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Daibes M, Lima BB. Cracking the heart code: using ChatGPT's Data Analyst feature for cardiovascular imaging research. Int J Cardiovasc Imaging 2024:10.1007/s10554-024-03115-w. [PMID: 38652397 DOI: 10.1007/s10554-024-03115-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Mariana Daibes
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bruno B Lima
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Division of Cardiovascular Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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2
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Kim S, Ren H, Charton J, Hu J, Maraboto Gonzalez CA, Khambhati J, Cheng J, DeFrancesco J, Waheed AA, Marciniak S, Moura F, Cardoso RN, Lima BB, McKinney S, Picard MH, Li X, Li Q. Assessment of valve regurgitation severity via contrastive learning and multi-view video integration. Phys Med Biol 2024; 69:045020. [PMID: 38271727 DOI: 10.1088/1361-6560/ad22a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/25/2024] [Indexed: 01/27/2024]
Abstract
Objective. This paper presents a novel approach for addressing the intricate task of diagnosing aortic valve regurgitation (AR), a valvular disease characterized by blood leakage due to incompetence of the valve closure. Conventional diagnostic techniques require detailed evaluations of multi-modal clinical data, frequently resulting in labor-intensive and time-consuming procedures that are vulnerable to varying subjective assessment of regurgitation severity.Approach. In our research, we introduce the multi-view video contrastive network, designed to leverage multiple color Doppler imaging inputs for multi-view video processing. We leverage supervised contrastive learning as a strategic approach to tackle class imbalance and enhance the effectiveness of our feature representation learning. Specifically, we introduce a contrastive learning framework to enhance representation learning within the embedding space through inter-patient and intra-patient contrastive loss terms.Main results. We conducted extensive experiments using an in-house dataset comprising 250 echocardiography video series. Our results exhibit a substantial improvement in diagnostic accuracy for AR compared to state-of-the-art methods in terms of accuracy by 9.60%, precision by 8.67%, recall by 9.01%, andF1-score by 8.92%. These results emphasize the capacity of our approach to provide a more precise and efficient method for evaluating the severity of AR.Significance. The proposed model could quickly and accurately make decisions about the severity of AR, potentially serving as a useful prescreening tool.
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Affiliation(s)
- Sekeun Kim
- Center of Advanced Medical Computing and Analysis, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Hui Ren
- Center of Advanced Medical Computing and Analysis, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jerome Charton
- Center of Advanced Medical Computing and Analysis, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jiang Hu
- Center of Advanced Medical Computing and Analysis, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | | | - Jay Khambhati
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Justin Cheng
- Brigham and Women's Hospital, Boston, MA, United States of America
| | | | - Anam A Waheed
- Brigham and Women's Hospital, Boston, MA, United States of America
| | - Sylwia Marciniak
- Brigham and Women's Hospital, Boston, MA, United States of America
| | - Filipe Moura
- Brigham and Women's Hospital, Boston, MA, United States of America
| | | | - Bruno B Lima
- Brigham and Women's Hospital, Boston, MA, United States of America
| | - Suzannah McKinney
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Michael H Picard
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Xiang Li
- Center of Advanced Medical Computing and Analysis, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Quanzheng Li
- Center of Advanced Medical Computing and Analysis, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
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3
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Lima BB, Benz DC. Casting aside the creep: harnessing cardiorespiratory dynamics to optimize myocardial flow assessment in cardiac PET. J Nucl Cardiol 2023; 30:2301-2302. [PMID: 37731013 DOI: 10.1007/s12350-023-03376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Bruno B Lima
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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Buto PT, Shah A, Pearce BD, Lima BB, Almuwaqqat Z, Martini A, Al-Abboud O, Tarlapally N, Sullivan S, Sun YV, Murrah NV, Driggers E, Shallenberger L, Lewis TT, Elon L, Bremner JD, Raggi P, Quyyumi A, Vaccarino V. Association of systemic inflammation with posttraumatic stress disorder after a myocardial infarction. Brain Behav Immun Health 2023; 30:100629. [PMID: 37396337 PMCID: PMC10308211 DOI: 10.1016/j.bbih.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 07/04/2023] Open
Abstract
Background Adverse mental health conditions including depression, posttraumatic stress disorder (PTSD), and anxiety are prevalent among patients who survive myocardial infarctions (MI) and are associated with adverse outcomes. The mechanisms underlying these associations, however, are not well understood. Inflammatory pathways may mediate the cardiovascular outcomes of patients with mental health disorders. We examined the bidirectional association between PTSD symptoms and inflammatory biomarkers in a young/middle-aged post MI population. We further examined how this association may differ between women and men as well as between Black and non-Black individuals. Methods Participants included individuals with early onset MI between the ages 25 and 60. Mental health scores for depression, PTSD, perceived stress, and anxiety as well as inflammatory biomarkers, interleukin-6 (IL-6) and high sensitivity C-reactive protein (hsCRP), were collected at baseline and at six-month follow up. We examined the bidirectional changes in mental health symptoms and inflammatory biomarkers between baseline and follow-up. Results Among 244 patients in the study (mean age: 50.8, 48.4% female, 64.3% Black), the geometric means for IL-6 level and hsCRP at rest were 1.7 pg/mL and 2.76 mg/L, respectively. Mental health scores at baseline did not consistently predict changes in inflammatory biomarkers at follow-up. However, baseline levels of both IL-6 and hsCRP were robustly associated with an increase in re-experiencing PTSD symptoms at 6 months: in adjusted linear mixed models, there was a 1.58-point increase in re-experiencing PTSD symptoms per unit of baseline hsCRP (p = 0.01) and 2.59-point increase per unit of baseline IL-6 (p = 0.02). Once the analysis was stratified by race, the association was only noted in Black individuals. Baseline inflammation was not associated with change in any of the other mental health symptom scores. Conclusion Markers of inflammation are associated with an increase in post-event PTSD symptoms in younger or middle-aged patients who experienced an MI, especially Black patients. These results suggest a mechanistic link between inflammation and the development of PTSD among individuals with cardiovascular disease.
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Affiliation(s)
- Peter T. Buto
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amit Shah
- 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
- Atlanta VA Health Care System, Decatur, GA, USA
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bruno B. Lima
- 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
| | - Zakaria Almuwaqqat
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Afif Martini
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Omar Al-Abboud
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nitya Tarlapally
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center, Houston, TX, USA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Atlanta VA Health Care System, Decatur, GA, USA
| | - Nancy V. Murrah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Emily Driggers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lucy Shallenberger
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - J. Douglas Bremner
- Atlanta VA Health Care System, Decatur, GA, USA
- Departments of Psychiatry and Behavioral Sciences and Radiology, Emory University School of Medicine, USA
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- 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, USA
| | - 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
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Okoh AK, Young A, Garcia M, Sullivan S, Almuwaqqat Z, Hu Y, Liu C, Moazzami K, Uphoff I, Lima BB, Ko YA, Elon L, Jajeh N, Rout P, Gupta S, Shah AJ, Bremner JD, Lewis T, Quyyumi A, Vaccarino V. Racial Differences in Mental Stress-Induced Transient Endothelial Dysfunction and Its Association With Cardiovascular Outcomes. Psychosom Med 2023; 85:431-439. [PMID: 37053106 PMCID: PMC10239336 DOI: 10.1097/psy.0000000000001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE This study aimed to investigate differences in transient endothelial dysfunction (TED) with mental stress in Black and non-Black individuals with coronary heart disease (CHD), and their potential impact on cardiovascular outcomes. METHODS We examined 812 patients with stable CHD between June 2011 and March 2016 and followed through February 2020 at a university-affiliated hospital network. Flow-mediated vasodilation (FMD) was assessed before and 30 minutes after mental stress. TED was defined as a lower poststress FMD than prestress FMD. We compared prestress FMD, post-stress FMD, and TED between Black and non-Black participants. In both groups, we examined the association of TED with an adjudicated composite end point of cardiovascular death or nonfatal myocardial infarction (first and recurring events) after adjusting for demographic, clinical, and socioeconomic factors. RESULTS Prestress FMD was lower in Black than non-Black participants (3.7 [2.8] versus 4.9 [3.8], p < .001) and significantly declined with mental stress in both groups. TED occurred more often in Black (76%) than non-Black patients (67%; multivariable-adjusted odds ratio = 1.6, 95% confidence interval = 1.5-1.7). Over a median (interquartile range) follow-up period of 75 (65-82) months, 142 (18%) patients experienced either cardiovascular death or nonfatal myocardial infarction. Black participants had a 41.9% higher risk of the study outcome than non-Black participants (95% confidence interval = 1.01-1.95). TED with mental stress explained 69% of this excess risk. CONCLUSIONS Among CHD patients, Black individuals are more likely than non-Black individuals to develop endothelial dysfunction with mental stress, which in turn explains a substantial portion of their excess risk of adverse events.
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Affiliation(s)
- Alexis K Okoh
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - An Young
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Mariana Garcia
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zakaria Almuwaqqat
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Chang Liu
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Kasra Moazzami
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Irina Uphoff
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Bruno B. Lima
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Nour Jajeh
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Pratik Rout
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Shishir Gupta
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Atlanta VA Medical Center, Decatur, GA
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Tene Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Arshed Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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Lima BB, Cuddy SAM. Myocardial perfusion imaging in anomalous coronary arteries: do we know who to refer for cardiac surgery? J Nucl Cardiol 2023; 30:790-791. [PMID: 36369626 DOI: 10.1007/s12350-022-03127-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Bruno B Lima
- Division of Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02116, USA
| | - Sarah A M Cuddy
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02116, USA.
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7
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sullivan S, Young A, Garcia M, Almuwaqqat Z, Moazzami K, Hammadah M, Lima BB, Hu Y, Alkhalaf M, Jajeh MN, Alkhoder A, Elon L, Lewis TT, Shah AJ, Mehta PK, Bremner JD, Quyyumi AA, Vaccarino V. Abstract P407: Sex Differences in Microvascular Response to Mental Stress and Adverse Cardiovascular Events Among Patients With Ischemic Heart Disease. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Introduction:
Microvascular dysfunction during acute mental stress may be an important determinant of major adverse cardiovascular outcomes (MACE) especially among middle-aged women survivors of an acute myocardial infarction (MI).
Hypothesis:
There are sex differences in the association between microvascular dysfunction and MACE.
Methods:
The Myocardial Infarction and Mental Stress Study 2 enrolled individuals who had been hospitalized for an MI in the past 8 months at the age of 60 years or younger, with an oversampling of women. Reactive hyperemia index (RHI) was used to measure digital microvascular function before and 30 minutes after a public-speaking mental stress task. This assessment was contrasted with macrovascular endothelial function at the brachial artery through flow-mediated dilation (FMD). Participants were followed for 5-years, and MACE was defined as a composite of cardiovascular death, first/recurring events for nonfatal MI, and hospitalizations for heart failure. Cox proportional hazards models were used to examine vascular response to stress (difference between post-stress and resting values) and MACE adjusting for demographics, clinical risk factors, medications, psychological factors, and mental stress ischemia. Lower RHI and FMD values are indicative of greater microvascular and endothelial dysfunction, respectively.
Results:
Of 263 participants, the mean age was 51 years and 48% were women. There were 64 patients with 141 adverse cardiovascular events (first and repeated). In the overall sample, there was no significant association between microvascular response to stress and MACE, but there was a significant interaction with sex (p = 0.03). Each standard deviation decrease in RHI response to stress was associated with 50% greater risk of MACE (HR: 1.50, 95% CI: 1.05, 2.13) among women only, while no association was observed in men (HR 0.93, 95% CI: 0.69, 1.26). Transient endothelial dysfunction in response to stress (for each standard deviation decrease in FMD) was associated with 35% greater risk of MACE (HR: 1.35; 95% CI: 1.07, 1.71), and was similar in women and men.
Conclusions:
Peripheral microvascular dysfunction with mental stress is associated with MACE among women but not among men. In contrast, brachial artery endothelial dysfunction is similarly related to MACE among both men and women. These results suggest that microvascular dysfunction is a female-specific mechanism linking psychological stress to adverse outcomes.
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Sullivan S, Young A, Garcia M, Almuwaqqat Z, Moazzami K, Hammadah M, Lima BB, Driggers EG, Levantsevych O, Alkhalaf M, Jajeh MN, Alkhoder A, Elon L, Gooding H, Lewis TT, Shah AJ, Bremner JD, Quyyumi AA, Vaccarino V. Gender Disparities Between Neighborhood Social Vulnerability and Psychological Distress Among Patients with Heart Disease. J Womens Health (Larchmt) 2022; 31:1440-1449. [PMID: 35960809 PMCID: PMC9618377 DOI: 10.1089/jwh.2021.0505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Psychological stress disorders are twice as prevalent in women with ischemic heart disease compared to men. The disproportionate psychological health experience of these women is not well understood. The objective of this study was to examine whether neighborhood social factors are associated with disparities in psychological health by gender. Materials and Methods: We studied 286 patients with heart disease recruited from Emory-based hospitals in the Myocardial Infarction and Mental Stress 2 Study (n = 286). A global measure of psychological distress was calculated by taking an average of ranks across symptom scales for depression, post-traumatic stress disorder, anxiety, anger, and perceived stress. The social vulnerability index (SVI) was developed by the Centers for Disease Control and Prevention and was used to rank patients' census tracks on 14 social factors. Beta coefficients for mean ranks in psychological distress scores were estimated per 10-unit increase in SVI percentile ranking using multilevel regression models. Results: The mean age of the sample was 51 years, 49% were women, and 66% African American. After adjusting for demographics, cardiovascular risk factors, and antidepressant use, each 10-unit increase in SVI percentile ranking was associated with 4.65 (95% CI: 0.61-8.69; p = 0.02) unit increase in mean scores for psychological distress among women only (SVI-by-gender-interaction = 0.01). These associations were driven by the SVI themes of lower socioeconomic status and poorer access to housing and transportation. Conclusion: Neighborhood social vulnerability may be a psychosocial stressor that potentiates women's susceptibility to adverse psychological and cardiovascular health.
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Affiliation(s)
- Samaah Sullivan
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health-Dallas Campus, The University of Texas Health Science Center at Houston, Dallas, Texas, USA
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
| | - An Young
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Mariana Garcia
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Kasra Moazzami
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Bruno B. Lima
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Emily G. Driggers
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Ayman Alkhoder
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, and Emory University, Atlanta, Georgia, USA
| | - Holly Gooding
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Tené T. Lewis
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
| | - Amit J. Shah
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
- Atlanta VA Medical Center, Atlanta, Georgia, USA
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
- Atlanta VA Medical Center, Atlanta, Georgia, USA
| | | | - Viola Vaccarino
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
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10
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Vaccarino V, Shah AJ, Moncayo V, Nye J, Piccinelli M, Ko YA, Ma X, Murrah N, Shallenberger L, Driggers E, Levantsevych OM, Hammadah M, Lima BB, Young A, O'Neal W, Alkhalaf M, Haffar A, Raggi P, Goldberg J, Smith NL, Garcia EV, Quyyumi AA, Bremner JD. Posttraumatic Stress Disorder, Myocardial Perfusion, and Myocardial Blood Flow: A Longitudinal Twin Study. Biol Psychiatry 2022; 91:615-625. [PMID: 34865854 PMCID: PMC8918004 DOI: 10.1016/j.biopsych.2021.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/31/2021] [Accepted: 09/17/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND The link between posttraumatic stress disorder (PTSD) and ischemic heart disease remains elusive owing to a shortage of longitudinal studies with a clinical diagnosis of PTSD and objective measures of cardiac compromise. METHODS We performed positron emission tomography in 275 twins who participated in two examinations approximately 12 years apart. At both visits, we obtained a clinical diagnosis of PTSD, which was classified as long-standing (both visit 1 and visit 2), late onset (only visit 2), and no PTSD (no PTSD at both visits). With positron emission tomography, we assessed myocardial flow reserve (MFR), which, in absence of significant coronary stenoses, indexes coronary microvascular function. We compared positron emission tomography data at visit 2 across the three categories of longitudinally assessed PTSD and examined changes between the two visits. RESULTS Overall, 80% of the twins had no or minimal obstructive coronary disease. Yet, MFR was depressed in twins with PTSD and was progressively lower across groups with no PTSD (2.13), late-onset PTSD (1.97), and long-standing PTSD (1.93) (p = .01). A low MFR (a ratio <2.0) was present in 40% of the twins without PTSD, in 56% of those with late-onset PTSD, and in 72% of those with long-standing PTSD (p < .001). Associations persisted in multivariable analysis, when examining changes in MFR between visit 1 and visit 2, and within twin pairs. Results were similar by zygosity. CONCLUSIONS Longitudinally, PTSD is associated with reduced coronary microcirculatory function and greater deterioration over time. The association is especially noted among twins with chronic, long-standing PTSD and is not confounded by shared environmental or genetic factors.
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Affiliation(s)
- 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.
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Atlanta Veterans Affairs Health Care System, Decatur, Georgia
| | - Valeria Moncayo
- 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
| | - Marina Piccinelli
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Xin Ma
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nancy Murrah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lucy Shallenberger
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Emily Driggers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Oleksiy M Levantsevych
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Muhammad Hammadah
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bruno B Lima
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - An Young
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Wesley O'Neal
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mhmtjamil Alkhalaf
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ammer Haffar
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Jack Goldberg
- Seattle Epidemiologic Research and Information Center, United States Department of Veterans Affairs Office of Research and Development, Seattle, Washington
| | - Nicholas L Smith
- Seattle Epidemiologic Research and Information Center, United States Department of Veterans Affairs Office of Research and Development, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - J Douglas Bremner
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia; Atlanta Veterans Affairs Health Care System, Decatur, Georgia
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11
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Almuwaqqat Z, Wittbrodt MT, Moazzami K, Nye JA, Lima BB, Shah AJ, Alkhalaf J, Pearce B, Sun YV, Quyyumi AA, Vaccarino V, Bremner JD. Neural correlates of stress and leucocyte telomere length in patients with coronary artery disease. J Psychosom Res 2022; 155:110760. [PMID: 35217318 PMCID: PMC8940678 DOI: 10.1016/j.jpsychores.2022.110760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Accelerated biological aging, as indicated by telomere shortening, is associated with CAD pathogenesis. In a cross-sectional study, we investigated neural correlates of acute psychological stress and short telomeres in patients with CAD. METHODS Individuals with CAD (N = 168) underwent a validated mental stress protocol including public speaking and mental arithmetic. Imaging of the brain with [O-15] water and high-resolution positron emission tomography (HR-PET) was performed during mental stress and control conditions. Blood flow during stressful tasks (average of speech and arithmetic) and control tasks were assessed. Telomere length in peripheral leucocytes was measured by quantitative polymerase chain reaction and expressed as Telomere/Single Copy Gene (T/S) ratio. Voxel-wise regression models were constructed to assess the association between brain areas and activity during rest and mental stress after adjustments for demographic factors and clinical characteristics. RESULTS The mean (SD) age of the sample was 62 (8) years, and 69% were men. Increased activation with mental stress in the lingual gyrus, cerebellum and superior and inferior frontal gyri were associated with reduced telomere length; 1.6 higher voxel activation of these areas was associated with 0.1 T/S-units reduction in telomere length (P < 0.005). Additionally, during neutral counting and speaking tasks, brain activity in the precentral, middle and superior frontal and middle temporal gyri was inversely associated with telomere length. Results remained consistent after adjustment for demographic and clinical risk factors. CONCLUSION Increased stress-induced activity in brain areas mediating the stress response was associated with shortened telomere length in CAD patients.
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Affiliation(s)
- Zakaria Almuwaqqat
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Matthew T Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, United States of America
| | - Kasra Moazzami
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Jonathan A Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Bruno B Lima
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America; Atlanta VA Medical Center, Decatur, Georgia
| | - Jamil Alkhalaf
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Yan V Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, United States of America; Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America; Atlanta VA Medical Center, Decatur, Georgia.
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Garcia M, Almuwaqqat Z, Moazzami K, Young A, Lima BB, Sullivan S, Kaseer B, Lewis TT, Hammadah M, Levantsevych O, Elon L, Bremner JD, Raggi P, Shah AJ, Quyyumi AA, Vaccarino V. Racial Disparities in Adverse Cardiovascular Outcomes After a Myocardial Infarction in Young or Middle-Aged Patients. J Am Heart Assoc 2021; 10:e020828. [PMID: 34431313 PMCID: PMC8649258 DOI: 10.1161/jaha.121.020828] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Black patients tend to develop coronary artery disease at a younger age than other groups. Previous data on racial disparities in outcomes of myocardial infarction (MI) have been inconsistent and limited to older populations. Our objective was to investigate racial differences in the outcome of MI among young and middle‐aged patients and the role played by socioeconomic, psychosocial, and clinical differences. Methods and Results We studied 313 participants (65% non‐Hispanic Black) <61 years old hospitalized for confirmed type 1 MI at Emory‐affiliated hospitals and followed them for 5 years. We used Cox proportional‐hazard models to estimate the association of race with a composite end point of recurrent MI, stroke, heart failure, or cardiovascular death after adjusting for demographic, socioeceonomic status, psychological, and clinical risk factors. The mean age was 50 years, and 50% were women. Compared with non‐Black patients, Black patients had lower socioeconomic status and more clinical and psychosocial risk factors but less angiographic coronary artery disease. The 5‐year incidence of cardiovascular events was higher in Black (35%) compared to non‐Black patients (19%): hazard ratio (HR) 2.1, 95% CI, 1.3 to 3.6. Adjustment for socioeconomic status weakened the association (HR 1.3, 95% CI, 0.8–2.4) more than adjustment for clinical and psychological risk factors. A lower income explained 46% of the race‐related disparity in outcome. Conclusions Among young and middle‐aged adult survivors of an MI, Black patients have a 2‐fold higher risk of adverse outcomes, which is largely driven by upstream socioeconomic factors rather than downstream psychological and clinical risk factors.
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Affiliation(s)
- Mariana Garcia
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Zakaria Almuwaqqat
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Kasra Moazzami
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - An Young
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Bruno B Lima
- 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
| | - Belal Kaseer
- 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
| | - Muhammad Hammadah
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Oleksiy Levantsevych
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - J Douglas Bremner
- Atlanta VA Medical Center Decatur GA.,Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Atlanta, GA.,Department of Radiology and Imaging Sciences Emory University School of Medicine Atlanta GA
| | - Paolo Raggi
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA.,Mazankowski Alberta Heart InstituteUniversity of Alberta Edmonton Alberta Canada
| | - Amit J Shah
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA.,Atlanta VA Medical Center Decatur GA
| | - Arshed A Quyyumi
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Viola Vaccarino
- Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
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14
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Moazzami K, Wittbrodt MT, Lima BB, Kim JH, Hammadah M, Ko YA, Obideen M, Abdelhadi N, Kaseer B, Gafeer MM, Nye JA, Shah AJ, Ward L, Raggi P, Waller EK, Bremner JD, Quyyumi AA, Vaccarino V. Circulating Progenitor Cells and Cognitive Impairment in Men and Women with Coronary Artery Disease. J Alzheimers Dis 2021; 74:659-668. [PMID: 32083582 DOI: 10.3233/jad-191063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Circulating progenitor cells (CPC) have been associated with memory function and cognitive impairment in healthy adults. However, it is unclear whether such associations also exist in patients with coronary artery disease (CAD). OBJECTIVE To assess the association between CPCs and memory performance among individuals with CAD. METHODS We assessed cognitive function in 509 patients with CAD using the verbal and visual Memory subtests of the Wechsler memory scale-IV and the Trail Making Test parts A and B. CPCs were enumerated with flow cytometry as CD45med/CD34+ blood mononuclear cells, those co-expressing other epitopes representing populations enriched for hematopoietic and endothelial progenitors. RESULTS After adjusting for demographic and cardiovascular risk factors, lower number of endothelial progenitor cell counts were independently associated with lower visual and verbal memory scores (p for all < 0.05). There was a significant interaction in the magnitude of this association with race (p < 0.01), such that the association of verbal memory scores with endothelial progenitor subsets was present in Black but not in non-Black participants. No associations were present with the hematopoietic progenitor-enriched cells or with the Trail Making Tests. CONCLUSION Lower numbers of circulating endothelial progenitor cells are associated with cognitive impairment in patients with CAD, suggesting a protective effect of repair/regeneration processes in the maintenance of cognitive status. Impairment of verbal memory function was more strongly associated with lower CPC counts in Black compared to non-Black participants with CAD. Whether strategies designed to improve regenerative capacity will improve cognition needs further study.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew T Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Bruno B Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeong Hwan Kim
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Muhammad Hammadah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Malik Obideen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Naser Abdelhadi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Belal Kaseer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - M Mazen Gafeer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathon A Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Medical Center, Decatur, GA, USA
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Mazankowski Alberta Heart Institute, University of Alberta, Alberta, Canada
| | - Edmund K Waller
- Department of Hematology and Oncology, Winship Cancer Institute, Atlanta, GA, USA
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Medical Center, Decatur, GA, USA
| | - Arshed A Quyyumi
- Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Medicine, Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
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15
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Moazzami K, Garcia M, Young A, Almuwaqqat Z, Lima BB, Martini A, Alkhalaf M, Shah AJ, Goldstein FC, Hajjar I, Levey AI, Bremner JD, Quyyumi AA, Vaccarino V. Association between symptoms of psychological distress and cognitive functioning among adults with coronary artery disease. Stress Health 2021; 37:538-546. [PMID: 33319483 PMCID: PMC8395370 DOI: 10.1002/smi.3018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 12/14/2022]
Abstract
Greater psychological distress is associated with cognitive impairment in healthy adults. Whether such associations also exist in patients with coronary artery disease (CAD) is uncertain. We assessed cognitive function in 496 individuals with CAD using the verbal and visual memory subtests of the Wechsler Memory Scale and executive functioning measured by the Trail Making Test Parts A and B. We used a composite score of psychological distress derived through summation of Z-transformed psychological distress symptom scales (depression, posttraumatic stress, anxiety, anger, hostility and perceived stress) and scores for each individual psychological scale. Multivariable linear regression models were used to determine the association between memory scores (as outcomes) and the psychological distress scores (both composite score and individual scales). After adjusting for demographic and cardiovascular risk factors, a higher psychological distress score was independently associated with worse memory and executive functioning. Each standard deviation increase in psychological distress score was associated with 3% (95% confidence interval [CI], 1%-5%) to 5% (95% CI, 3-7%) worse cognitive performance (higher Trail A and Trail B, and lower verbal and visual memory scores). Among individuals with CAD, a higher level of psychological distress is independently associated with worse cognitive performance. These findings suggest that psychological risk factors play a role in cognitive trajectories of persons with CAD.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mariana Garcia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - An Young
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bruno B Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Afif Martini
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mhmtjamil Alkhalaf
- 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.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA.,Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Felicia C Goldstein
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA.,Goizuetta Alzheimer's Disease Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ihab Hajjar
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA.,Goizuetta Alzheimer's Disease Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Allan I Levey
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA.,Goizuetta Alzheimer's Disease Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia, USA.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
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16
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Sullivan S, Young A, Garcia M, Almuwaqqat Z, Moazzami K, Hammadah M, Kim JH, Lima BB, Driggers EG, Levantsevych O, Elon L, Lewis TT, Shah AJ, Bremner JD, Quyyumi AA, Vaccarino V. Abstract MP52: Sex Differences In The Association Between Neighborhood Social Vulnerability And Psychological Distress Among Patients With Heart Disease. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.mp52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Psychological stress disorders are twice as prevalent in women with ischemic heart disease compared to their male counterparts. The disproportionate psychological health experience of these women is not well understood. Neighborhood social factors may help to explain disparities in psychological risk by sex.
Hypothesis:
We hypothesized that in patients with a recent myocardial infarction, living in neighborhoods with higher social vulnerability would be associated with greater psychological distress. We also hypothesized that this association would be moderated by sex, with a greater association among women than men.
Methods:
We studied 286 patients with heart disease recruited from Emory-based hospitals in the Myocardial Infarction and Mental Stress 2 Study. We used the social vulnerability index (SVI) developed by the Centers for Disease Control and Prevention to rank patients’ census tracks on 14 social factors, including unemployment, lack of vehicle access, and crowded housing, which are further grouped into four themes: socioeconomic status; household composition; minority status and language; and housing and transportation. Census tracts received a percentile ranking (0-100%), overall and for each theme, with higher values indicating greater social vulnerability. We calculated a global measure of psychological distress by ranking each participant on each of six symptom scales (depression, post-traumatic stress disorder, anxiety, anger, hostility, and perceived stress) and then taking an average of all ranks. Multilevel linear regression models were used to account for individuals nested within census tracts. Beta coefficients for mean ranks in psychological distress scores were estimated per 10-unit increase in SVI percentile ranking.
Results:
The mean age of the sample was 51 years (range: 26-61); 49% were women and 66% African American. Women in higher SVI census tracts had greater psychological distress scores. After adjusting for demographics (age, race, individual-level education and income), lifestyle and medical risk factors, and anti-depressant use, there were significant differences by sex (SVI-by-sex-interaction = 0.01) such that each 10 unit increase in SVI percentile ranking was associated with 4.09 (95% CI: 0.02, 8.08; p = 0.05) unit increase in mean scores for psychological distress among women only. These associations were driven by the SVI themes of lower socioeconomic status and poorer access to housing and transportation. There were no significant interactions by race.
Conclusions:
We show for the first time that neighborhood social vulnerability is associated with psychological distress among women with heart disease. These findings support the role of contextual influences of the neighborhood environment on the mental health of high-risk women, independent of individual-level measures of income and education.
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17
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Almuwaqqat Z, Liu C, Kim JH, Lima BB, Hammadah M, Alkhoder A, Shah AJ, Bremner JD, Vaccarino V, Sun Y, Quyyumi AA. Abstract MP10: A Novel Genetic Locus Influences Microvascular Reactivity To Acute Psychological Stress. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.mp10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Excessive peripheral microvascular constriction during acute psychological stress, measured using peripheral arterial tonometry reflects similar changes in coronary blood flow.The ratio of digital pulse wave amplitude during stress compared to rest (sPAT) is used to estimate the degree of microvascular response to stress.
Hypothesis:
We hypothesized that genetic factors contribute to the degree of microvascular constriction during mental stress and that excessive vasoconstriction is associated with adverse cardiovascular outcomes.
Methods:
A total of 580 stable CAD subjects of European and African ancestries from two prospective cohort studies underwent mental stress testing with a standardized public speaking stressor. Digital pulse wave amplitude was continuously measured using PAT and the stress/rest PAT ratio (sPAT) of pulse wave amplitude during mental stress/baseline was calculated. Genotyping was performed using Illumina’s Multi-Ethnic Genotyping Array platform and imputed to the 1000 Genome reference panel. Ethnicity-specific genome-wide association studies (GWAS) of sPAT were conducted using linear regression of additive genetic mode adjusted for age, sex and population stratification in both cohorts. A trans-ethnic meta-analysis integrated the GWAS results from four sub-cohorts. Upon 5-year follow-up, Fine and Gray’s sub-distribution hazard ratios (sHR) were used to examine the association between sPAT ratio (> vs=< median) and the composite endpoint of cardiovascular death, myocardial infarction, revascularization, and hospitalization for heart failure.
Results:
Mean age was 63±9; 65% male, 35% African American. We identified three SNPs in linkage disequilibrium on chr7:111,666,943 T>C (rs6466396); chr7: 111,668,622 T>G (rs876170); chr7: 111,668,623 T>G (rs876169) that were associated with greater sPAT ratio by means of 0.13, 0.12 and 0.10, (
P
= 1.42E-08). The sPAT-associated locus was within
DOCK4
gene which encodes Dedicator of Cytokinesis 4, an essential protein for angiogenesis and brain development, and a known locus for obesity. 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 (sHR 1.8 [95% CI 1.1 - 2.8]).
Conclusion:
We have identified a genetic basis for stress-induced vasomotion. Presence of allele C (rs6466396) is associated with increased vasoconstriction during mental stress, and thus may predispose CAD patients to a higher risk for adverse cardiovascular outcomes with stressful exposure.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Yan Sun
- EMORY UNIVERSITY, Atlanta, GA
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18
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Almuwaqqat Z, young A, Garcia M, Sullivan S, Lima BB, Kim JH, alkhalaf M, Moazzami K, Driggers E, Ko YA, Lewis TT, Shah AJ, Garcia EV, Bremner JD, Quyyumi AA, Vaccarino V. Abstract 014: Posttraumatic Stress Disorder, Mental Stress-induced Myocardial Ischemia And Cardiovascular Outcomes In Patients With CAD. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Mental stress-induced myocardial ischemia (MSI) is a risk marker for adverse outcomes among coronary artery disease (CAD) that is more prevalent among patients with posttraumatic stress disorder (PTSD).
Hypothesis:
CAD patients with PTSD who develop MSI experience a higher risk of adverse cardiovascular events compared with those who do not develop MSI.
Methods:
We studied 995 individuals with stable CAD who participated in two contemporary cohort studies with similar protocols, the Mental Stress Ischemia Prognosis Study (MIPS), and the Myocardial Infarction and Mental Stress Study (MIMS). Provocation of myocardial ischemia with a standardized mental stress test (speech task) was assessed with single-photon emission computed tomography. PTSD was assessed with the structured clinical interviews for DSM-IV. Participants were categorized into four groups based on their MSI and PTSD status. The primary endpoint was a composite outcome of cardiovascular death or nonfatal myocardial infarction (MI), stroke, or heart failure hospitalization. Cox regression models were used to investigate the interaction of PTSD and MSI on the study endpoint in the two samples pooled with meta-analysis.
Results:
In total, 603 participants in MIPS and 392 in MIMS were included. MSI occurred in 16% of the patients in MIPS and 17% in MIMS. Over a 5-year median follow-up, there were 126 outcome events in MIPS and 117 in MIMS. In Cox regression models with adjustment for demographic and clinical risk factors, participants with both MSI and PTSD had a higher risk for the study endpoint, compared to those with neither. In contrast, participants with PTSD or MSI but not both were not at a higher risk (
p
interaction=0.01). Separate analyses in the two studies were consistent.
Conclusions:
There is a synergistic association of PTSD and MSI on adverse outcomes in CAD patients. These findings support the confluence of chronic mental health vulnerability with acute stress responses in defining elevated risk in CAD patients.patients.
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19
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Moazzami K, Wittbrodt MT, Lima BB, Kim JH, Almuwaqqat Z, Shah AJ, Hajjar I, Goldstein FC, Levey AI, Nye JA, Bremner JD, Vaccarino V, Quyyumi AA. Neurobiological Pathways Linking Acute Mental Stress to Impairments in Executive Function in Individuals with Coronary Artery Disease. J Alzheimers Dis Rep 2021; 5:99-109. [PMID: 33782663 PMCID: PMC7990469 DOI: 10.3233/adr-200287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Individuals with coronary artery disease (CAD) have worse executive function compared to the general population but the mechanisms are unknown. OBJECTIVE To investigate the role of acute mental stress (MS) on the executive function of patients with CAD. METHODS Participants with stable CAD underwent acute MS testing with simultaneous peripheral vascular function measurements and brain imaging using high resolution-positron emission tomography. Digital pulse wave amplitude was continuously measured using peripheral artery tonometry (PAT, Itamar Inc). Stress/rest PAT ratio (sPAT) of pulse wave amplitude during MS/baseline was calculated as a measure of microvascular constriction during MS. Plasma levels of catecholamine and interleukin-6 were assessed at baseline and after MS. Executive function was assessed both at baseline and at 2 years follow-up using the Trail Making Test parts A and B. RESULTS We studied 389 individuals with brain data available for 148 participants. Of this population follow-up cognitive assessments were performed in 226 individuals (121 with brain imaging). After multivariable adjustment for baseline demographics, risk factors, and medication use, a lower sPAT, indicating greater vasoconstriction, a higher inferior frontal lobe activation with MS, and increases in norepinephrine and IL-6 levels with MS were all independently associated with greater time to complete Trail B test.-38.4pt. CONCLUSION In response to acute MS, greater peripheral vasoconstriction, higher inferior frontal lobe brain activation, and increases in the levels of norepinephrine and IL-6 are associated with worse executive function.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeong Hwan Kim
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA,Atlanta VA Medical Center, Decatur, GA, USA
| | - Ihab Hajjar
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, USA,
Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Felicia C. Goldstein
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, USA,
Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Allan I. Levey
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, USA,
Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathon A. Nye
- Department of Radiology and Imaging Sciences, 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,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA,
Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA,Correspondence to: Arshed A. Quyyumi, MD, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road N.E. Suite 507, Atlanta, GA 30322, USA. Tel.: +1 404 727 3655; Fax: +1 404 712 8785; E-mail:
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20
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Moazzami K, Sullivan S, Lima BB, Kim JH, Hammadah M, Almuwaqqat Z, Shah AJ, Hajjar I, Goldstein FC, Levey AI, Bremner JD, Quyyumi AA, Vaccarino V. Mental stress-induced myocardial ischemia and cognitive impairment in coronary atherosclerosis. J Psychosom Res 2021; 141:110342. [PMID: 33360843 PMCID: PMC7857648 DOI: 10.1016/j.jpsychores.2020.110342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/10/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To understand if presence of mental stress-induced myocardial ischemia (MSIMI) is associated with higher prevalence of cognitive impairment at baseline and its decline over time. METHODS A cohort of participants with stable coronary atherosclerosis underwent acute mental stress testing using a series of standardized speech/arithmetic stressors. The stress/rest digital vasomotor response to mental stress (sPAT) was assessed to measure microvascular constriction during mental stress. Patients received 99mTc-sestamibi myocardial perfusion imaging at rest, with mental stress and with conventional (exercise/pharmacological) stress. Cognitive function was assessed both at baseline and at a 2 year follow-up using the Trail Making Test parts A and B and the verbal and visual memory subtests of the Wechsler Memory Scale. RESULTS We studied 486 individuals (72% male, 32.1% Black, 62 ± 9 (mean ± SD) years old). After multivariable adjustment for baseline demographics, risk factors, and medication use, presence of MSIMI was associated with 21% and 20% slower completion of Trail-A and Trail-B, respectively (p for all <0.01). After a 2-year follow-up period, presence of MSIMI was associated with a 33% slower completion of Trail-B, denoting cognitive decline (B = 0.33, 95% CI, 0.04, 0.62). A lower sPAT, indicating greater vasoconstriction, mediated the association between MSIMI and worsening Trail-B performance by 18.2%. Ischemia with a conventional stress test was not associated with any of the cognitive tests over time. CONCLUSION MSIMI is associated with slower visuomotor processing and worse executive function at baseline and with greater decline in these abilities over time.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Jeong Hwan Kim
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Muhammad Hammadah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ihab Hajjar
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, United States of America,Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, United States of America,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, United States of America
| | - Felicia C. Goldstein
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, United States of America,Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Allan I. Levey
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, United States of America,Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, United States of America
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA, United States of America,Department of Radiology and Imaging Sciences, Emory University School of Medicine, United States of America,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America; Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America.
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21
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Moazzami K, Lima BB, Hammadah M, Ramadan R, Al Mheid I, Kim JH, Alkhoder A, Obideen M, Levantsevych O, Shah A, Liu C, Bremner JD, Kutner M, Sun YV, Waller EK, Hesaroieh IG, Raggi P, Vaccarino V, Quyyumi AA. Association Between Change in Circulating Progenitor Cells During Exercise Stress and Risk of Adverse Cardiovascular Events in Patients With Coronary Artery Disease. JAMA Cardiol 2021; 5:147-155. [PMID: 31799987 PMCID: PMC6902161 DOI: 10.1001/jamacardio.2019.4528] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Stem and progenitor cells mobilize from the bone marrow in response to myocardial ischemia. However, the association between the change in circulating progenitor cell (CPC) counts and disease prognosis among patients with ischemia is unknown. Objective To investigate the association between the change in CPC counts during stress testing and the risk of adverse cardiovascular events in patients with stable coronary artery disease (CAD). Design, Setting, and Participants This prospective cohort study included a population-based sample of 454 patients with stable CAD who were recruited between June 1, 2011, and August 15, 2014, at Emory University-affiliated hospitals and followed up for 3 years. Data were analyzed from September 15, 2018, to October 15, 2018. Exposures Myocardial perfusion imaging with technetium Tc 99m sestamibi at rest and 30 to 60 minutes after conventional stress testing. Main Outcomes and Measures Circulating progenitor cells were enumerated with flow cytometry as CD34-expressing mononuclear cells (CD45med/CD34+), with additional quantification of subsets coexpressing the chemokine (C-X-C motif) receptor 4 (CD34+/CXCR4+). Changes in CPC counts were calculated as poststress minus resting CPC counts. Cox proportional hazards regression models were used to identify factors associated with the combined end point of cardiovascular death and myocardial infarction after adjusting for clinical covariates, including age, sex, race, smoking history, body mass index, and history of heart failure, hypertension, dyslipidemia, and diabetes. Results Of the 454 patients (mean [SD] age, 63 [9] years; 76% men) with stable CAD enrolled in the study, 142 (31.3%) had stress-induced ischemia and 312 (68.7%) did not, as measured by single-photon emission computed tomography. During stress testing, patients with stress-induced ischemia had a mean decrease of 20.2% (interquartile range [IQR], -45.3 to 5.5; P < .001) in their CD34+/CXCR4+ counts, and patients without stress-induced ischemia had a mean increase of 3.2% (IQR, -20.6 to 35.1; P < .001) in their CD34+/CXCR4+ counts. Twenty-four patients (5.2%) experienced adverse events. After adjustment, baseline CPC counts were associated with worse adverse outcomes, but this association was not present after stress-induced ischemia was included in the model. However, the change in CPC counts during exercise remained significantly associated with adverse events (hazard ratio, 2.59; 95% CI, 1.15-5.32, per 50% CD34+/CXCR4+ count decrease), even after adjustment for clinical variables and the presence of ischemia. The discrimination of risk factors associated with incident adverse events improved (increase in C statistic from 0.72 to 0.77; P = .003) with the addition of the change in CD34+/CXCR4+ counts to a model that included clinical characteristics, baseline CPC count, and ischemia. Conclusions and Relevance In this study of patients with CAD, a decrease in CPC counts during exercise is associated with a worse disease prognosis compared with the presence of stress-induced myocardial ischemia. Further studies are needed to evaluate whether strategies to improve CPC responses during exercise stress will be associated with improvements in the prognosis of patients with CAD.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Bruno B Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Mohammad Hammadah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Ronnie Ramadan
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Ibhar Al Mheid
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Jeong Hwan Kim
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Ayman Alkhoder
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Malik Obideen
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Oleksiy Levantsevych
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia.,Atlanta VA Medical Center, Decatur, Georgia
| | - Chang Liu
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia.,Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yan V Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Edmund K Waller
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Iraj Ghaini Hesaroieh
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Alberta, Canada
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
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22
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Lima BB, Hammadah M, Kim JH, Uphoff I, Shah A, Levantsevych O, Almuwaqqat Z, Moazzami K, Sullivan S, Ward L, Sun Y, Kutner M, Ko YA, Sheps DS, Beshiri A, Murtagh G, Bremner JD, Vaccarino V, Quyyumi AA. Relation of High-sensitivity Cardiac Troponin I Elevation With Exercise to Major Adverse Cardiovascular Events in Patients With Coronary Artery Disease. Am J Cardiol 2020; 136:1-8. [PMID: 32941818 PMCID: PMC8057114 DOI: 10.1016/j.amjcard.2020.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/29/2020] [Accepted: 09/01/2020] [Indexed: 11/29/2022]
Abstract
High sensitive cardiac troponin I (hs-cTnI) increases with inducible myocardial ischemia in patients with coronary artery disease (CAD). We aimed to assess if the change in hs-cTnI levels with exercise stress testing is associated with major adverse cardiac events (MACE). A cohort of 365 (age 62 ± 9 years, 77% men) patients with stable CAD underwent 99mTc sestamibi myocardial perfusion imaging with treadmill testing. Plasma hs-cTnI level was measured at rest and at 45 min after stress. Multivariable Fine & Gray's subdistribution hazards models were used to determine the association between the change in hs-cTnI and MACE, a composite end point of cardiovascular death, myocardial infarction, and unstable angina requiring revascularization. During a median follow-up of 3 years, 39 (11%) patients experienced MACE. After adjustment, for each two-fold increment in hs-cTnI with stress, there was a 2.2 (95% confidence interval 1.3-3.6)-fold increase in the hazard for MACE. Presence of both a high resting hs-cTnI level (>median) and ≥ 20% stress-induced hs-cTnI elevation was associated with the highest incidence of MACE (subdistribution hazards models 4.6, 95% confidence interval 1.6 to 13.0) compared with low levels of both. Risk discrimination statistics significantly improved after addition of resting and change in hs-cTnI levels to a model including traditional risk factors and inducible ischemia (0.67 to 0.71). Conversely, adding inducible ischemia by SPECT did not significantly improve the C-statistic from a model including traditional risk factors, baseline and change in hs-cTnI (0.70 to 0.71). In stable CAD patients, higher resting levels and elevation of hs-cTnI with exercise are predictors of adverse cardiovascular outcomes beyond traditional cardiovascular risk factors and presence of inducible ischemia.
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Affiliation(s)
- Bruno B Lima
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Muhammad Hammadah
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jeong Hwan Kim
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Irina Uphoff
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Atlanta VA Medical Center, Decatur, Georgia
| | - Oleksiy Levantsevych
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Zakaria Almuwaqqat
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kasra Moazzami
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yan Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Michael Kutner
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yi-An Ko
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - David S Sheps
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Agim Beshiri
- Diagnostics Division, Abbott Laboratories, North Chicago, Illinois
| | - Gillian Murtagh
- Diagnostics Division, Abbott Laboratories, North Chicago, Illinois
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia; Departments of Psychiatry and Behavioral Sciences and Radiology, Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
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23
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Almuwaqqat Z, Wittbrodt M, Young A, Lima BB, Hammadah M, Garcia M, Elon L, Pearce B, Hu Y, Sullivan S, Mehta PK, Driggers E, Kim YJ, Lewis TT, Suglia SF, Shah AJ, Bremner JD, Quyyumi AA, Vaccarino V. Association of Early-Life Trauma and Risk of Adverse Cardiovascular Outcomes in Young and Middle-aged Individuals With a History of Myocardial Infarction. JAMA Cardiol 2020; 6:2773087. [PMID: 33185652 PMCID: PMC7666433 DOI: 10.1001/jamacardio.2020.5749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/29/2020] [Indexed: 01/23/2023]
Abstract
IMPORTANCE Compared with older patients, young adults with a history of myocardial infarction (MI) tend to have a higher burden of psychosocial adversity. Exposure to early-life stressors may contribute to the risk of adverse outcomes in this patient population, potentially through inflammatory pathways. OBJECTIVE To investigate the association of early-life trauma with adverse events and examine whether inflammation plays a role. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients aged 18 to 60 years with a verified history of MI in the past 8 months from a university-affiliated hospital network. Baseline data were collected from June 2011 to March 2016, and follow-up data were obtained through July 2019. Analysis began September 2019. EXPOSURES Early-life trauma was assessed using the Early Trauma Inventory-Self Report short form (ETI-SR-SF), both as a continuous and as a binary variable at the threshold of a score of 7 or higher. Inflammatory biomarkers, interleukin 6, and C-reactive protein were obtained at baseline. MAIN OUTCOMES AND MEASURES A composite end point of recurrent MI, stroke, heart failure hospitalization, and cardiovascular death over a median 3-year follow-up. RESULTS Of 300 patients, the mean (SD) age was 51 (7) years, 198 (66%) were African American, and 150 (50%) were women. Compared with participants with MI with an ETI-SR-SF score less than 7, those with a score of 7 or higher had higher levels of interleukin 6 and C-reactive protein at baseline. Compared with participants with an ETI-SR-SF score less than 7, those with a score of 7 or higher were at a greater risk for adverse outcomes, with a hazards ratio of 2.3 (95% CI, 1.3-3.9). Results remained consistent in multivariable analysis. Further adjustment for C-reactive protein rendered the results no longer statistically significant. Early-life trauma displayed a dose-dependent response when analyzed as a continuous variable and by quartiles. CONCLUSIONS AND RELEVANCE Early-life trauma is an independent risk factor for adverse outcomes in young and middle-aged individuals with a history of MI. Neurobiological mechanisms leading to lifetime activation of systemic inflammatory cascades may be implicated.
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Affiliation(s)
- Zakaria Almuwaqqat
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Matthew Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - An Young
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Bruno B. Lima
- 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
| | - Mariana Garcia
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Bradley Pearce
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Samaah Sullivan
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Puja K. Mehta
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Emily Driggers
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Ye Ji Kim
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Tene` T. Lewis
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Shakira F. Suglia
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Amit J. Shah
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
- Atlanta VA Medical Center, Decatur, Georgia
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
- Atlanta VA Medical Center, Decatur, Georgia
| | - Arshed A. Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Viola Vaccarino
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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25
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Martins CS, Costa DVS, Lima BB, Leitäo RFC, Freire GE, Silva GFM, Pacífico DM, Abreu JG, Brito GAC. Clostridioides difficile Toxin A-Induced Wnt/β-Catenin Pathway Inhibition Is Mediated by Rac1 Glucosylation. Front Microbiol 2020; 11:1998. [PMID: 32983019 PMCID: PMC7483921 DOI: 10.3389/fmicb.2020.01998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
Clostridioides difficile toxin A (TcdA) has been shown to inhibit cellular Wnt signaling, the major driving force behind the proliferation of epithelial cells in colonic crypts, likely through the inhibition of β-catenin nuclear translocation. Herein, we aimed to advance the understanding of this mechanism by replicating the findings in vivo and by investigating the specific role of Rac1, a member of the Rho GTPase family, on the inhibition of the Wnt-induced β-catenin nuclear translocation triggered by TcdA. To investigate the effects of TcdA on the Wnt/β-catenin pathway in vivo, we injected the ileal loops of C57BL/6 mice with TcdA [phosphate-buffered saline (PBS) as the control] to induce C. difficile disease-like ileitis. After 4 h post-injection, we obtained ileum tissue samples to assess Wnt signaling activation and cell proliferation through Western blotting, immunohistochemistry, and qPCR. To assess the role of Rac1 on Wnt signaling inhibition by TcdA, we transfected rat intestinal epithelial cells (IEC-6) with either a constitutively active Rac1 plasmid (pcDNA3-EGFP-Rac1-Q61L) or an empty vector, which served as the control. We incubated these cells with Wnt3a-conditioned medium (Wnt3a-CM) to induce Wnt/β-catenin pathway activation, and then challenged the cells with TcdA. We assessed Wnt signaling activation in vitro with TOP/FOPflash luciferase assays, determined nuclear β-catenin translocation by immunofluorescence, measured cyclin D1 protein expression by Western blotting, and quantified cell proliferation by Ki67 immunostaining. In vivo, TcdA decreased β-catenin, cyclin D1, and cMYC expression and inhibited the translocation of β-catenin into the nucleus in the ileum epithelial cells. In addition, TcdA suppressed cell proliferation and increased Wnt3a expression, but did not alter Rac1 gene expression in the ileum tissue. In vitro, constitutively active Rac1 prevented Wnt signaling inhibition by enabling the β-catenin nuclear translocation that had been blocked by TcdA. Our results show that TcdA inhibits Wnt/β-catenin pathway in vivo and demonstrate that this inhibition is likely caused by a Rac1-mediated mechanism.
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Affiliation(s)
- Conceição S Martins
- Postgraduate Program in Morphofunctional Sciences, Department of Morphology, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Deiziane V S Costa
- Department of Physiology and Pharmacology, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Bruno B Lima
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Renata F C Leitäo
- Postgraduate Program in Morphofunctional Sciences, Department of Morphology, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Gildênio E Freire
- Postgraduate Program in Morphofunctional Sciences, Department of Morphology, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Guilherme F M Silva
- Department of Medical Sciences, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Dvison M Pacífico
- Department of Medical Sciences, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - José G Abreu
- Department of Anatomy, Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gerly A C Brito
- Postgraduate Program in Morphofunctional Sciences, Department of Morphology, School of Medicine, Federal University of Ceará, Fortaleza, Brazil.,Department of Physiology and Pharmacology, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
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26
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Moazzami K, Wittbrodt MT, Alkhalaf M, Lima BB, Nye JA, Mehta PK, Quyyumi AA, Vaccarino V, Bremner JD, Shah AJ. Association Between Mental Stress-Induced Inferior Frontal Cortex Activation and Angina in Coronary Artery Disease. Circ Cardiovasc Imaging 2020; 13:e010710. [PMID: 32772572 PMCID: PMC7422935 DOI: 10.1161/circimaging.120.010710] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The inferior frontal lobe is an important area of the brain involved in the stress response, and higher activation with acute mental stress may indicate a more severe stress reaction. However, it is unclear if activation of this region with stress correlates with angina in individuals with coronary artery disease. METHODS Individuals with stable coronary artery disease underwent acute mental stress testing using a series of standardized speech/arithmetic stressors in conjunction with high resolution positron emission tomography imaging of the brain. Blood flow to the inferior frontal lobe was evaluated as a ratio compared with whole brain flow for each scan. Angina was assessed with the Seattle Angina Questionnaire's angina frequency subscale at baseline and 2 years follow-up. RESULTS We analyzed 148 individuals with coronary artery disease (mean age [SD] 62 [8] years; 69% male, and 35.8% Black). For every doubling in the inferior frontal lobe activation, angina frequency was increased by 13.7 units at baseline ([Formula: see text], 13.7 [95% CI, 6.3-21.7]; P=0.008) and 11.6 units during follow-up ([Formula: see text], 11.6 [95% CI, 4.1-19.2]; P=0.01) in a model adjusted for baseline demographics. Mental stress-induced ischemia and activation of other brain pain processing regions (thalamus, insula, and amygdala) accounted for 40.0% and 13.1% of the total effect of inferior frontal lobe activation on angina severity, respectively. CONCLUSIONS Inferior frontal lobe activation with mental stress is independently associated with angina at baseline and during follow-up. Mental stress-induced ischemia and other pain processing brain regions may play a contributory role.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (K.M., B.B.L., V.V., A.J.S.).,Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine (K.M., M.A., B.B.L., P.K.M., A.A.Q., A.J.S.), Emory University School of Medicine, Atlanta, GA
| | - Matthew T Wittbrodt
- Department of Psychiatry and Behavioral Sciences (M.T.W., J.D.B.), Emory University School of Medicine, Atlanta, GA
| | - Mhmtjamil Alkhalaf
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine (K.M., M.A., B.B.L., P.K.M., A.A.Q., A.J.S.), Emory University School of Medicine, Atlanta, GA
| | - Bruno B Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (K.M., B.B.L., V.V., A.J.S.).,Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine (K.M., M.A., B.B.L., P.K.M., A.A.Q., A.J.S.), Emory University School of Medicine, Atlanta, GA
| | - Jonathon A Nye
- Department of Radiology and Imaging Sciences (J.A.N., J.D.B.), Emory University School of Medicine, Atlanta, GA
| | - Puja K Mehta
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine (K.M., M.A., B.B.L., P.K.M., A.A.Q., A.J.S.), Emory University School of Medicine, Atlanta, GA
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine (K.M., M.A., B.B.L., P.K.M., A.A.Q., A.J.S.), Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (K.M., B.B.L., V.V., A.J.S.)
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences (M.T.W., J.D.B.), Emory University School of Medicine, Atlanta, GA.,Department of Radiology and Imaging Sciences (J.A.N., J.D.B.), Emory University School of Medicine, Atlanta, GA.,Atlanta VA Medical Center, Decatur, GA (J.D.B., A.J.S.)
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (K.M., B.B.L., V.V., A.J.S.).,Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine (K.M., M.A., B.B.L., P.K.M., A.A.Q., A.J.S.), Emory University School of Medicine, Atlanta, GA.,Atlanta VA Medical Center, Decatur, GA (J.D.B., A.J.S.)
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27
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Moazzami K, Wittbrodt MT, Lima BB, Nye JA, Mehta PK, Pearce BD, Almuwaqqat Z, Hammadah M, Levantsevych O, Sun YV, Raggi P, Garcia EV, Goetz M, Quyyumi AA, Bremner JD, Vaccarino V, Shah AJ. Higher Activation of the Rostromedial Prefrontal Cortex During Mental Stress Predicts Major Cardiovascular Disease Events in Individuals With Coronary Artery Disease. Circulation 2020; 142:455-465. [PMID: 32522022 PMCID: PMC7677173 DOI: 10.1161/circulationaha.119.044442] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Psychological stress is a risk factor for major adverse cardiovascular events (MACE) in individuals with coronary artery disease. Certain brain regions that control both emotional states and cardiac physiology may be involved in this relationship. The rostromedial prefrontal cortex (rmPFC) is an important brain region that processes stress and regulates immune and autonomic functions. Changes in rmPFC activity with emotional stress (reactivity) may be informative of future risk for MACE. METHODS Participants with stable coronary artery disease underwent acute mental stress testing using a series of standardized speech/arithmetic stressors and simultaneous brain imaging with high-resolution positron emission tomography brain imaging. We defined high rmPFC activation as a difference between stress and control scans greater than the median value for the entire cohort. Interleukin-6 levels 90 minutes after stress, and high-frequency heart rate variability during stress were also assessed. We defined MACE as a composite of cardiovascular death, myocardial infarction, unstable angina with revascularization, and heart failure hospitalization. RESULTS We studied 148 subjects (69% male) with mean±SD age of 62±8 years. After adjustment for baseline demographics, risk factors, and baseline levels of interleukin-6 and high-frequency heart rate variability, higher rmPFC stress reactivity was independently associated with higher interleukin-6 and lower high-frequency heart rate variability with stress. During a median follow-up of 3 years, 34 subjects (21.3%) experienced a MACE. Each increase of 1 SD in rmPFC activation with mental stress was associated with a 21% increase risk of MACE (hazard ratio, 1.21 [95% CI, 1.08-1.37]). Stress-induced interleukin-6 and high-frequency heart rate variability explained 15.5% and 32.5% of the relationship between rmPFC reactivity and MACE, respectively. Addition of rmPFC reactivity to conventional risk factors improved risk reclassification for MACE prediction, and C-statistic improved from 0.71 to 0.76 (P=0.03). CONCLUSIONS Greater rmPFC stress reactivity is associated with incident MACE. Immune and autonomic responses to mental stress may play a contributory role.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Jonathon A. Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Puja K. Mehta
- Emory Clinical Cardiovascular Research Institute, 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
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Muhammad Hammadah
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Oleksiy Levantsevych
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Margarethe Goetz
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA,Department of Radiology and Imaging Sciences, 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,Emory Clinical Cardiovascular Research Institute, 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,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA,Atlanta VA Medical Center, Decatur, GA
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Pimple P, Lima BB, Hammadah M, Wilmot K, Ramadan R, Levantsevych O, Sullivan S, Kim JH, Kaseer B, Shah AJ, Ward L, Raggi P, Bremner JD, Hanfelt J, Lewis T, Quyyumi AA, Vaccarino V. Psychological Distress and Subsequent Cardiovascular Events in Individuals With Coronary Artery Disease. J Am Heart Assoc 2020; 8:e011866. [PMID: 31055991 PMCID: PMC6512132 DOI: 10.1161/jaha.118.011866] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Higher symptom levels of a variety of measures of emotional distress have been associated with cardiovascular disease ( CVD ), especially among women. Here, our goal was to investigate the association between a composite measure of psychological distress and incident cardiovascular events. Methods and Results In a prospective cohort study, we assessed 662 individuals (28% women; 30% blacks) with stable coronary artery disease. We used a composite score of psychological distress derived through summation of Z-transformed psychological distress symptom scales (depression, posttraumatic stress, anxiety, anger, hostility, and perceived stress) as a predictor of an adjudicated composite end point of adverse events (cardiovascular death, myocardial infarction, stroke, heart failure, or unstable angina). During a mean follow-up of 2.8 years, 120 (18%) subjects developed CVD events. In the overall population, there was no association between the psychological distress measure and CVD events, but there was a sex-based interaction ( P=0.004). In women, higher psychological distress was associated with a higher incidence of CVD events; each SD increase in the composite score of psychological distress was associated with 1.44 times adjusted hazard of CVD events (95% CI, 1.09-1.92). No such association was found in men. Conclusions Among patients with coronary artery disease, higher psychological distress is associated with future cardiovascular events in women only.
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Affiliation(s)
- Pratik Pimple
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Bruno B Lima
- 2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Muhammad Hammadah
- 2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Kobina Wilmot
- 2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Ronnie Ramadan
- 2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | | | - Samaah Sullivan
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Jeong Hwan Kim
- 2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Belal Kaseer
- 2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Amit J Shah
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA.,2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Laura Ward
- 3 Department of Biostatistics & Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Paolo Raggi
- 4 Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - J Douglas Bremner
- 5 Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Atlanta GA
| | - John Hanfelt
- 3 Department of Biostatistics & Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Tene Lewis
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Arshed A Quyyumi
- 2 Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Viola Vaccarino
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA.,2 Division of Cardiology Department of Medicine Emory University Atlanta GA
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Lima BB, Hammadah M, Kim JH, Uphoff I, Shah A, Levantsevych O, Almuwaqqat Z, Moazzami K, Sullivan S, Ward L, Kutner M, Ko YA, Sheps DS, Bremner JD, Quyyumi AA, Vaccarino V. Association of Transient Endothelial Dysfunction Induced by Mental Stress With Major Adverse Cardiovascular Events in Men and Women With Coronary Artery Disease. JAMA Cardiol 2020; 4:988-996. [PMID: 31509180 PMCID: PMC6739728 DOI: 10.1001/jamacardio.2019.3252] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance Acute mental stress can result in transient endothelial dysfunction, but the prognostic relevance of this phenomenon is unknown. Objective To determine the association between mental stress-induced impairment in endothelium-dependent relaxation as assessed by brachial artery flow-mediated vasodilation and adverse cardiovascular outcomes among individuals with stable coronary artery disease. Design, Setting, and Participants This cohort study was conducted at a university-affiliated hospital network between June 2011 and August 2014. A cohort of individuals with stable coronary artery disease were included. Data analysis took place from November 2018 to May 2019. Exposures Study participants were subjected to a laboratory mental stress task (public speaking). Main Outcomes and Measures Flow-mediated vasodilation was measured before and 30 minutes after a public-speaking mental stress task. We examined the association of the rest (prestress), poststress, and δ flow-mediated vasodilation (poststress minus prestress levels) with an adjudicated composite end point of adverse events, including cardiovascular death, myocardial infarction, unstable angina leading to revascularization, and heart failure hospitalization, after adjusting for sociodemographic factors, medical history, and depression. Results A total of 569 patients were included (mean [SD] age, 62.6 [9.3] years; 420 men [73.8%]). Flow-mediated vasodilation decreased from a mean (SD) of 4.8% (3.7%) before mental stress to 3.9% (3.6%) after mental stress (a 23% reduction; P < .001), and 360 participants (63.3%) developed transient endothelial dysfunction (a decrease in flow-mediated vasodilation). During a median (interquartile range) follow-up period of 3.0 (2.9-3.1) years, 74 patients experienced a major adverse cardiovascular event. The presence of transient endothelial dysfunction with mental stress was associated with a 78% increase (subdistribution hazard ratio [sHR], 1.78 [95% CI, 1.15-2.76]) in the incidence of major adverse cardiovascular event. Both the δ flow-mediated vasodilation (sHR, 1.15 [95% CI, 1.03-1.27] for each 1% decline) and poststress flow-mediated vasodilation (sHR, 1.14 [95% CI, 1.04-1.24] for each 1% decline) were associated with major adverse cardiovascular event. Risk discrimination statistics demonstrated a significant model improvement after addition of either poststress flow-mediated vasodilation (change in the area under the curve, 0.05 [95% CI, 0.01-0.09]) or prestress plus δ flow-mediated vasodilation (change in the area under the curve, 0.04 [95% CI, 0.00-0.08]) compared with conventional risk factors. Conclusions and Relevance In this study, transient endothelial dysfunction with mental stress was associated with adverse cardiovascular outcomes in patients with coronary artery disease. Endothelial responses to stress represent a possible mechanism through which psychological stress may affect outcomes in patients with coronary artery disease.
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Affiliation(s)
- Bruno B Lima
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Muhammad Hammadah
- 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
| | - Irina Uphoff
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amit Shah
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia.,Atlanta VA Medical Center, Decatur, Georgia
| | - Oleksiy Levantsevych
- 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.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Kasra Moazzami
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Samaah Sullivan
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Laura Ward
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Michael Kutner
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Yi-An Ko
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - David S Sheps
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Department of Radiology, 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
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
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Wittbrodt MT, Moazzami K, Shah AJ, Lima BB, Hammadah M, Mehta PK, Quyyumi AA, Vaccarino V, Nye JA, Bremner JD. Neural responses during acute mental stress are associated with angina pectoris. J Psychosom Res 2020; 134:110110. [PMID: 32345456 PMCID: PMC8082434 DOI: 10.1016/j.jpsychores.2020.110110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/31/2022]
Abstract
UNLABELLED Angina pectoris is associated with increased risk of adverse cardiovascular events in coronary artery disease (CAD) patients, an effect not entirely attributable to the severity of CAD. OBJECTIVE Examine brain correlates of mental stress in patients with CAD with and without a history of angina. METHODS Participants (n = 170) with stable CAD completed the Seattle Angina Questionnaire along with other psychometric assessments. In this cross-sectional study, participants underwent laboratory-based mental stress testing using mental arithmetic and public speaking tasks along with control conditions in conjunction with positron emission tomography brain imaging using radiolabeled water. Brain activity during mental stress was compared between participants who did or did not report chest pain/angina in the previous month. A factor analysis was coupled with dominance analysis to identify brain regions associated with angina. RESULTS Participants reporting angina in the past month experienced greater (p < .005) activations within the left: frontal lobe (z = 4.01), temporal gyrus (z = 3.32), parahippocampal gyrus (z = 3.16), precentral gyrus (z = 3.14), right fusiform gyrus (z = 3.07), and bilateral cerebellum (z = 3.50) and deactivations within the right frontal gyrus (z = 3.67), left precuneus (z = 3.19), and left superior temporal gyrus (z = 3.11) during mental stress. A factor containing the left motor areas, inferior frontal lobe, and operculum (average McFadden's number addition = 0.057) in addition to depression severity (0.10) and adulthood trauma exposure (0.064) correlated with angina history. CONCLUSIONS Self-reported angina in patients with stable CAD is associated with increased neural responses to stress in a network including the inferior frontal lobe, motor areas, and operculum, potentially indicating an upregulated pain perception response.
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Affiliation(s)
- Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America,Corresponding author at: 1821 Clifton Rd, Room 214, Atlanta, GA 30307, United States of America. (M.T. Wittbrodt)
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America,Atlanta VA Medical Center, Decatur, GA, United States of America
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Muhammad Hammadah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Puja K. Mehta
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Arshed A. Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Jonathon A. Nye
- Department of Radiology, Emory University School of Medicine, United States of America
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America,Department of Radiology, Emory University School of Medicine, United States of America,Atlanta VA Medical Center, Decatur, GA, United States of America
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31
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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] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lima BB, Quyyumi AA, Vaccarino V. A Future for Flow-Mediated Dilation-Just Follow the Guidelines-Reply. JAMA Cardiol 2020; 5:361. [PMID: 31968052 DOI: 10.1001/jamacardio.2019.5701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Bruno B Lima
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, 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
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Sullivan S, Hammadah M, Wilmot K, Ramadan R, Pearce BD, Shah A, Kaseer B, Gafeer MM, Lima BB, Kim JH, Ward L, Ko YA, Lewis TT, Hankus A, Elon L, Li L, Bremner JD, Raggi P, Quyyumi A, Vaccarino V. Young Women With Coronary Artery Disease Exhibit Higher Concentrations of Interleukin-6 at Baseline and in Response to Mental Stress. J Am Heart Assoc 2019; 7:e010329. [PMID: 30571600 PMCID: PMC6405549 DOI: 10.1161/jaha.118.010329] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Young women with coronary artery disease (CAD), a group with high psychosocial burden, were previously shown to have higher levels of interleukin‐6 (IL‐6) compared with men of similar age. We sought to examine IL‐6 response to acute stress in CAD patients across sex and age, and contrast results to healthy controls and other biomarkers known to increase with mental stress (monocyte chemoattractant protein‐1 and matrix metallopeptidase‐9) and known limited stress‐reactivity (high‐sensitivity C‐reactive protein). Methods and Results Inflammatory biomarkers were measured at rest and 90 minutes after mental stress (speech task) among 819 patients with CAD and 89 healthy controls. Repeated‐measures models were used to investigate age (continuous) and sex differences across time, before and after adjusting for demographics, CAD risk factors, depressive symptoms, medication use, and CAD severity. Among patients with CAD, the mean age was 60 years (range, 25–79) and 31% were women. Younger women with CAD had significantly higher concentrations of IL‐6 at rest, 90 minutes after mental stress, as well as a higher response to stress, compared with similarly aged men (P<0.05 for sex by age interactions). In contrast, IL‐6 increased with age, and there were no sex differences in IL‐6 levels or response to stress among controls. Inflammatory responses to stress for high‐sensitivity C‐reactive protein, monocyte chemoattractant protein‐1, and matrix metallopeptidase‐9 among CAD patients were similar in women and men. Conclusions IL‐6 response to mental stress are higher in young women with CAD than men of similar age.
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Affiliation(s)
- Samaah Sullivan
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Muhammad Hammadah
- 2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Kobina Wilmot
- 2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Ronnie Ramadan
- 2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Brad D Pearce
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Amit Shah
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA.,2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,3 Atlanta VA Medical Center Decatur GA
| | - Belal Kaseer
- 2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Mohamad Mazen Gafeer
- 2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Bruno B Lima
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA.,2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Jeong Hwan Kim
- 2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Laura Ward
- 4 Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Yi-An Ko
- 4 Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Tené T Lewis
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Allison Hankus
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Lisa Elon
- 4 Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Lian Li
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - J Douglas Bremner
- 3 Atlanta VA Medical Center Decatur GA.,5 Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Atlanta GA
| | - Paolo Raggi
- 6 Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - Arshed Quyyumi
- 2 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Viola Vaccarino
- 1 Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA.,2 Division of Cardiology Department of Medicine 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] [What about the content of this article? (0)] [Affiliation(s)] [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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36
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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: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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38
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Affiliation(s)
- Puja K Mehta
- Emory Women’s Heart Center, 1432 Clifton Rd NE, Suite 505, Atlanta, GA, USA
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1432 Clifton Rd NE, Suite 505, Atlanta, GA, USA
| | - Bruno B Lima
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1432 Clifton Rd NE, Suite 505, Atlanta, GA, USA
- Rollins School of Public Health, 1518 Clifton Rd, Atlanta, GA, USA
| | - Michael D Nelson
- University of Texas at Arlington, 701 W Nedderman Dr, Arlington Room 105, TX, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd #A3600, Los Angeles, CA, USA
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39
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Moazzami K, Lima BB, Sullivan S, Shah A, Bremner JD, Vaccarino V. Independent and joint association of obesity and metabolic syndrome with depression and inflammation. Health Psychol 2019; 38:586-595. [PMID: 31120270 DOI: 10.1037/hea0000764] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate the separate and combined associations of obesity and metabolic syndrome (MetS) with depression and the role of inflammation. METHOD Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9) and was defined with a cutpoint of ≥10. Obesity was defined as body mass index (BMI) ≥30 kg/m2 from measured height and weight. MetS was defined based on the American Heart Association consensus definition. Participants were divided into four groups: healthy normal weight (MHN), metabolically healthy obese (MHO), metabolically unhealthy normal weight (MUN), and metabolic unhealthy obese (MUO). C-Reactive protein was assessed in a subsample. RESULTS A total of 18,025 subjects were included in the analysis. Participants with MUO had the highest prevalence of depression compared with the MHN group (14.8% vs. 6.8, p < .001). While both obesity and MetS were independently associated with depression, there was a significant interaction between the two (p < .001), indicating that the associations of obesity and MetS with depression were synergistic. After adjusting for baseline characteristics, compared with the MHN group, the MUO group had the highest odds of depression (odds ratio [OR] = 2.30, 95% CI [2.03, 2.61]), followed by MHO group (OR = 1.51, 95% CI [1.30, 1.74]) and the MUN group (OR = 1.39, 95% CI [1.18, 1.64]). The MUO group also showed the highest level of C-reactive protein, and the latter partially mediated the effect between MUO and depressive symptoms (20.5% of the total effect). CONCLUSION Both obesity and MetS are associated with depression independent of each other, but when present together, these conditions have a synergistic association with depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Bruno B Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | | | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University
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40
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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. Corrigendum to "Posttraumatic stress disorder is associated with enhanced interleukin-6 response to mental stress in subjects with a recent myocardial infarction" [Brain Behav. Immun. 75 (2019) 26-33]. Brain Behav Immun 2019; 78:204-205. [PMID: 30926160 DOI: 10.1016/j.bbi.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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 Hwang 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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41
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Lima BB, Hammadah M, Kim JH, Ko YA, Sullivan S, Moazzami K, Young A, Alkhoder A, Obideen M, Abdelhadi N, Kaseer B, Gafeer MM, Shah A, Ward L, Bremner D, Raggi P, Vaccarino V, Quyyumi AA. HIGH SENSITIVITY CARDIAC TROPONIN I ELEVATION WITH EXERCISE PREDICTS MAJOR CARDIOVASCULAR DISEASE EVENTS IN CORONARY ARTERY DISEASE PATIENTS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)33677-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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42
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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: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Shah A, Chen C, Campanella C, Kasher N, Evans S, Reiff C, Mishra S, Hammadah M, Lima BB, Wilmot K, Mheid IA, Alkhoder A, Isakadze N, Levantsevych O, Pimple PM, Garcia EV, Wittbrodt M, Nye J, Ward L, Lewis TT, Kutner M, Raggi P, Quyyumi A, Vaccarino V, Bremner JD. Brain correlates of stress-induced peripheral vasoconstriction in patients with cardiovascular disease. Psychophysiology 2019; 56:e13291. [PMID: 30276815 PMCID: PMC6331265 DOI: 10.1111/psyp.13291] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/27/2018] [Accepted: 08/21/2018] [Indexed: 01/15/2023]
Abstract
The influence of acute psychological stress on cardiovascular disease is an emerging public health concern. Identification of brain mechanisms underlying this may aid in the discovery of possible treatments. Acute psychological stress may induce arteriolar vasoconstriction and reduce blood flow to vital organs. We hypothesized that functional changes in brain regions involved with memory and autonomic/emotional regulation are implicated in the vasoconstrictive stress response, including the medial prefrontal cortex (anterior cingulate), insula, and dorsolateral prefrontal cortex. Subjects with a history of coronary artery disease (N = 59) underwent measurement of microvascular vasomotor tone with the EndoPAT device and O-15 positron emission tomography (PET) imaging of the brain during exposure to mental stress and control conditions. The peripheral arterial tonometry (PAT) ratio was calculated as the mean peripheral vasomotor tone during stress divided by the mean tone during rest. Whole brain contrasts were performed between groups above and below the median PAT ratio, and significant contrasts were defined with cutoff p < 0.005. Stress-induced peripheral vasoconstriction (below median PAT ratio) was associated with increased stress activation in insula and parietal cortex, and decreased activation in the medial prefrontal cortex with stress tasks compared to control tasks. These findings demonstrate that stress-induced vasoreactivity is associated with changes in brain responses to stress in areas involved in emotion and autonomic regulation. These findings have important implications on possible treatments for mental stress-induced vascular toxicity.
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Affiliation(s)
- Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
- Atlanta Veterans Affairs Medical Center, Decatur, GA
| | - Chuqing Chen
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | | | - Nicole Kasher
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
| | - Sarah Evans
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Collin Reiff
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Sanskriti Mishra
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Muhammad Hammadah
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Kobina Wilmot
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Ibhar Al Mheid
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Ayman Alkhoder
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Nino Isakadze
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Oleksiy Levantsevych
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
| | - Pratik M Pimple
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
| | | | - Matthew Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Jonathon Nye
- Department of Radiology, Emory University School of Medicine
| | - Laura Ward
- Department of Biostatistics, Rollins School of Public Health, Emory University
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
| | - Michael Kutner
- Department of Biostatistics, Rollins School of Public Health, Emory University
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Arshed Quyyumi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, and the Departments
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - J. Douglas Bremner
- Atlanta Veterans Affairs Medical Center, Decatur, GA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
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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: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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45
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Hammadah M, Kim JH, Tahhan AS, Kindya B, Liu C, Ko YA, Al Mheid I, Wilmot K, Ramadan R, Alkhoder A, Choudhary F, Gafeer MM, Abdelhadi N, Pimple P, Sandesara P, Lima BB, Shah AJ, Ward L, Kutner M, Bremner JD, Sheps DS, Raggi P, Sperling LS, Vaccarino V, Quyyumi AA. Use of High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia: A Cohort Study. Ann Intern Med 2018; 169:751-760. [PMID: 30398528 PMCID: PMC6942174 DOI: 10.7326/m18-0670] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Many patients with coronary artery disease (CAD) are routinely referred for surveillance stress testing despite recommendations against it. OBJECTIVE To determine whether low levels of resting high-sensitivity cardiac troponin I (hs-cTnI) can identify persons without inducible myocardial ischemia. DESIGN Observational study. SETTING A university-affiliated hospital network. PATIENTS Persons with stable CAD: 589 in the derivation group and 118 in the validation cohort. MEASUREMENTS Presence of inducible myocardial ischemia was determined by myocardial perfusion imaging with technetium-99m single-photon emission computed tomography during either treadmill or pharmacologic stress testing. Resting plasma hs-cTnI was measured within 1 week of the stress test, and the negative predictive value (NPV) for inducible ischemia was calculated. The derivation cohort was followed for 3 years for incident cardiovascular death and myocardial infarction. RESULTS In the derivation cohort, 10 of 101 patients with an hs-cTnI level below 2.5 pg/mL had inducible myocardial ischemia (NPV, 90% [95% CI, 83% to 95%]) and 3 of 101 had inducible ischemia involving at least 10% of the myocardium (NPV, 97% [CI, 92% to 99%]). In the validation cohort, 4 of 32 patients with an hs-cTnI level below 2.5 pg/mL had inducible ischemia (NPV, 88% [CI, 71% to 96%]) and 2 of 32 had ischemia of 10% or greater (NPV, 94% [CI, 79% to 99%]). After a median follow-up of 3 years in the derivation cohort, no adverse events occurred in patients with an hs-cTnI level below 2.5 pg/mL, compared with 33 (7%) cardiovascular deaths or incident myocardial infarctions among those with an hs-cTnI level of 2.5 pg/mL or greater. LIMITATION The data may not be applicable to a population without known CAD or to persons with unstable angina, and the modest sample sizes warrant further validation in a larger cohort. CONCLUSION Very low hs-cTnI levels may be useful in excluding inducible myocardial ischemia in patients with stable CAD. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Muhammad Hammadah
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Jeong Hwan Kim
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Ayman Samman Tahhan
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Bryan Kindya
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Chang Liu
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Yi-An Ko
- Emory University, Atlanta, Georgia (Y.K., P.P., L.W., M.K.)
| | - Ibhar Al Mheid
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Kobina Wilmot
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Ronnie Ramadan
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Ayman Alkhoder
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Fahad Choudhary
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Mohamad Mazen Gafeer
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Naser Abdelhadi
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Pratik Pimple
- Emory University, Atlanta, Georgia (Y.K., P.P., L.W., M.K.)
| | - Pratik Sandesara
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Bruno B Lima
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Amit J Shah
- Emory University School of Medicine and Emory University, Atlanta, Georgia (A.J.S., V.V.)
| | - Laura Ward
- Emory University, Atlanta, Georgia (Y.K., P.P., L.W., M.K.)
| | - Michael Kutner
- Emory University, Atlanta, Georgia (Y.K., P.P., L.W., M.K.)
| | - J Douglas Bremner
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - David S Sheps
- University of Florida, Gainesville, Florida (D.S.S.)
| | - Paolo Raggi
- University of Alberta, Edmonton, Alberta, Canada (P.R.)
| | - Laurence S Sperling
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
| | - Viola Vaccarino
- Emory University School of Medicine and Emory University, Atlanta, Georgia (A.J.S., V.V.)
| | - Arshed A Quyyumi
- Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)
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Thombs BD, de Jonge P, Coyne JC, Whooley MA, Frasure-Smith N, Mitchell AJ, Zuidersma M, Eze-Nliam C, Lima BB, Smith CG, Soderlund K, Ziegelstein RC. Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA 2008; 300:2161-71. [PMID: 19001627 DOI: 10.1001/jama.2008.667] [Citation(s) in RCA: 376] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Several practice guidelines recommend that depression be evaluated and treated in patients with cardiovascular disease, but the potential benefits of this are unclear. OBJECTIVE To evaluate the potential benefits of depression screening in patients with cardiovascular disease by assessing (1) the accuracy of depression screening instruments; (2) the effect of depression treatment on depression and cardiac outcomes; and (3) the effect of screening on depression and cardiac outcomes in patients in cardiovascular care settings. DATA SOURCES MEDLINE, PsycINFO, CINAHL, EMBASE, ISI, SCOPUS, and Cochrane databases from inception to May 1, 2008; manual journal searches; reference list reviews; and citation tracking of included articles. STUDY SELECTION We included articles in any language about patients in cardiovascular care settings that (1) compared a screening instrument to a valid major depressive disorder criterion standard; (2) compared depression treatment with placebo or usual care in a randomized controlled trial; or (3) assessed the effect of screening on depression identification and treatment rates, depression, or cardiac outcomes. DATA EXTRACTION Methodological characteristics and outcomes were extracted by 2 investigators. RESULTS We identified 11 studies about screening accuracy, 6 depression treatment trials, but no studies that evaluated the effects of screening on depression or cardiovascular outcomes. In studies that tested depression screening instruments using a priori-defined cutoff scores, sensitivity ranged from 39% to 100% (median, 84%) and specificity ranged from 58% to 94% (median, 79%). Depression treatment with medication or cognitive behavioral therapy resulted in modest reductions in depressive symptoms (effect size, 0.20-0.38; r(2), 1%-4%). There was no evidence that depression treatment improved cardiac outcomes. Among patients with depression and history of myocardial infarction in the ENRICHD trial, there was no difference in event-free survival between participants treated with cognitive behavioral therapy supplemented by an antidepressant vs usual care (75.5% vs 74.7%, respectively). CONCLUSIONS Depression treatment with medication or cognitive behavioral therapy in patients with cardiovascular disease is associated with modest improvement in depressive symptoms but no improvement in cardiac outcomes. No clinical trials have assessed whether screening for depression improves depressive symptoms or cardiac outcomes in patients with cardiovascular disease.
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Affiliation(s)
- Brett D Thombs
- Department of Psychiatry, McGill University, Montréal, Québec, Canada.
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