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Mental stress-induced myocardial ischemia and events in coronary artery disease. MSIMI is associated with twofold increased events in patients with CAD compared to those with no ischemia, and almost a fourfold increased risk when combined with conventional stress ischemia. MI, myocardial infarction. (Figure reprinted with permission from JAMA. 2021. 326(18): 1818–28. Copyright© (2021) American Medical Association. All rights reserved)
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Purpose of Review
To summarize recent evidence on mental stress-induced myocardial ischemia (MSIMI), its mechanisms, and clinical significance.
Recent Findings
MSIMI can occur in patients with normal cardiac stress testing, is only weakly related to severity of coronary artery disease (CAD), and it is often silent. Among patients with CAD, MSIMI i...
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Underlying coronary artery disease (CAD) is increasingly considered to be a key issue in the pathophysiology of type 2 myocardial infarction (T2MI). In T2MI, which is attributable to a mismatch between oxygen supply/demand, CAD is common and appears to be more severe than in type 1 myocardial infarction (T1MI). Little is known about the heterogeneo...
Citations
... While traditional risk factors implicated in heart disease in women are causal (i.e., hypertension, smoking, dyslipidemia), some factors are associative (i.e., depression) and the exact contribution of psychological risk factors is difficult to determine in isolation. Psychological and psychosocial stress factors are prevalent in women and contribute to increased cardiometabolic risk, partly due to less risk factor control, non-adherence, and lack of access [65,119,120] . The impact of psychological risk factors such as mental stress-induced ischemia, depression, and anxiety in the setting of established traditional risk factors in heart disease in women is an active area of investigation [120][121][122][123][124][125]65] . ...
Heart disease remains a major health threat in women. Cardiometabolic risk factors such as obesity and diabetes differentially and adversely impact heart disease risk. Although obstructive coronary artery disease is an important cause of ischemic heart disease in women and is prognostic, women are more likely to have angina and myocardial ischemia without obstructive atherosclerosis, which has been attributed to coronary microvascular dysfunction (CMD). Heart failure with preserved ejection fraction (HFpEF) is another condition that predominates in women. CMD and HFpEF are both associated with cardiometabolic risk factors that are prevalent in women. Women are also more likely to have additional risk-enhancing conditions such as autoimmune dysfunction, chronic inflammation, and sex-specific hormonal factors that adversely influence risk. In this review, we focus on cardiometabolic risk factors of obesity and diabetes in heart disease in women, including ischemic heart disease from CMD, HFpEF, and arrythmias. Team-based care to focus on cardiometabolic risk reduction is needed to alter adverse heart disease outcomes in women. Identification, education, treatment, and active surveillance of these dysmetabolic risk factors are imperative in the primary and secondary prevention of heart disease in women.
... Así pues, y dada su prevalencia, padecer estrés, ansiedad o depresión representa un serio problema de salud mental entre los universitarios (Lee & Kim, 2018;Schultchen et al., 2019), el cual se ha agravado aún más a raíz de la pasada pandemia por covid-19 (Dosil-Santamaria et al., 2022;Mehta et al., 2022). ...
... Desde el punto de vista psicológico, producen sentimientos de incompetencia, frustración y enojo; además, pueden afectar procesos cognitivos relevantes como la atención, la concentración, la toma de decisiones y las habilidades sociales (Ortiz et al., 2019). En cuanto a la salud física, se ven perjudicados diferentes sistemas como el cardiaco, respiratorio y digestivo (Mehta et al., 2022); asimismo, los estados emocionales negativos promueven conductas de riesgo como el uso de drogas, malos hábitos alimenticios y una actividad física reducida (Schultchen et al., 2019). Al final, el conjunto de todos estos factores o la combinación de algunos de ellos afecta el rendimiento escolar y la permanencia de los estudiantes en su programa educativo (Kuz & Morales, 2023). ...
... Así, puede registrarse, por ejemplo, los niveles de cortisol en saliva, el ritmo cardiaco, la actividad de las glándulas sudoríparas y los biomarcadores de inflamación (Schultchen et al., 2019). Generalmente, estos marcadores psicofisiológicos se relacionan con desbalances autonómicos (en los cuales hay predominancia simpática) y con alteraciones en la respuesta inflamatoria (Mehta et al., 2022). Como se ha documentado, el sistema nervioso autonómico modula las respuestas fisiológicas del organismo ante diferentes estímulos, por lo que en general controla las respuestas de estrés y relajación (Mehta et al., 2022). ...
El entrenamiento en respiración es útil para modificar el estado emocional y autonómico. El objetivo de este estudio fue determinar el efecto de la respiración diafragmática sobre la actividad autonómica y el estado emocional de universitarios irregulares. Mediante un muestreo no probabilístico y sin grupo control, se realizó un entrenamiento en relajación. Se midieron variables emocionales (ansiedad, depresión y estrés) y autonómicas (conductancia galvánica de la piel [CGP] y frecuencia cardiaca [FC]) para comparar los registros antes y después del entrenamiento. La intervención promovió decrementos significativos en los niveles de depresión (t = 5.559, gl = 28, p < 0.001), así como de ansiedad y estrés (t = 6.432, gl = 28, p < 0.001). La CGP también disminuyó (t = 2.327, gl = 28, p = 0.027), pero no la FC (t = 0.405, gl =28, p = 0.689). Es decir, las personas estaban menos estresadas, aunque no más relajadas. La respiración diafragmática es eficaz para el control emocional y el funcionamiento autonómico de universitarios irregulares.
... The increased thromboembolic risk in cancer patients is a complex and multifactorial phenomenon, including the release of several pro-coagulant factors by tumors [29]. Since ATE risk is higher in the early months after cancer diagnosis, psychological stress affecting cancer patients can represent a trigger for ATE events [37]. Thrombus formation is the final stage of complex interactions between coagulation, fibrinolysis, and innate immune systems. ...
The correlation between cancer and venous thromboembolism (VTE) is solid, whereas the knowledge about cancer-related arterial thromboembolism (ATE) still needs a deeper investigation to clarify its pathogenesis. We describe two cases that represent useful hints for a comprehensive review of the thrombotic issue. A 75-year-old man with advanced rectal cancer treated with fluo-ropyrimidines suffered two catheter-related VTE events managed according to current guidelines. There was no indication for "extended" anticoagulant therapy for him, but during antithrombotic wash-out and fluoropyrimidines plus panitumumab regimen, he suffered a massive right coronary artery (RCA) thrombosis. Another patient with no cardiovascular (CV) risk factors and affected by advanced bladder cancer was treated with a platinum-containing regimen and suffered an acute inferior myocardial infarction 2 days after chemotherapy administration. He was successfully treated with primary Percutaneous Transluminal Coronary Angioplasty of RCA, discontinuing platinum-based therapy. Our observations raise the issue of cancer-associated thrombosis (CAT) complexity and the potential correlation between arterial and venous thrombotic events. Moreover, physicians should be aware of the thrombotic risk associated with anticancer therapies, suggesting that an appropriate prophylaxis should be considered.
... However, gender-related differences in socio-economic and psychological status have emerged as additional important contributors to these conditions. stress-induced ischemia is associated with 2-fold higher mortality during follow up [40,41]. ...
... [57][58][59] Although there have recently been several review articles on mental stress and cardiovascular disease, no new large prospective clinical studies of MSIMI have been reported. [60][61][62] The methodology for inducing mental stress and the method of diagnosing myocardial ischaemia have not been standardised. Reported trials included only between 35 and 660 patients, and the largest series reporting over 900 patients was only possible because of pooling together two different studies. ...
Increasing observational and experimental trial data have shown that mental stress can lead to an increase in adverse clinical cardiovascular events. Mental stress affects the heart by inducing ischaemia and precipitating myocardial infarction (MI) or direct myocardial injury. Mental stress leads to systemic inflammation. Inflammation is known to cause rapid atheromatous plaque progression, instability and thrombosis—the classic type 1 MI. Inflammation can also lead to type 2 MI or myocarditis and injury. The published data linking systemic inflammation, mental stress and cardiovascular disease will be reviewed to establish the linkage between mind and heart, thereby highlighting the importance of holistically managing the patient, not only addressing separate organ systems. Finally, recent trial evidence showing the value of anti-inflammatory drugs in cardiovascular and mental conditions will be briefly considered.
... Данные многочисленных исследований, продемонстрировавших высокий риск развития фатальных и нефатальных сердечно-сосудистых осложнений у пациентов, перенесших острый или хронический стресс, свидетельствуют о возрастаю щей актуальности выявления и коррекции эмоциональных факторов риска [6][7][8][9][10][11][12][13][14]. ...
Acute and chronic stress, as well as emotional disturbances as a consequence of stressful situations, are significant risk factors for the development and progression of some of acute and chronic non-communicable diseases, including cardiovascular diseases (CVD), among which the most common are arterial hypertension, chronic heart failure and atherosclerotic CVD. Specific emotional disturbances that arise after exposure to significant traumatic or stressful situations include acute and post-traumatic stress disorder. When a stress factor does not reach high intensity or significance, adjustment disorder may develop. Stress-related emotional disturbances significantly affect other CVD risk factors, reduce patients’ adherence to healthy lifestyle changes and drug therapy, deteriorate quality of life and increase the risk of disability. The urgency of identifying and managing post-stress emotional disturbances in the practice of internists is caused by high frequency of these disturbances in outpatient patients. It is especially important to manage and prevent these disturbances in patients with CVD due to increased number of adverse outcomes resulting from this combination. Treatment of emotional disturbances resulting from stressful situations includes both drug and non-drug methods. Antidepressants and benzo-diazepine anxiolytics are the main classes among the drugs used to treat post-stress emotional disorders. However, the prescription of these drugs requires taking into account a wide range of possible side effects, especially in patients with CVD. The choice of drugs with a favourable safety profile and a rapid onset of sedative and anti-anxiety effects is a key element in the modern effective patient management strategy. Tofisopam and buspirone are the most advanced of this group of drugs in therapeutic and cardiological practice.
... [44] In such a case scenario, behavioral therapy focusing on stress reduction has proven its benefit to reduce the burden of SMI. [45] conclusIon Much progress has been made to reduce mortality from CAD. However, this condition remains the leading cause of death worldwide. ...
Silent myocardial ischemia (SMI) is a relatively common phenomenon in patients with coronary artery disease (CAD). The original description of SMI dates back to the 1970s. We performed an extensive search of the literature starting from 2000, using MEDLINE or PubMed, and 676 documents were analyzed, and only 45 articles found suitable for the study were selected. Data regarding the prevalence and risk factors of SMI were discussed, along with the different mechanistic processes behind it; also, methods for screening and diagnosis are exposed, namely electrocardiographic stress test, stress echocardiography, and single-photon emission computed tomography (SPECT). The silent nature of the condition presumes that patients are diagnosed at a more advanced stage, and screening high-risk patients for early management is essential. Education of patients is necessary, and medical management along with cardiac rehabilitation is valid for mild cases, whereas patients with moderate-to-severe myocardial ischemia might require a more invasive approach. SMI is relatively common, diagnostic approach offers data regarding the presence of ischemia along with its anatomic extent, providing important prognostic value. Given its silent and critical nature, future directions for better screening and management must be searched and implemented extensively.
... 21,49 While mental stress is a lower hemodynamic stress compared to exercise stress, prior work has noted that mental stress leads to attenuated myocardial blood flow, and is associated with adverse cardiovascular outcomes. 35,50,51 Moreover, the present finding that differences in HR and HRV are revealed only during mental stress and not at rest reinforces the notion of a clinical phenotype of patients with angina, with no obstructive CAD but microvascular This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4569303 ...
BACKGROUND
Mental stress–induced myocardial ischemia (MSIMI) is associated with adverse cardiovascular outcomes in individuals with coronary artery disease, but the mechanisms underlying this phenomenon are unknown. We examined the relationship between stress-induced autonomic dysfunction, measured by low heart rate variability (HRV) in response to stress, and MSIMI in patients with stable coronary artery disease. We hypothesized that stress-induced autonomic dysfunction is associated with higher odds of MSIMI.
METHODS
In 735 participants with stable coronary artery disease, we measured high- and low-frequency HRV in 5-minute intervals before and during a standardized laboratory-based speech stressor using Holter monitoring. HRV at rest and stress were categorized into low HRV (first quartile) versus high HRV (second to fourth quartiles); the low category was used as an indicator of autonomic dysfunction. Multivariable logistic regression models were used to examine the association of autonomic dysfunction with MSIMI.
RESULTS
The mean age was 58 (SD, ±10) years, 35% were women, 44% were Black participants, and 16% developed MSIMI. Compared with high HRV during stress, low HRV during stress (both high and low frequencies) was associated with higher odds of MSIMI after adjusting for demographic and clinical factors (odds ratio for high-frequency HRV, 2.1 [95% CI, 1.3–3.3]; odds ratio for low-frequency HRV, 2.1 [95% CI, 1.3–3.3]). Low-frequency HRV at rest was also associated with MSIMI but with slightly reduced effect estimates.
CONCLUSIONS
In individuals with coronary artery disease, mental stress-induced autonomic dysfunction may be a mechanism implicated in the causal pathway of MSIMI.
