Mental Stress–Induced Ischemia and All-Cause Mortality in Patients With Coronary Artery Disease

Abstract

Background-Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates. Methods and Results-To determine whether mental stress-induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5Ϯ0.4 years and 5.2Ϯ0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (Pϭ0.04) and significantly predicted death (rate ratioϭ3.0; 95% CI, 1.04 to 8.36; Pϭ0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (Pϭ0.9) and did not predict death even after adjusting for resting ejection fraction (Pϭ0.63), which was similar in both groups (mean, 56.4 versus 59.7; Pϭ0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise. Conclusions-In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stressinduced ischemia predicts subsequent death.

Cintilografia miocárdica com estresse mental na investigação de dor torácica

“…The presence of stress-induced myocardial ischemia in patients with atypical anginous thoracic pain, but without obstructive coronary disease, is frequently associated with endothelial dysfunction 7 . Several experimental studies have contributed to a better understanding on the association between psychological stress and myocardial ischemia, with emphasis given to the Psychophysiological Interventions in Myocardial Ischemia (PIMI) study, in which the different responses to physical and psychological stress of carriers of coronary arterial disease and the association of psychological stress ischemia with mortality are documented 8 . Psychological stress unleashes an increase in heart rate and in blood pressure, which are measured through stimulation of adrenergic sympathetic activity.…”

Mental Stress–Induced Ischemia and All-Cause Mortality in Patients With Coronary Artery Disease

“…1 The conclusion reached in the article is that the association between wall motion abnormalities during mental stress and mortality is important and probably underestimated by the unadjusted risk ratio of 2.79 (1.00 to 7.85). The authors suggest that investigations should be undertaken to determine whether a cheaper version of this test could be developed for the clinical setting.…”

Variability of myocardial ischemic responses to mental versus exercise or adenosine stress in patients with coronary artery disease

“…2, 3 Several studies have shown that the development of myocardial ischemia in this setting, predicts ischemia during daily life, is a poor prognostic factor and is linked to fatal and nonfatal cardiac events in patients with CAD. [2][3][4][5][6][7][8] Exercise or adenosine stress testing is commonly used in clinical settings as a risk stratification tool in patients with CAD. However there is evidence that these testing modalities may not adequately assess the likelihood of risk related to mental stress.…”