Effect of Escitalopram on Mental Stress–Induced Myocardial Ischemia

Jiang, Wei; Velázquez, Eric J.; Kuchibhatla, Maragatha; Samad, Zainab; Boyle, Stephen H.; Kuhn, Cynthia M.; Becker, Richard C.; Ortel, Thomas L.; Williams, Redford B.; Rogers, Joseph G.; O’Connor, Christopher M.

doi:10.1001/jama.2013.5566

Cited by 88 publications

(62 citation statements)

References 36 publications

(47 reference statements)

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“…10 From a diagnostic perspective, several reviews of myocardial perfusion studies (the method used in the article by Sullivan et al to assess ischemia) using exercise/pharmacological stress have consistently found lower sensitivity and specificity for the prediction of heart disease in women relative to men. 11,12 Historically, one of the primary explanations for this imbalance in imaging techniques in women, compared with men, has been attributed to anatomy.…”

Section: See Accompanying Article On Page 473mentioning

confidence: 99%

“…After 6 weeks, the selective serotonin reuptake inhibitor lead to significant reductions in MSIMI and no statistical impact on exercise-induced ischemia. 10 This improvement seemed to be driven by increased left ventricular function (at rest and after mental stress) and stress-induced decreases in rate pressure product (a measure of myocardial oxygen demand). Unfortunately, these outcomes were not Bacon Sex, Gender, Stress, and Heart Disease 291 broken down to explore sex-specific patterns.…”

Section: See Accompanying Article On Page 473mentioning

confidence: 99%

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The Importance of Sex in the Stress–Heart Disease Relationship and the Potential Contribution of Gender to Future Research

Bacon

2018

ATVB

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We now have numerous studies that have linked increased levels of negative emotions and stress with the development and progression of cardiovascular disease-a relationship that seems to be sex specific in its pattern of outcomes. 1,2 However, the mechanisms of these relationships are still a source of much debate. One of the strongest potential pathways linking acute psychological stress with worse outcomes is through mental stress-induced myocardial ischemia (MSIMI).3 Though there is a large overlap (ca. 70%) in individuals who demonstrate both MSIMI and more common (ie, exercise or pharmacological) stress-induced ischemia, 4 these seem to be distinctly different entities. Firstly, it would seem that more individuals are likely to have MSIMI only than exercise/pharmacological stress-induced ischemia only (20% versus 10%).5 Furthermore, the profiles and potential mechanistic factors of those at risk for MSIMI compared with exercise/pharmacological stress-induced ischemia are different. For example, those individuals who exhibit MSIMI are more likely to be women, have greater microvascular disease, have poorer left ventricular dysfunction, and display endothelial dysfunction, whereas exercise/pharmacological stress-induced ischemia is generally associated with men and those with larger and more diffuse coronary artery plaque. [4][5][6] Though there are sex differences in the rates of presentations of both MSIMI and exercise/pharmacological stress-induced ischemia, both men and women do exhibit both of these forms of ischemia. However, we do not know if the mechanistic factors that underlie these stress-induced ischemia differ by sex; for example, does MSIMI in women differ from MSIMI in men? Understanding these processes can ultimately help in the development of better tailored diagnostic procedures and interventions to treat cardiovascular disease. See accompanying article on page 473The article by Sullivan et al 7 provides some important initial insights into sex differences in the potential mechanisms driving MSIMI. This secondary analysis of 678 (25% women) patients in the MIPS study (Mental Stress Ischemia Mechanisms and Prognosis) evaluated mental stress (public speaking)-induced vascular and hemodynamic responses. The authors found that MSIMI was generally driven by peripheral vasoconstriction in women compared with increased hemodynamic workload in men, results that were independent of exercise/pharmacological stress-induced ischemia. These results suggest that men with MSIMI are effectively cardiac stress reactors, with increased myocardial oxygen demands, and women with MSIMI are more likely to be vascular reactors, with greater endothelial driven increases in vascular resistance (which leads to increased left ventricular afterload and dysfunction).8 However, the article by Sullivan et al does only provide initial insights, and there is a great deal of further information that we need. For example, building a more complex map of MSIMI, to include additional measures of the autonomic nervous system, the...

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Section: See Accompanying Article On Page 473mentioning

confidence: 99%

Section: See Accompanying Article On Page 473mentioning

confidence: 99%

The Importance of Sex in the Stress–Heart Disease Relationship and the Potential Contribution of Gender to Future Research

Bacon

2018

ATVB

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“…The REMIT study was a double-blind trial that randomised 127 patients with stable coronary disease and MSIMI, demonstrated on echocardiography and/or ECG, to either escitalopram or placebo for 6 weeks 78. At follow–up, more patients taking escitalopram versus placebo had no evidence of MSIMI on rechallenge (34% vs 18%, p=0.04).…”

Section: Management Of Msimimentioning

confidence: 99%

“…There was an improvement in LVEF both at rest and after mental stress, as well as decreases in HR and RPP during the mental stress protocol in the treatment group. The positive effects of Escitalopram observed may be due to reduced platelet aggregation79 or a downstream effect of modification of central and peripheral serotenergic function 78…”

Section: Management Of Msimimentioning

confidence: 99%

Mental stress-induced myocardial ischaemia

Arri

Ryan

Redwood

et al. 2016

Heart

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“…The baseline description 10 and primary findings 11 from the largest single study of MSI to date (N=310), the Responses of Myocardial Ischemia to Escitalopram Treatment (REMIT) Trial were published this year. The REMIT placebo controlled randomized trial was designed to investigate whether treatment with escitalopram, a selective serotonin reuptake inhibitor (SSRI), can improve MSI 12 .…”

Section: Recent Findingsmentioning

confidence: 99%