to life-changing events and social isolation has become even more important. In the current review our multidisciplinary team discusses stress from a psychosocial perspective and aims to define psychological stress as rigorously as possible; discuss the pathophysiologic mechanisms by which stress may mediate cardiovascular disease, with a particular focus to its effects on vascular health; outline existing methods and approaches to quantify stress by means of a vascular biomarker; outline the mechanisms whereby psychosocial stressors may have their pathologic effects ultimately transduced to the vasculature through the neuroendocrine immunologic axis; highlight areas for improvement to refine existing approaches in clinical research when studying the consequences of psychological stress on cardiovascular health; and discuss evidence-based therapies directed at reducing the deleterious effects of mental stress including those that target endothelial dysfunction. To this end we searched PubMed and Google Scholar to identify studies evaluating the relationship between mental or psychosocial stress and cardiovascular disease with a particular focus on vascular health. Search terms included "myocardial ischemia," "coronary artery disease," "mental stress," "psychological stress," "mental∗ stress∗," "psychologic∗ stress∗," and "cardiovascular disease∗." The search was limited to studies published in English in peer-reviewed journals between 1990 and the present day. To identify potential studies not captured by our database search strategy, we also searched studies listed in the bibliography of relevant publications and reviews.
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Key Words
- cad, coronary artery disease
- cbt, cognitive behavioral therapy
- cvd, cardiovascular disease
- fmd, flow-mediated dilatation
- il, interleukin
- mi, myocardial infarction
- ms, mental stress
- msimi, mental stress induced myocardial ischemia
- pat, peripheral arterial tonometry
- ped, peripheral endothelial dysfunction
- pet, positron emission tomography
- rh, reactive hyperemia
- ses, socioeconomic status
- tnf, tumor necrosis factor
- vsmc, vascular smooth muscle cells
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Affiliation(s)
| | - Takumi Toya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ali Ahmad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Wesley P Gilliam
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Lliach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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13
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Howard S. OLD IDEAS, NEW DIRECTIONS: RE-EXAMINING THE PREDICTIVE UTILITY OF THE HEMODYNAMIC PROFILE OF THE STRESS RESPONSE IN HEALTHY POPULATIONS. Health Psychol Rev 2022; 17:104-120. [PMID: 35452356 DOI: 10.1080/17437199.2022.2067210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The 'reactivity hypothesis' has a long and fruitful history in health psychology and behavioural medicine, with elements of its thesis taken as core and others lost in the plethora of research on its utility as a theory of psychosomatic disease. One such thesis is that the underlying hemodynamic profile of the stress response may be particularly revealing when detailing the impact of psychological stress on the development of cardiovascular disease. This paper re-examines old ideas surrounding the hemodynamic profile of the stress response, asking why its health-predictive properties were never fully explored. Further, this paper reviews the evidence that a vascular profile of stress responding may be especially predictive of disease development, particularly in the case of hypertension. In addition, measurement of hemodynamic profile as well as its known psychosocial moderators are reviewed including how examination of patterns of cardiovascular-stress response adaptation may extend the field. This paper highlights that the extension of the reactivity hypothesis to include both hemodynamic profile and patterns of cardiovascular stress-response adaptation may hold much explanatory power in detailing the impact of how stress responding and stress tolerance promotes disease development.
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Affiliation(s)
- Siobhán Howard
- SASHLab, Centre for Social Issues Research, Department of Psychology, University of Limerick, Ireland.,Health Research Institute, University of Limerick, Ireland
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14
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Bullock-Palmer RP, Peix A, Aggarwal NR. Nuclear Cardiology in Women and Underrepresented Minority Populations. Curr Cardiol Rep 2022; 24:553-566. [PMID: 35262873 DOI: 10.1007/s11886-022-01673-w] [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] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW To outline sex-specific features of coronary artery disease (CAD) that should be considered in the assessment of women, including those from ethnic minority populations with suspected stable ischemic heart disease (IHD). Second, to determine the latest nuclear imaging tools available to assess microvascular CAD. RECENT FINDINGS Latest studies indicate that women are more likely to have ischemia with no obstructive coronary arteries (INOCA) and paradoxically have worse outcomes. Therefore, the evaluation of women with suspected IHD should include assessing microvascular and epicardial coronary circulation. The prevalence of CAD is increasing in younger women due to the increased cardiovascular disease (CVD) risk burden. CAD is often underrecognized in these patients. There is increasing recognition that INOCA is not benign and should be accurately diagnosed and managed. Nuclear imaging assesses the full spectrum of CAD from microvascular CAD to multivessel obstructive epicardial CAD. Further research on myocardial blood flow (MBF) assessment with PET MPI is needed.
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Affiliation(s)
- Renee P Bullock-Palmer
- Department of Cardiology, Deborah Heart and Lung Center, Trenton Road, Browns Mills, NJ, 08015, USA.
| | - Amalia Peix
- Institute of Cardiology and Cardiovascular Surgery, La Habana, Havana, Cuba
| | - Niti R Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, 55902, USA
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15
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Mehta PK, Sharma A, Bremner JD, Vaccarino V. Mental Stress-Induced Myocardial Ischemia. Curr Cardiol Rep 2022; 24:2109-2120. [PMID: 36322365 PMCID: PMC9628301 DOI: 10.1007/s11886-022-01821-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To summarize recent evidence on mental stress-induced myocardial ischemia (MSIMI), its mechanisms, and clinical significance. RECENT FINDINGS MSIMI can occur in patients with normal cardiac stress testing, is only weakly related to severity of coronary artery disease (CAD), and it is often silent. Among patients with CAD, MSIMI is associated with a twofold increased risk of major adverse cardiovascular events compared to those who do not have MSIMI. Certain groups such as young women with myocardial infarction and those with psychological comorbidities are more susceptible to MSIMI. Abnormal microvascular vasoreactivity and inflammation are implicated mechanisms in MSIMI. Increased brain activity in regions that modulate autonomic reactivity to emotional stress and fear is associated with MSIMI. MSIMI has important prognostic implications in patients with CAD. Stress can no longer be ignored as a risk factor in cardiology care. Clinical trials testing effective strategies to target MSIMI are needed.
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Affiliation(s)
- Puja K. Mehta
- grid.189967.80000 0001 0941 6502Division of Cardiology, Emory Women’s Heart Center and Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA 30322 USA
| | - Ashish Sharma
- grid.259906.10000 0001 2162 9738Internal Medicine Residency Program, Mercer University School of Medicine, Macon, GA USA
| | - J. Douglas Bremner
- grid.189967.80000 0001 0941 6502Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA USA ,grid.414026.50000 0004 0419 4084Atlanta VA Medical Center, Decatur, GA USA
| | - Viola Vaccarino
- grid.189967.80000 0001 0941 6502Division of Cardiology, Emory Women’s Heart Center and Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA 30322 USA ,grid.189967.80000 0001 0941 6502Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
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16
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Vaccarino V, Almuwaqqat Z, Kim JH, Hammadah M, Shah AJ, Ko YA, Elon L, Sullivan S, Shah A, Alkhoder A, Lima BB, Pearce B, Ward L, Kutner M, Hu Y, Lewis TT, Garcia EV, Nye J, Sheps DS, Raggi P, Bremner JD, Quyyumi AA. Association of Mental Stress-Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease. JAMA 2021; 326:1818-1828. [PMID: 34751708 PMCID: PMC8579237 DOI: 10.1001/jama.2021.17649] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Mental stress-induced myocardial ischemia is a recognized phenomenon in patients with coronary heart disease (CHD), but its clinical significance in the contemporary clinical era has not been investigated. OBJECTIVE To compare the association of mental stress-induced or conventional stress-induced ischemia with adverse cardiovascular events in patients with CHD. DESIGN, SETTING, AND PARTICIPANTS Pooled analysis of 2 prospective cohort studies of patients with stable CHD from a university-based hospital network in Atlanta, Georgia: the Mental Stress Ischemia Prognosis Study (MIPS) and the Myocardial Infarction and Mental Stress Study 2 (MIMS2). Participants were enrolled between June 2011 and March 2016 (last follow-up, February 2020). EXPOSURES Provocation of myocardial ischemia with a standardized mental stress test (public speaking task) and with a conventional (exercise or pharmacological) stress test, using single-photon emission computed tomography. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of cardiovascular death or first or recurrent nonfatal myocardial infarction. The secondary end point additionally included hospitalizations for heart failure. RESULTS Of the 918 patients in the total sample pool (mean age, 60 years; 34% women), 618 participated in MIPS and 300 in MIMS2. Of those, 147 patients (16%) had mental stress-induced ischemia, 281 (31%) conventional stress ischemia, and 96 (10%) had both. Over a 5-year median follow-up, the primary end point occurred in 156 participants. The pooled event rate was 6.9 per 100 patient-years among patients with and 2.6 per 100 patient-years among patients without mental stress-induced ischemia. The multivariable adjusted hazard ratio (HR) for patients with vs those without mental stress-induced ischemia was 2.5 (95% CI, 1.8-3.5). Compared with patients with no ischemia (event rate, 2.3 per 100 patient-years), patients with mental stress-induced ischemia alone had a significantly increased risk (event rate, 4.8 per 100 patient-years; HR, 2.0; 95% CI, 1.1-3.7) as did patients with both mental stress ischemia and conventional stress ischemia (event rate, 8.1 per 100 patient-years; HR, 3.8; 95% CI, 2.6-5.6). Patients with conventional stress ischemia alone did not have a significantly increased risk (event rate, 3.1 per 100 patient-years; HR, 1.4; 95% CI, 0.9-2.1). Patients with both mental stress ischemia and conventional stress ischemia had an elevated risk compared with patients with conventional stress ischemia alone (HR, 2.7; 95% CI, 1.7-4.3). The secondary end point occurred in 319 participants. The event rate was 12.6 per 100 patient-years for patients with and 5.6 per 100 patient-years for patients without mental stress-induced ischemia (adjusted HR, 2.0; 95% CI, 1.5-2.5). CONCLUSIONS AND RELEVANCE Among patients with stable coronary heart disease, the presence of mental stress-induced ischemia, compared with no mental stress-induced ischemia, was significantly associated with an increased risk of cardiovascular death or nonfatal myocardial infarction. Although these findings may provide insights into mechanisms of myocardial ischemia, further research is needed to assess whether testing for mental stress-induced ischemia has clinical value.
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Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zakaria Almuwaqqat
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeong Hwan Kim
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Muhammad Hammadah
- Emory Clinical Cardiovascular Research Institute, 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
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Atlanta VA Medical Center, Decatur, Georgia
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anish Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ayman Alkhoder
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bruno B. Lima
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ernest V. Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathon Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David S. Sheps
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, Gainesville
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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17
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van der Meer RE, Maas AH. The Role of Mental Stress in Ischaemia with No Obstructive Coronary Artery Disease and Coronary Vasomotor Disorders. Eur Cardiol 2021; 16:e37. [PMID: 34721671 PMCID: PMC8532004 DOI: 10.15420/ecr.2021.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/12/2021] [Indexed: 01/22/2023] Open
Abstract
Ischaemic heart disease has been estimated to affect 126.5 million people globally. Approximately 70% of patients with angina and suspected myocardial ischaemia show no signs of obstructed coronary arteries after coronary angiography, but may still demonstrate ischaemia. Ischaemia with no obstructive coronary artery disease (INOCA) is increasingly acknowledged as a serious condition because of its association with poor quality of life and elevated risk for cardiovascular events. The negative effects of psychological stress on INOCA are gaining more attention. Psychological stress is associated with adverse cardiovascular outcomes such as mental stress-induced myocardial ischaemia. Psychological stress includes anxiety, depression, anger and personality disturbances. Coronary microvascular dysfunction and coronary arterial spasm are phenotypes of coronary vasomotor disorders that are triggered by psychological distress and depression, thereby increasing cardiovascular disease risk. Coronary vasomotor disorders are often co-existent in INOCA patients and might be considered as a contributing factor to mental stress-associated adverse cardiovascular outcomes. Additionally, psychological stress induces endothelial dysfunction more often in (young) women with INOCA than in men. Overall, many studies demonstrate an association between mental stress, coronary microvascular dysfunction and coronary vasospasm in patients with INOCA - especially women. Future research on stress-reducing therapies that target coronary vasomotor disorders in patients with INOCA is needed. This is particularly the case in young adolescents, in whom this type of ischaemic heart disease is increasing.
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Affiliation(s)
| | - Angela Hem Maas
- Department of Cardiology, Radboud University Medical Center Nijmegen, the Netherlands
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18
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McKinnon II, Shah AJ, Lima B, Moazzami K, Young A, Sullivan S, Almuwaqqat Z, Garcia M, Elon L, Bremner JD, Raggi P, Quyyumi AA, Vaccarino V, Lewis TT. Everyday Discrimination and Mental Stress-Induced Myocardial Ischemia. Psychosom Med 2021; 83:432-439. [PMID: 34080584 PMCID: PMC8225242 DOI: 10.1097/psy.0000000000000941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Mental stress-induced myocardial ischemia (MSIMI), a transient myocardial ischemic response to mental stress, is associated with poorer outcomes among patients with coronary heart disease and is more likely to occur among women. However, predictors of MSIMI are not well explored. The current study investigated the association between experiences of everyday discrimination and MSIMI among patients with recent myocardial ischemia and contrasted the results with conventional stress-induced myocardial ischemia (CSIMI). We examined sex differences in associations. METHODS We studied 295 post-MI patients (145 women, 150 men). Provocation of myocardial ischemia with mental stress (speech task) and conventional stress (exercise or pharmacologic) was assessed by myocardial perfusion imaging. Frequency of exposure to everyday discrimination was assessed via questionnaire using the Everyday Discrimination Scale (EDS). RESULTS The mean age was 51 years in both women and men, and the EDS score ranged from 10 to 38 (mean [standard deviation] = 17 [6] years). After multivariable analysis, each standard deviation increase in the EDS score (more frequent exposure) was associated with an increased odds of MSIMI (odds ratio [OR] = 1.57 [1.10-2.23]). The EDS score was not associated with CSIMI (OR = 0.86 [0.64-1.17]). Women demonstrated a twofold increase (OR = 1.96 [1.13-3.38], p = .02) in the adjusted odds of MSIMI, with each standard deviation increase in the EDS score compared with a 1.4-fold increase (OR = 1.40 [0.80-2.44], p = .24) among men; however, interaction was not statistically significant. CONCLUSIONS Among post-MI patients, everyday discrimination was positively associated with occurrence of MSIMI, but not with CSIMI; associations were more pronounced among women.
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Affiliation(s)
- Izraelle I. McKinnon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur, Georgia
| | - Bruno Lima
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - An Young
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zakaria Almuwaqqat
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Mariana Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Lisa Elon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Paolo Raggi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Arshed A. Quyyumi
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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19
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Brain-heart connections in stress and cardiovascular disease: Implications for the cardiac patient. Atherosclerosis 2021; 328:74-82. [PMID: 34102426 PMCID: PMC8254768 DOI: 10.1016/j.atherosclerosis.2021.05.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/05/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022]
Abstract
The influence of psychological stress on the physiology of the cardiovascular system, and on the etiology and outcomes of cardiovascular disease (CVD) has been the object of intense investigation. As a whole, current knowledge points to a "brain-heart axis" that is especially important in individuals with pre-existing CVD. The use of acute psychological stress provocation in the laboratory has been useful to clarify the effects of psychological stress on cardiovascular physiology, immune function, vascular reactivity, myocardial ischemia, neurobiology and cardiovascular outcomes. An emerging paradigm is that dynamic perturbations of physiological and molecular pathways during stress or negative emotions are important in influencing cardiovascular outcomes, and that some patient subgroups, such as women, patients with an early-onset myocardial infarction, and patients with adverse psychosocial exposures, may be at especially high risk for these effects. This review summarizes recent knowledge on mind-body connections in CVD among cardiac patients and highlights important pathways of risk which could become the object of future intervention efforts. As a whole, this research suggests that an integrated study of mind and body is necessary to fully understand the determinants and consequences of CVD.
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20
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Godo S, Suda A, Takahashi J, Yasuda S, Shimokawa H. Coronary Microvascular Dysfunction. Arterioscler Thromb Vasc Biol 2021; 41:1625-1637. [PMID: 33761763 DOI: 10.1161/atvbaha.121.316025] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (S.G., A.S., J.T., S.Y., H.S.)
| | - Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (S.G., A.S., J.T., S.Y., H.S.)
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (S.G., A.S., J.T., S.Y., H.S.)
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (S.G., A.S., J.T., S.Y., H.S.)
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Narita, Japan (H.S.)
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21
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Sex and gender aspects in vascular pathophysiology. Clin Sci (Lond) 2020; 134:2203-2207. [PMID: 32844996 DOI: 10.1042/cs20200876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/11/2020] [Accepted: 08/17/2020] [Indexed: 12/13/2022]
Abstract
Cardiovascular disease (CVD) is a leading cause of global mortality in men and women. The prevalence, pathophysiology, clinical manifestations and outcomes of CVD observed in these two populations is being increasingly recognized as distinct. In this editorial, we provide an overview of mechanisms related to differences in vascular pathophysiology between men and women and explore the contributions of both sex and gender.
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22
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Sullivan S, Young A, Hammadah M, Lima BB, Levantsevych O, Ko YA, Pearce BD, Shah AJ, Kim JH, Moazzami K, Driggers EG, Haffar A, Ward L, Herring I, Hankus A, Lewis TT, Mehta PK, Bremner JD, Raggi P, Quyyumi A, Vaccarino V. Sex differences in the inflammatory response to stress and risk of adverse cardiovascular outcomes among patients with coronary heart disease. Brain Behav Immun 2020; 90:294-302. [PMID: 32916271 PMCID: PMC7872132 DOI: 10.1016/j.bbi.2020.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 12/18/2022] Open
Abstract
Stress may contribute to progression of coronary heart disease (CHD) through inflammation, especially among women. Thus, we sought to examine whether increased inflammatory response to stress among patients with CHD is associated with a greater risk of cardiovascular events and whether this risk is higher in women. We examined inflammatory biomarkers known to increase with mental stress (speech task), including interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and matrix metallopeptidase-9 (MMP-9) among 562 patients with stable CHD. Inflammatory response, the difference between post-stress and resting values, was examined as a predictor of major adverse cardiovascular events (MACE) using subdistribution hazards models for competing risks adjusting for demographics, cardiovascular risk factors, and medications. MACE was defined as a composite endpoint of cardiovascular death, myocardial infarction, unstable angina with revascularization, and heart failure. All biomarkers were standardized. The mean age was 63 years (range 34-79) and 24% were women. During a median follow-up of 3 years, 71 patients experienced MACE. Overall, there was no significant association between inflammatory response to stress and risk of MACE, but there were sex-based interactions for IL-6 (p = 0.001) and MCP-1 (p = 0.01). The risk of MACE increased 56% (HR: 1.56; 95% CI: 1.21, 2.01; p = 0.001) and 30% (HR: 1.30; 95% 1.09, 1.55; p = 0.004) for each standard deviation increase in IL-6 and MCP-1 response to mental stress for women, respectively, while there was no association among men. Increased inflammation in response to stress is associated with future adverse cardiovascular outcomes among women with CHD.
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Affiliation(s)
- Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
| | - An Young
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Oleksiy Levantsevych
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States,Atlanta VA Medical Center, Decatur, Georgia, 30322, United States
| | - Jeong Hwan Kim
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Emily G. Driggers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Ammer Haffar
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | | | - Allison Hankus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Puja K. Mehta
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia, 30322, United States,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Arshed Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
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23
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Mehta PK, Bess C, Elias-Smale S, Vaccarino V, Quyyumi A, Pepine CJ, Bairey Merz CN. Gender in cardiovascular medicine: chest pain and coronary artery disease. Eur Heart J 2020; 40:3819-3826. [PMID: 31713592 DOI: 10.1093/eurheartj/ehz784] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/26/2019] [Accepted: 10/23/2019] [Indexed: 01/10/2023] Open
Abstract
Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality among women and men yet women are more often underdiagnosed, have a delay in diagnosis, and/or receive suboptimal treatment. An implicit gender-bias with regard to lack of recognition of sex-related differences in presentation of IHD may, in part, explain these differences in women compared with men. Indeed, existing knowledge demonstrates that angina does not commonly relate to obstructive coronary artery disease (CAD). Emerging knowledge supports an inclusive approach to chest pain symptoms in women, as well as a more thoughtful consideration of percutaneous coronary intervention for angina in stable obstructive CAD, to avoid chasing our tails. Emerging knowledge regarding the cardiac autonomic nervous system and visceral pain pathways in patients with and without obstructive CAD offers explanatory mechanisms for angina. Interdisciplinary investigation approaches that involve cardiologists, biobehavioural specialists, and anaesthesia/pain specialists to improve angina treatment should be pursued.
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Affiliation(s)
- Puja K Mehta
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Suite 505, Atlanta, GA, USA
| | - Courtney Bess
- J. Willis Hurst Internal Residency Program, Emory University, 49 Jesse Hill Jr Drive, FOB Building, 4th floor, Box #92, Atlanta, GA, USA
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Geert grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, CNR Building, Room 3041, Atlanta, GA, USA
| | - Arshed Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Suite 505, Atlanta, GA, USA
| | - Carl J Pepine
- Divsion of Cardiology, University of Florida, 1329 SW 6th Street, PO Box 100288, Gainesville, FL, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA, USA
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24
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Waheed N, Elias-Smale S, Malas W, Maas AH, Sedlak TL, Tremmel J, Mehta PK. Sex differences in non-obstructive coronary artery disease. Cardiovasc Res 2020; 116:829-840. [PMID: 31958135 DOI: 10.1093/cvr/cvaa001] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/03/2019] [Accepted: 01/13/2020] [Indexed: 12/31/2022] Open
Abstract
Ischaemic heart disease is a leading cause of morbidity and mortality in both women and men. Compared with men, symptomatic women who are suspected of having myocardial ischaemia are more likely to have no obstructive coronary artery disease (CAD) on coronary angiography. Coronary vasomotor disorders and coronary microvascular dysfunction (CMD) have been increasingly recognized as important contributors to angina and adverse outcomes in patients with no obstructive CAD. CMD from functional and structural abnormalities in the microvasculature is associated with adverse cardiac events and mortality in both sexes. Women may be particularly susceptible to vasomotor disorders and CMD due to unique factors such as inflammation, mental stress, autonomic, and neuroendocrine dysfunction, which predispose to endothelial dysfunction and CMD. CMD can be detected with coronary reactivity testing and non-invasive imaging modalities; however, it remains underdiagnosed. This review focuses on sex differences in presentation, pathophysiologic risk factors, diagnostic testing, and prognosis of CMD.
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Affiliation(s)
- Nida Waheed
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Waddah Malas
- Emory Women's Heart Center, Division of Cardiology, Department of Medicine, Emory University, 1462 Clifton Rd, Suite 505, Atlanta, GA 30329, USA
| | - Angela H Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tara L Sedlak
- Leslie Diamond Women's Heart Center, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Puja K Mehta
- Emory Women's Heart Center, Division of Cardiology, Department of Medicine, Emory University, 1462 Clifton Rd, Suite 505, Atlanta, GA 30329, USA
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25
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Research progress regarding the diagnosis and treatment of mental stress-induced myocardial ischemia. Anatol J Cardiol 2020; 24:126-136. [PMID: 32870175 PMCID: PMC7585978 DOI: 10.14744/anatoljcardiol.2020.69447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myocardial ischemia resulting from psychological stress [mental stress-induced myocardial ischemia (MSIMI)] refers to the condition wherein psychosocial and psychological stimulations cause myocardial ischemia in patients with coronary heart disease, which is different from drug-induced myocardial ischemia. Therefore, this condition often escapes diagnosis, portends clinical risk, and affects the quality of life of MSIMI survivors. MSIMI is closely related to the poor prognosis of cardiovascular diseases, especially in young women, according to recent randomized, controlled trials (RCTs) on MSIMI. These RCTs involved different sample sizes, interventional measures, and detection techniques. Moreover, differences exist regarding the prevalence rate, distribution characteristics, possible pathogenesis, and clinical significance. Nevertheless, currently, the diagnostic criteria, pathogenesis, and treatment of MSIMI are still in the clinical exploration stage. Hence, considering recent RCTs, this paper summarizes the research status of MSIMI from the aspects of pathogenesis, diagnosis, and treatment strategies to provide a theoretical basis for the follow-up diagnostic methods and treatment guidelines for MSIMI.
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26
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Vaccarino V, Badimon L, Bremner JD, Cenko E, Cubedo J, Dorobantu M, Duncker DJ, Koller A, Manfrini O, Milicic D, Padro T, Pries AR, Quyyumi AA, Tousoulis D, Trifunovic D, Vasiljevic Z, de Wit C, Bugiardini R. Depression and coronary heart disease: 2018 position paper of the ESC working group on coronary pathophysiology and microcirculation. Eur Heart J 2020; 41:1687-1696. [PMID: 30698764 PMCID: PMC10941327 DOI: 10.1093/eurheartj/ehy913] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/25/2018] [Accepted: 01/03/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road Northeast, Atlanta, GA, 30322, USA
- Department of Medicine (Cardiology), Emory University School of Medicine, 1518 Clifton Road Northeast, Atlanta, GA, 30322, USA
| | - Lina Badimon
- Cardiovascular Program (ICCC), IR-Hospital de la Santa Creu i Sant Pau. CiberCV-Institute Carlos III. Autonomous University of Barcelona, C/ Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive Northeast, Atlanta, GA, 30329, USA
- Department of Radiology, Emory University School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA, 30322, USA
- Atlanta Veterans Administration Medical Center, 670 Clairmont Road, Decatur, GA, 30033, USA
| | - Edina Cenko
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Judit Cubedo
- Cardiovascular Program (ICCC), IR-Hospital de la Santa Creu i Sant Pau. CiberCV-Institute Carlos III. Autonomous University of Barcelona, C/ Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain
| | - Maria Dorobantu
- Cardiology Department, University of Medicine and Pharmacy ‘Carol Davila’ of Bucharest, Emergency Clinical Hospital of Bucharest, Calea Floreasca 8, Sector 1, Bucuresti, 014461, Romania
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus MC, University Medical Center, Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Akos Koller
- Institute of Natural Sciences, University of Physical Education, Alkotas street, 44, 1123, Budapest, Hungary
- Department of Physiology, New York Medical College, Valhalla, NY, 10595, USA
| | - Olivia Manfrini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Davor Milicic
- Department for Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb, Kispaticeva 12, HR-10000, Zagreb, Croatia
| | - Teresa Padro
- Cardiovascular Program (ICCC), IR-Hospital de la Santa Creu i Sant Pau. CiberCV-Institute Carlos III. Autonomous University of Barcelona, C/ Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain
| | - Axel R Pries
- Department of Physiology, Charitè-University Medicine, Thielallee 71, D-14195, Berlin, Germany
| | - Arshed A Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, 1518 Clifton Road Northeast, Atlanta, GA, 30322, USA
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, University of Athens Medical School, Vasilissis Sofias 114, TK 115 28, Athens, Greece
| | - Danijela Trifunovic
- Department of Cardiology, University Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Zorana Vasiljevic
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Cor de Wit
- Institut für Physiologie, Universität zu Lübeck and Deutsches Zentrumfür Herz-Kreislauf-Forschung (DZHK), Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Raffaele Bugiardini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
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27
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Almuwaqqat Z, O'Neal WT, Hammadah M, Lima BB, Bremner JD, Soliman EZ, Shah AJ, Quyyumi AA, Vaccarino V. Abnormal P-wave axis and myocardial ischemia development during mental stress. J Electrocardiol 2020; 60:3-7. [PMID: 32179275 PMCID: PMC7311287 DOI: 10.1016/j.jelectrocard.2020.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/15/2020] [Accepted: 02/29/2020] [Indexed: 01/03/2023]
Abstract
Exposure to psychological stress has been associated with the development of sustained arrhythmias. Acute changes in atrial electrophysiology may serve as intermediate phenotypes for stress-induced atrial arrhythmia such as atrial fibrillation. We examined if acute mental stress was associated with the development of abnormal P-wave axis (aPWA) and the role played by stress-induced myocardial ischemia. A total of 359 patients (mean age = 56 ± 9.9 years; 62% men; 43% white) with stable coronary heart disease and normal baseline P-wave axis (between 0° and 75°) were studied. All patients underwent mental stress testing (speech task). A total of 46 (13%) patients developed abnormal P-wave axis during either stress or recovery (stress: n = 43, 12%; recovery: n = 12, 3%). A rise in heart rate during mental stress was associated with an increased risk of an abnormal P-wave axis (per 5-unit increase: OR = 1.37, 95%CI = 1.03, 1.30). Myocardial ischemia induced by mental stress was associated with an increased risk of aPWA in women (OR = 5.2, 95%CI = 1.7, 15.6) and not in men (OR = 0.1, 95%CI = 0.01, 1.01), p-interaction = 0.004). In conclusion, in a sizable proportion of patients, acute mental stress results in the development of an abnormal P-wave axis, and this phenomenon is related to increases in heart rate and, among women, mental stress-induced ischemia. Our data suggest that acute psychological stress can promote adverse transient electrical changes in the atria that may predispose to AF.
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Affiliation(s)
- Zakaria Almuwaqqat
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Rd, Atlanta, GA 30322, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, United States of America; Emory Clinical Cardiology Research Institute, Emory University, 1462 Clifton Rd, Atlanta, GA 30322, United States of America
| | - Wesley T O'Neal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Rd, Atlanta, GA 30322, United States of America
| | - Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Rd, Atlanta, GA 30322, United States of America
| | - Bruno B Lima
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Rd, Atlanta, GA 30322, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, United States of America
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Dr NE #200, Atlanta, GA 30329, United States of America; Atlanta Veterans Affairs Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, United States of America
| | - Elsayed Z Soliman
- Department of Internal Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston-Salem, Bowman Gray Center for Medical Education, 475 Vine St, Winston-Salem, NC 27101, United States of America; Epidemiological Cardiology Research Center, Wake Forest School of Medicine, Winston-Salem, 475 Vine Street, Winston-Salem, NC 27101, United States of America
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Rd, Atlanta, GA 30322, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, United States of America; Emory Clinical Cardiology Research Institute, Emory University, 1462 Clifton Rd, Atlanta, GA 30322, United States of America; Atlanta Veterans Affairs Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, United States of America
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Rd, Atlanta, GA 30322, United States of America; Emory Clinical Cardiology Research Institute, Emory University, 1462 Clifton Rd, Atlanta, GA 30322, United States of America
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Rd, Atlanta, GA 30322, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, United States of America; Emory Clinical Cardiology Research Institute, Emory University, 1462 Clifton Rd, Atlanta, GA 30322, United States of America.
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Lima BB, Hammadah M, Pearce BD, Shah A, Moazzami K, Kim JH, Sullivan S, Levantsevych O, Lewis TT, Weng L, Elon L, Li L, Raggi P, Bremner JD, Quyyumi A, Vaccarino V. Association of Posttraumatic Stress Disorder With Mental Stress-Induced Myocardial Ischemia in Adults After Myocardial Infarction. JAMA Netw Open 2020; 3:e202734. [PMID: 32286655 PMCID: PMC7156990 DOI: 10.1001/jamanetworkopen.2020.2734] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE Posttraumatic stress disorder (PTSD) is prevalent among patients who survived an acute coronary syndrome and is associated with adverse outcomes, but the mechanisms underlying these associations are unclear. OBJECTIVE To evaluate the association of PTSD with mental stress-induced myocardial ischemia among individuals who survived a myocardial infarction (MI). DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included 303 patients aged 18 to 60 years enrolled from a university-affiliated network. Participants had a verified history of MI within 8 months. Data were collected from June 2011 to March 2016, and data analysis was conducted from March to June 2019. EXPOSURES A clinical diagnosis of PTSD (lifetime and current) was obtained using the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), and PTSD symptom subscales were assessed with the civilian version of the PTSD Symptom Checklist. MAIN OUTCOMES AND MEASURES Patients received technetium 99m-labeled sestamibi myocardial perfusion imaging at rest, with mental stress (ie, a speech task) and conventional stress (ie, exercise or pharmacologic). A summed difference score (ie, the difference between stress and rest scores) was used to assess ischemia under both stress conditions. RESULTS Among 303 participants (148 [48.8%] women; 198 [65.3%] African American; mean [SD] age, 51 [7] years), the prevalence of PTSD was 14.5% (44 patients). Patients with PTSD had a higher rate of ischemia with mental stress than those without PTSD (12 of 44 [27.3%] vs 38 of 259 [14.7%]; P = .04) and more than twice the mean number of ischemic segments (1.2 [95% CI, 0.5-1.8] vs 0.5 [95% CI, 0.3-0.7]; P < .001), but there was no difference in conventional stress ischemia (10 of 44 [22.7%] vs 60 of 259 [23.2%]; P = .91). Increasing levels of PTSD symptoms were associated with higher odds of ischemia with mental stress (adjusted odds ratio [OR] per 5-point score increase, 1.18; 95% CI 1.04-1.35; P = .01) but not with conventional stress (adjusted OR per 5-point score increase, 1.05; 95% CI, 0.92-1.21; P = .47). Reexperiencing trauma was the symptom cluster most robustly associated with the presence of ischemia with mental stress (adjusted OR per 5-point score increase, 1.87; 95% CI 1.21-2.91; P = .005), followed by avoidance and numbing (adjusted OR per 5-point score increase, 1.51; 95% CI, 1.07-2.14; P = .02). CONCLUSIONS AND RELEVANCE In this study of young and middle-aged individuals with MI, with a large representation of women and patients from racial/ethnic minority groups, PTSD was associated with the development of myocardial ischemia with mental stress. A higher ischemic response to mental stress represents a potential pathway associating PTSD with adverse outcomes after MI.
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Affiliation(s)
- Bruno B. Lima
- 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
| | - Muhammad Hammadah
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Amit 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
- Atlanta VA Medical Center, Decatur, Georgia
| | - Kasra Moazzami
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeong Hwan Kim
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Oleksiy Levantsevych
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lei Weng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lian Li
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Departments of Psychiatry, Emory University School of Medicine, Atlanta, Georgia
- Behavioral Sciences and Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 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
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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: 3] [Impact Index Per Article: 0.8] [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.
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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
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Bremner JD, Fani N, Cheema FA, Ashraf A, Vaccarino V. Effects of a mental stress challenge on brain function in coronary artery disease patients with and without depression. Health Psychol 2019; 38:910-924. [PMID: 31380683 PMCID: PMC6746592 DOI: 10.1037/hea0000742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Coronary artery disease (CAD) patients with comorbid depression show an increase in mortality compared to cardiac patients without depression, but the mechanisms mediating this effect remain obscure. One possible explanation for this finding is that depressed patients with CAD exhibit an increased vulnerability to stress. The purpose of this study was to assess the effects of stress and depression on brain function and to explore its relationship with myocardial ischemia in CAD patients. METHODS Patients with CAD and depression (N = 13) and CAD without depression (N = 15) underwent imaging of the brain with positron emission tomography and [O-15] water and imaging of the heart with single photon emission computed tomography (SPECT) and [Tc-99m] sestamibi under mental stress task and control conditions. RESULTS CAD patients with depression compared to nondepressed showed decreased function with mental stress in the rostral anterior cingulate, the hippocampus, parts of the dorsolateral temporal and parietal cortex, the cerebellum, and the uncus, with increased blood flow in the parahippocampus, visual association cortex, and posterior cingulate. Depressed CAD patients who became ischemic during a mental stress task had relative decreases in the caudal and posterior cingulate, orbitofrontal cortex, and cerebellum, and increased activation in the parietal cortex and precuneus/visual association cortex compared to nonischemic depressed CAD patients. CONCLUSIONS These findings are consistent with dysfunction in a network of brain regions involved in the stress response in patients with comorbid CAD and depression that has direct and indirect links to the heart, suggesting a pathway by which stress and depression could lead to increased risk of heart disease related morbidity and mortality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences
| | | | - Ali Ashraf
- Department of Psychiatry and Behavioral Sciences
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Kim JH, Almuwaqqat Z, Hammadah M, Liu C, Ko YA, Lima B, Sullivan S, Alkhoder A, Abdulbaki R, Ward L, Bremner JD, Sheps DS, Raggi P, Sun YV, Shah AJ, Vaccarino V, Quyyumi AA. Peripheral Vasoconstriction During Mental Stress and Adverse Cardiovascular Outcomes in Patients With Coronary Artery Disease. Circ Res 2019; 125:874-883. [PMID: 31550998 PMCID: PMC7134565 DOI: 10.1161/circresaha.119.315005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
RATIONALE Excessive vasoconstriction in response to mental stress may be a potential mechanism by which acute psychological stress leads to adverse cardiac events. OBJECTIVES We investigated whether excessive digital vasoconstriction during acute mental stress predicts adverse cardiovascular outcomes among patients with coronary artery disease. METHODS AND RESULTS Five hundred forty-nine patients with stable coronary artery disease (age 63±9, 76% male, 29% black) underwent mental stress testing with a standardized public speaking stressor and followed prospectively for cardiovascular end points. Digital pulse wave amplitude was continuously measured using peripheral artery tonometry (PAT, Itamar Inc). Stress/rest PAT ratio (sPAT) of pulse wave amplitude during mental stress/baseline was calculated and dichotomized by the median value into low and high sPAT ratio groups. Upon 3-year follow-up, Fine and Gray's subdistribution hazard ratios were used to examine the association between sPAT ratio and the composite end point of cardiovascular death, myocardial infarction, revascularization, and hospitalization for heart failure. The median sPAT ratio was 0.68 (interquartile range, 0.48-0.88), indicating 32% vasoconstriction with mental stress. Men were more likely to have low sPAT ratio than women (odds ratio, 1.79; P=0.007) while those on β-blockers were less likely to have low sPAT ratio (odds ratio, 0.52; P=0.003). After adjusting for demographic and cardiovascular risk factors, medications, and rate-pressure product change during mental stress, those with low sPAT ratio were at significantly higher risk of adverse outcomes (subdistribution hazard ratio, 1.77 [95% CI, 1.12-2.80]). CONCLUSIONS Greater peripheral vasoconstriction with mental stress, denoted by a low sPAT ratio, is associated with a higher risk of adverse cardiovascular outcomes in patients with coronary artery disease.
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Affiliation(s)
- Jeong Hwan Kim
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Zakaria Almuwaqqat
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Muhammad Hammadah
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Chang Liu
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA.,Department of Biostatistics and Bioinformatics (C.L., Y.-A.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics (C.L., Y.-A.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Bruno Lima
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Samaah Sullivan
- Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ayman Alkhoder
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Rami Abdulbaki
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Laura Ward
- Department of Biostatistics and Bioinformatics (C.L., Y.-A.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA.,Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences (J.D.B.), Emory University School of Medicine, Atlanta, GA.,Atlanta VA Medical Center, Decatur, Georgia (J.D.B., A.J.S.)
| | - David S Sheps
- Department of Epidemiology, University of Florida College of Medicine, Gainesville (D.S.S.)
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Yan V Sun
- Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit J Shah
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA.,Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA.,Atlanta VA Medical Center, Decatur, Georgia (J.D.B., A.J.S.)
| | - Viola Vaccarino
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA.,Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Arshed A Quyyumi
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
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Kasher N, Wittbrodt MT, Alam ZS, Lima BB, Nye JA, Campanella C, Ladd S, Hammadah M, Shah AJ, Raggi P, Quyyumi AA, Vaccarino V, Bremner JD. Sex differences in brain activation patterns with mental stress in patients with coronary artery disease. Biol Sex Differ 2019; 10:35. [PMID: 31300046 PMCID: PMC6626382 DOI: 10.1186/s13293-019-0248-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/27/2019] [Indexed: 12/19/2022] Open
Abstract
Background Stress is an important contributor to myocardial ischemia and the progression of coronary artery disease (CAD), and women are more susceptible than men to these effects. Little is known, however, about the neural basis of these sex differences. Methods We investigated sex differences in neural correlates of mental stress in a sample of 53 female and 112 male participants (N = 165) with CAD, with and without mental stress-induced myocardial ischemia (MSI), during exposure to mental arithmetic tasks and public speaking stress tasks using high-resolution positron emission tomography (HR-PET) and radiolabeled water imaging of the brain. Results Women compared to men had significantly greater activation with stress in the right frontal (BA 9, 44), right parietal lobe (Area 3, 6, 40), right posterior cingulate gyrus (BA 31), bilateral cerebellum, and left temporal/fusiform gyrus (BA 37) and greater deactivation in bilateral anterior cingulate gyrus (BA 24, 32), bilateral medial frontal gyrus (BA 6, 8, 9, 10), right parahippocampal gyrus, and right middle temporal gyrus (BA 21). Women with MSI (but not those without MSI) showed significantly greater activation than men in the right posterior cingulate gyrus (BA 31) and greater deactivation in several frontal and temporal lobe areas. Conclusion Men and women with CAD show differences in responses to stress in brain limbic areas that regulate emotion, and these functional responses differ by MSI status. Our results suggest that the cingulate gyrus may be involved in sex differences in MSI. Electronic supplementary material The online version of this article (10.1186/s13293-019-0248-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicole Kasher
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Matthew T Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Zuhayr S Alam
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Bruno B Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine (Cardiology), Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Jonathon A Nye
- Department of Radiology, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Carolina Campanella
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Stacy Ladd
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Muhammad Hammadah
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine (Cardiology), Emory University School of Medicine, Emory University, Atlanta, GA, USA.,Atlanta VA Medical Center, Decatur, GA, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Arshed A Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine (Cardiology), Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta, GA, USA. .,Department of Radiology, Emory University School of Medicine, Emory University, Atlanta, GA, USA. .,Atlanta VA Medical Center, Decatur, GA, USA.
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Wittbrodt MT, Moazzami K, Lima BB, Alam ZS, Corry D, Hammadah M, Campanella C, Ward L, Quyyumi AA, Shah AJ, Vaccarino V, Nye JA, Bremner JD. Early childhood trauma alters neurological responses to mental stress in patients with coronary artery disease. J Affect Disord 2019; 254:49-58. [PMID: 31103906 PMCID: PMC6592739 DOI: 10.1016/j.jad.2019.05.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/08/2019] [Accepted: 05/11/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Early childhood trauma is known to independently increase adverse outcome risk in coronary artery disease (CAD) patients, although the neurological correlates are not well understood. The purpose of this study was to examine whether early childhood trauma alters neural responses to acute mental stress in CAD patients. METHODS Participants (n = 152) with CAD underwent brain imaging with High Resolution Positron Emission Tomography and radiolabeled water during control (verbal counting, neutral speaking) and mental stress (mental arithmetic, public speaking). Traumatic events in childhood were assessed with the Early Trauma Inventory (ETI-SR-SF) and participants were separated by presence (ETI+) or absence (ETI-) of early childhood trauma. Brain activity during mental stress was compared between ETI+ and ETI-. RESULTS Compared to ETI-, ETI+ experienced greater (p < 0.005) activations during mental stress within the left anterior cingulate, bilateral frontal lobe and deactivations (p < 0.005) within the left insula, left parahippocampal gyrus, right dorsal anterior cingulate, bilateral cerebellum, bilateral fusiform gyrus, left inferior temporal gyrus, and right parietal lobe. Significant (p < 0.005) positive correlations between brain activation and ETI-SR-SF scores were observed within the left hippocampus, bilateral frontal lobe, left occipital cuneus, and bilateral temporal lobe. LIMITATIONS Results in non-CAD samples may differ and ETI may be subject to recall bias. CONCLUSION Early childhood trauma exacerbated activations in stress-responsive limbic and cognitive brain areas with direct and indirect connections to the heart, potentially contributing to adverse outcomes in CAD patients.
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Affiliation(s)
- Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zuhayr S. Alam
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Daniel Corry
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Muhammad Hammadah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Carolina Campanella
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Arshed A. Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA,Atlanta VA Medical Center, Decatur, GA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Jonathon A. Nye
- Department of Radiology, Emory University School of Medicine
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA,Department of Radiology, Emory University School of Medicine,Atlanta VA Medical Center, Decatur, GA
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Bremner JD, Campanella C, Khan Z, Shah M, Hammadah M, Wilmot K, Mheid IA, Lima BB, Garcia EV, Nye J, Ward L, Kutner MH, Raggi P, Pearce BD, Shah A, Quyyumi A, Vaccarino V. Brain Correlates of Mental Stress-Induced Myocardial Ischemia. Psychosom Med 2019; 80:515-525. [PMID: 29794945 PMCID: PMC6023737 DOI: 10.1097/psy.0000000000000597] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Coronary artery disease (CAD) is a major cause of morbidity and mortality, and despite important advances in our understanding of this disorder, the underlying mechanisms remain under investigation. Recently, increased attention has been placed on the role of behavioral factors such as emotional stress on CAD risk. Brain areas involved in memory and the stress response, including medial prefrontal cortex, insula, and parietal cortex, also have outputs to the peripheral cardiovascular system. The purpose of this study was to assess the effects of mental stress on brain and cardiac function in patients with CAD. METHODS CAD patients (N = 170) underwent cardiac imaging with [Tc-99m] sestamibi single-photon emission tomography at rest and during a public speaking mental stress task. On another day, they underwent imaging of the brain with [O-15] water positron emission tomography (PET) during mental stress (arithmetic and public speaking) and control conditions. RESULTS Patients with mental stress-induced myocardial ischemia showed increased activation with stress in anterior cingulate, inferior frontal gyrus, and parietal cortex (p < .005). This was seen with both arithmetic stress and public speaking stress. Arithmetic stress was additionally associated with left insula activation, and public speaking with right pre/postcentral gyrus and middle temporal gyrus activation (p < .005). CONCLUSIONS These findings suggest that mental stress-induced myocardial ischemia is associated with activation in brain areas involved in the stress response and autonomic regulation of the cardiovascular system. Altered brain reactivity to stress could possibly represent a mechanism through which stress leads to increased risk of CAD-related morbidity and mortality.
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Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
- Department of Radiology, Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Carolina Campanella
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Zehra Khan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Majid Shah
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Muhammad Hammadah
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Kobina Wilmot
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Ibhar Al Mheid
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Bruno B. Lima
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Ernest V. Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, GA
| | - Jonathon Nye
- Department of Radiology, Emory University School of Medicine, Atlanta, GA
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michael H. Kutner
- Department Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amit Shah
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Arshed Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Abstract
Symptomatic individuals suspected of having myocardial ischemia often have no obstructive atherosclerotic narrowing of epicardial coronary arteries. Abnormal coronary vascular reactivity and, in particular, coronary artery vasospasm (CAS) may be an explanation in a subset of these patients. Psychological factors play an important role in ischemic heart disease, but their role in CAS is not clear; autonomic dysfunction and increased inflammation are two prevailing pathophysiological mechanisms implicated in abnormal coronary reactivity resulting from mental health conditions. Interrelationships between psychological factors, abnormal coronary reactivity, and sex/gender differences are poorly defined in the etiology of CAS. In this issue of Psychosomatic Medicine (2019;81:237-245), Hung et al. report a frequency of less than 0.1% of new-onset CAS in the Taiwanese population, with higher occurrence in women and younger individuals. Patients with CAS had a higher prevalence of previous anxiety and depression compared with those with coronary artery disease and controls, with no sex differences. In this editorial comment, we discuss the potential reasons for underreporting of CAS and the challenges regarding the use of administrative health records for psychosomatic research. In this editorial, a model is presented to explain the association between emotional stressors and mental health factors with CAS, including the role of sympathetic nervous system activation, inflammation, oxidative stress, endothelial dysfunction, and smooth muscle cell dysregulation.
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36
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Sullivan S, Kelli HM, Hammadah M, Topel M, Wilmot K, Ramadan R, Pearce BD, Shah A, Lima BB, Kim JH, Hardy S, Levantsevych O, Obideen M, Kaseer B, Ward L, Kutner M, Hankus A, Ko YA, Kramer MR, Lewis TT, Bremner JD, Quyyumi A, Vaccarino V. Neighborhood poverty and hemodynamic, neuroendocrine, and immune response to acute stress among patients with coronary artery disease. Psychoneuroendocrinology 2019; 100:145-155. [PMID: 30336337 PMCID: PMC6530548 DOI: 10.1016/j.psyneuen.2018.09.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/30/2018] [Accepted: 09/28/2018] [Indexed: 12/29/2022]
Abstract
Living in neighborhoods characterized by poverty may act as a chronic stressor that results in physiological dysregulation of the sympathetic nervous system. No previous study has assessed neighborhood poverty with hemodynamic, neuroendocrine, and immune reactivity to stress. We used data from 632 patients with coronary artery disease. Patients' residential addresses were geocoded and merged with poverty data from the 2010 American Community Survey at the census-tract level. A z-transformation was calculated to classify census tracts (neighborhoods) as either having 'high' or 'low' poverty. Systolic blood pressure, diastolic blood pressure, heart rate, rate-pressure product, epinephrine, interleukin-6, and high-sensitivity C-reactive protein were measured before and after a public speaking stress task. Multilevel models were used for repeated measures and accounting for individuals nested within census tracts. Adjusted models included demographics, lifestyle and medical risk factors, and medication use. Another set of models included propensity scores weighted by the inverse probability of neighborhood status for sex, age, race, and individual-level income. The mean age was 63 years and 173 were women. After adjusting for potential confounders, participants living in high (vs. low) poverty neighborhoods had similar hemodynamic values at rest and lower values during mental stress for systolic blood pressure (157 mmHg vs. 161 mmHg; p = 0.07), heart rate (75 beats/min vs. 78 beats/min; p = 0.02) and rate-pressure product (11839 mmHg x beat/min vs 12579 mmHg x beat/min; p = 0.01). P-values for neighborhood poverty-by-time interactions were <0.05. Results were similar in the propensity weighted models. There were no significant differences in inflammatory and epinephrine responses to mental stress based on neighborhood poverty status. A blunted hemodynamic response to mental stress was observed among participants living in high poverty neighborhoods. Future studies should explore whether neighborhood poverty and blunted hemodynamic response to stress translate into differences in long-term cardiovascular outcomes.
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Affiliation(s)
- Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
| | - Heval M. Kelli
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Matthew Topel
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Kobina Wilmot
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Ronnie Ramadan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA,Atlanta VA Medical Center, Decatur, GA
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Jeong Hwan Kim
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Shakia Hardy
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Oleksiy Levantsevych
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Malik Obideen
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Belal Kaseer
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta,
GA
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta,
GA
| | - Allison Hankus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta,
GA
| | - Michael R. Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA,Departments of Psychiatry and Behavioral Sciences and Radiology, Emory University School of Medicine, Atlanta, GA
| | - Arshed Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
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Bremner JD, Campanella C, Khan Z, Fani N, Kasher N, Evans S, Reiff C, Mishra S, Ladd S, Nye JA, Raggi P, Vaccarino V. Brain mechanisms of stress and depression in coronary artery disease. J Psychiatr Res 2019; 109:76-88. [PMID: 30508746 PMCID: PMC6317866 DOI: 10.1016/j.jpsychires.2018.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/24/2018] [Accepted: 11/20/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Major depression is associated with an increased risk for and mortality from coronary artery disease (CAD), however the mechanisms by which this occurs are not clear. Depression, which is linked to stress, is associated with changes in brain areas involved in memory and the stress response, and it is likely that these regions play an important role in this increased risk. This study assessed the effects of stress on brain and cardiac function in patients with CAD with and without depression. METHODS CAD patients with (N = 17) and without (N = 21) major depression based on the Structured Clinical Interview for DSM-IV (DSM-IV) and/or a Hamilton Depression Scale score of nine or greater underwent imaging of the brain with high resolution positron emission tomography (HR-PET) and [O-15] water and imaging of the heart with single photon emission tomography (SPECT) and [Tc-99 m] sestamibi during mental stress (mental arithmetic) and control conditions. RESULTS Patients with CAD and major depression showed increased parietal cortex activation and a relative failure of medial prefrontal/anterior cingulate activation during mental stress compared to CAD patients without depression. Depressed CAD patients with stress-induced myocardial ischemia, however, when compared to depressed CAD patients without showed increased activation in rostral portions of the anterior cingulate. CONCLUSIONS These findings are consistent with a role for brain areas implicated in stress and depression in the mechanism of increased risk for CAD morbidity and mortality in CAD patients with the diagnosis of major depression.
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Affiliation(s)
- J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA; Department of Radiology, and Internal Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA.
| | | | - Zehra Khan
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Nicole Kasher
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Sarah Evans
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Collin Reiff
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Sanskriti Mishra
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Stacy Ladd
- Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Jonathon A Nye
- Department of Radiology, and Internal Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Viola Vaccarino
- Department of Internal Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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38
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Sex-Specific Association Between Coronary Artery Disease Severity and Myocardial Ischemia Induced by Mental Stress. Psychosom Med 2019; 81:57-66. [PMID: 30571661 PMCID: PMC6800112 DOI: 10.1097/psy.0000000000000636] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE It is unclear whether mental stress-induced myocardial ischemia (MSIMI) is related to obstructive coronary artery disease (CAD). We examined this question and contrasted results with ischemia induced by conventional stress testing (CSIMI). Because women are more susceptible to ischemia without coronary obstruction than men, we examined sex differences. METHODS We studied 276 patients 61 years and younger with recent myocardial infarction. CAD severity was quantified using the log-transformed Gensini Score (lnGS) and the Sullivan Stenosis Score. Patients underwent myocardial perfusion imaging with mental stress (public speaking) and conventional (exercise or pharmacological) stress testing. MSIMI and CSIMI were defined as a new or worsening perfusion defect. RESULTS The prevalence of MSIMI was 15% in men and 20% in women. The median GS for patients with MSIMI was 65.0 in men and 28.5 in women. In logistic regression models adjusted for demographic and cardiovascular risk factors, CAD severity was associated with CSIMI in the full sample (odds ratio [OR] = 1.49, 95% [CI], 1.14-1.95, per 1-unit increase in lnGS), with no significant difference by sex. Although CAD severity was not associated with MSIMI in the entire sample, results differed by sex. CAD severity was associated with MSIMI among men (OR = 1.95, 95% CI, 1.13-3.36, per 1-unit increase in lnGS), but not among women (OR = 1.02, 95% CI, 0.74-1.42, p = .042 for interaction). Analysis using Sullivan Stenosis Score yielded similar results. CONCLUSIONS Findings suggest that CAD severity is related to MSIMI in men but not women. MSIMI in women may therefore be driven by alternative mechanisms such as coronary microvascular disease.
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Lima BB, Hammadah M, Wilmot K, Pearce BD, Shah A, Levantsevych O, Kaseer B, Obideen M, Gafeer MM, Kim JH, Sullivan S, Lewis TT, Weng L, Elon L, Li L, Bremner JD, Raggi P, Quyyumi A, Vaccarino V. Posttraumatic stress disorder is associated with enhanced interleukin-6 response to mental stress in subjects with a recent myocardial infarction. Brain Behav Immun 2019; 75:26-33. [PMID: 30172946 PMCID: PMC6279471 DOI: 10.1016/j.bbi.2018.08.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/08/2018] [Accepted: 08/28/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Posttraumatic Stress Disorder (PTSD) is prevalent among patients who survived an acute coronary syndrome, and is associated with adverse outcomes, but the mechanisms underlying these associations are unclear. Individuals with PTSD have enhanced sensitivity of the noradrenergic system to stress which may lead to immune activation. We hypothesized that survivors of a myocardial infarction (MI) who have PTSD would show an enhanced inflammatory response to acute psychological stress compared to those without PTSD. METHODS Individuals with a verified history of MI within 8 months and a clinical diagnosis of current PTSD underwent a mental stress speech task. Inflammatory biomarkers including interleukin-6 (IL-6), high-sensitivity C reactive protein (HsCRP), matrix metallopeptidase 9 (MMP-9), intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1 and monocyte chemoattractant protein (MCP)-1 were measured at rest and 90 min after mental stress. RESULTS Among 271 patients in the study (mean age 51 ± 7 years, 50% female, 60% African-American), the prevalence of PTSD was 12%. Mental stress resulted in a significant increase in IL-6, but the increase was more marked in patients with PTSD (126% increase) than those without (63% increase) (p = 0.001). MCP-1 showed a modest increase with stress which was similar in patients with PTSD (9% increase) and without PTSD (6% increase) (p = 0.35). CRP did not increase with stress in either group. CONCLUSION MI patients with current PTSD exhibit enhanced IL-6 response to psychosocial stress, suggesting a mechanistic link between PTSD and adverse cardiovascular outcomes as well as other diseases associated with inflammation.
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Affiliation(s)
- Bruno B Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Kobina Wilmot
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Brad D Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Atlanta VA Medical Center, Decatur, GA, United States
| | - Oleksiy Levantsevych
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Belal Kaseer
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Malik Obideen
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Mohamad Mazen Gafeer
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeong Hwan Kim
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Lei Weng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Lian Li
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA, United States; Departments of Psychiatry and Behavioral Sciences and Radiology, Emory University School of Medicine, United States
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Arshed Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States.
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40
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Bacon SL. The Importance of Sex in the Stress-Heart Disease Relationship and the Potential Contribution of Gender to Future Research. Arterioscler Thromb Vasc Biol 2018; 38:290-291. [PMID: 29367230 DOI: 10.1161/atvbaha.117.310461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Simon L Bacon
- From the Montreal Behavioural Medicine Centre, CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; and Department of Exercise Science, Concordia University, Montreal, Quebec, Canada.
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41
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Clayton JA, Arnegard ME. Taking cardiology clinical trials to the next level: A call to action. Clin Cardiol 2018; 41:179-184. [PMID: 29480590 DOI: 10.1002/clc.22907] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/18/2018] [Accepted: 01/22/2018] [Indexed: 12/19/2022] Open
Abstract
Physicians previously perceived heart disease to be a man's disease; yet, since 1984, more women have died of ischemic heart disease. Because women who develop obstructive coronary heart disease and heart failure tend to do so 10 years later than men, cardiology clinical trials that use arbitrary age cutoffs or exclusion criteria based on comorbidities and polypharmacy often limit the pool of potential participants to a greater extent for women. Issues related to trial design and insufficient accounting for female-predominant disease patterns have contributed to low rates of enrollment of women in certain domains of cardiology research. Accordingly, women do not benefit from as rich an evidence base for cardiology as men. Here, we review major sex differences in heart disease and discuss areas of cardiology research in which women have been underrepresented. Considering the widespread sex differences in cardiovascular structure and function, it is important to include balanced numbers of women and men in cardiovascular clinical trials. Beyond inclusion, sex-specific reporting is also essential. Moreover, with ongoing developments of clinical-trial methodology, it is imperative to seek innovative ways to learn as much as possible about how interventions behave in women and men. Adaptive trials are specifically identified as promising opportunities to consider sex-based analyses at interim stages, allowing sex-specific flexibility as these trials unfold. Finally, we emphasize the importance of factoring sex as a biological variable into the design, analysis, and reporting of preclinical research, because this research critically informs the design and execution of clinical trials.
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Affiliation(s)
- Janine A Clayton
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland
| | - Matthew E Arnegard
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland
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42
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Vaccarino V, Sullivan S, Hammadah M, Wilmot K, Al Mheid I, Ramadan R, Elon L, Pimple PM, Garcia EV, Nye J, Shah AJ, Alkhoder A, Levantsevych O, Gay H, Obideen M, Huang M, Lewis TT, Bremner JD, Quyyumi AA, Raggi P. Mental Stress-Induced-Myocardial Ischemia in Young Patients With Recent Myocardial Infarction: Sex Differences and Mechanisms. Circulation 2018; 137:794-805. [PMID: 29459465 PMCID: PMC5822741 DOI: 10.1161/circulationaha.117.030849] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 12/19/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) is frequent in patients with coronary artery disease and is associated with worse prognosis. Young women with a previous myocardial infarction (MI), a group with unexplained higher mortality than men of comparable age, have shown elevated rates of MSIMI, but the mechanisms are unknown. METHODS We studied 306 patients (150 women and 156 men) ≤61 years of age who were hospitalized for MI in the previous 8 months and 112 community controls (58 women and 54 men) frequency matched for sex and age to the patients with MI. Endothelium-dependent flow-mediated dilation and microvascular reactivity (reactive hyperemia index) were measured at rest and 30 minutes after mental stress. The digital vasomotor response to mental stress was assessed using peripheral arterial tonometry. Patients received 99mTc-sestamibi myocardial perfusion imaging at rest, with mental (speech task) and conventional (exercise/pharmacological) stress. RESULTS The mean age of the sample was 50 years (range, 22-61). In the MI group but not among controls, women had a more adverse socioeconomic and psychosocial profile than men. There were no sex differences in cardiovascular risk factors, and among patients with MI, clinical severity tended to be lower in women. Women in both groups showed a higher peripheral arterial tonometry ratio during mental stress but a lower reactive hyperemia index after mental stress, indicating enhanced microvascular dysfunction after stress. There were no sex differences in flow-mediated dilation changes with mental stress. The rate of MSIMI was twice as high in women as in men (22% versus 11%, P=0.009), and ischemia with conventional stress was similarly elevated (31% versus 16%, P=0.002). Psychosocial and clinical risk factors did not explain sex differences in inducible ischemia. Although vascular responses to mental stress (peripheral arterial tonometry ratio and reactive hyperemia index) also did not explain sex differences in MSIMI, they were predictive of MSIMI in women only. CONCLUSIONS Young women after MI have a 2-fold likelihood of developing MSIMI compared with men and a similar increase in conventional stress ischemia. Microvascular dysfunction and peripheral vasoconstriction with mental stress are implicated in MSIMI among women but not among men, perhaps reflecting women's proclivity toward ischemia because of microcirculatory abnormalities.
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Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Samaah Sullivan
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
| | - Muhammad Hammadah
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Kobina Wilmot
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Ibhar Al Mheid
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Ronnie Ramadan
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics (L.E.), Rollins School of Public, Emory University, Atlanta, GA
| | - Pratik M Pimple
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
| | | | | | - Amit J Shah
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
- Atlanta VA Medical Center, Decatur (A.J.S., J.D.B.)
| | - Ayman Alkhoder
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Oleksiy Levantsevych
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Hawkins Gay
- Northwestern University Medical Center, Chicago, IL (H.G.)
| | - Malik Obideen
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
| | - Minxuan Huang
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
| | - Tené T Lewis
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences (J.D.B.), Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur (A.J.S., J.D.B.)
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology (V.V., M.H., K.W., I.A.M., R.R., A.J.S., A.A., O.L., A.A.Q.)
| | - Paolo Raggi
- Department of Epidemiology (V.V., S.S., P.M.P., A.J.S., M.O., M.H., T.T.L., P.R.)
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
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