Variability of myocardial ischemic responses to mental versus exercise or adenosine stress in patients with coronary artery disease (original) (raw)
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Mental Stress-Induced Ischemia in Patients With Coronary Artery Disease
Psychosomatic Medicine, 2012
Objective: The aims of this study were to investigate the incidence and parameters associated with myocardial ischemia during mental stress (MS) as measured by echocardiography and to evaluate the relation between MS-induced and exercise-induced myocardial ischemia. Methods: Study participants were 79 patients (63 men; mean [M] [standard deviation {SD}] age = 52 [8] years) with angiographically confirmed coronary artery disease and previous positive exercise test result. The MS protocol consisted of mental arithmetic and anger recall task. The patients performed a treadmill exercise test 15 to 20 minutes after the MS task. Data of postYMS exercise were compared with previous exercise stress test results. Results: The frequency of echocardiographic abnormalities was 35% in response to the mental arithmetic task, compared with 61% with anger recall and 96% with exercise ( p G .001, exercise versus MS). Electrocardiogram abnormalities and chest pain were substantially less common during MS than were echocardiographic abnormalities. Independent predictors of MS-induced myocardial ischemia were: wall motion score index at rest ( p = .02), peak systolic blood pressure ( p = .005), and increase in rate-pressure product ( p = .004) during MS. The duration of exercise stress test was significantly shorter p G .001) when MS preceded the exercise and in the case of earlier exercise (M [SD] = 4.4 [1.9] versus 6.7 [2.2] minutes for patients positive on MS and 5.7 [1.9] versus 8.0 [2.3] minutes for patients negative on MS). Conclusions: Echocardiography can be successfully used to document myocardial ischemia induced by MS. MS-induced ischemia was associated with an increase in hemodynamic parameters during MS and worse function of the left ventricle. MS may shorten the duration of subsequent exercise stress testing and can potentiate exercise-induced ischemia in susceptible patients with coronary artery disease. Key words: mental stress, myocardial ischemia, exercise stress echocardiography. MS = mental stress; CAD = coronary artery disease; ECG = electrocardiogram.
Objective: The aims of this study were to investigate the incidence and parameters associated with myocardial ischemia during mental stress (MS) as measured by echocardiography and to evaluate the relation between MS-induced and exercise-induced myocardial ischemia. Methods: Study participants were 79 patients (63 men; mean [M] [standard deviation {SD}] age = 52 [8] years) with angiographically confirmed coronary artery disease and previous positive exercise test result. The MS protocol consisted of mental arithmetic and anger recall task. The patients performed a treadmill exercise test 15 to 20 minutes after the MS task. Data of postYMS exercise were compared with previous exercise stress test results. Results: The frequency of echocardiographic abnormalities was 35% in response to the mental arithmetic task, compared with 61% with anger recall and 96% with exercise (p G .001, exercise versus MS). Electrocardiogram abnormalities and chest pain were substantially less common during MS than were echo-cardiographic abnormalities. Independent predictors of MS-induced myocardial ischemia were: wall motion score index at rest (p = .02), peak systolic blood pressure (p = .005), and increase in rate-pressure product (p = .004) during MS. The duration of exercise stress test was significantly shorter (p G .001) when MS preceded the exercise and in the case of earlier exercise (M [SD] = 4.4 [1.9] versus 6.7 [2.2] minutes for patients positive on MS and 5.7 [1.9] versus 8.0 [2.3] minutes for patients negative on MS). Conclusions: Echocardiography can be successfully used to document myocardial ischemia induced by MS. MS-induced ischemia was associated with an increase in hemodynamic parameters during MS and worse function of the left ventricle. MS may shorten the duration of subsequent exercise stress testing and can potentiate exercise-induced ischemia in susceptible patients with coronary artery disease. Key words: mental stress, myocardial ischemia, exercise stress echocardiography. MS = mental stress; CAD = coronary artery disease; ECG = electrocardiogram.
American Journal of Cardiology, 2005
To examine the susceptibility to myocardial ischemia with mental stress in patients who have coronary artery disease and normal left ventricular (LV) function versus those who have impaired LV function, we examined 58 patients who had coronary artery disease, including 22 who had normal LV function (ejection fraction >50%), 16 who had mild to moderate LV dysfunction (ejection fraction 30% to 50%), and 20 who had severe LV dysfunction (ejection fraction <30%) and underwent bicycle and mental stress testing with myocardial perfusion scintigraphy on consecutive days in random order. Ischemia was assessed based on summed difference scores in regional rest versus stress myocardial perfusion and defined as a summed difference score >3. At comparable double products across the 3 groups, ischemia was induced with mental stress more frequently in patients who had severe LV dysfunction (50%) than in those who had normal LV function (9%; p <0.01). The frequency of exercise-induced ischemia was different only between those who had mild/moderate LV dysfunction and those who had normal LV function (56% vs 18%, respectively, p <0.05). The pattern of mental stress versus exercise ischemia differed between groups (p <0.02): there was a higher prevalence of mental stress ischemia versus exercise ischemia in patients who had severe LV dysfunction (p ؍ 0.06), a marginally higher prevalence of exercise versus mental stress ischemia in those who had moderate LV dysfunction (p ؍ 0.07), and no difference in mental stress versus exercise ischemia in those who had normal LV function. Thus, at comparable double products during mental stress and similar extent of coronary artery disease, ischemia with mental stress was induced more frequently in patients who had severe LV dysfunction than in those who had normal LV function. These data suggest that mental stress ischemia may be of particular clinical importance in patients who have coronary artery disease and LV dysfunction. ᮊ2005 by Excerpta Medica Inc.
Myocardial ischemia during mental stress: role of coronary artery disease burden and vasomotion
Journal of the American Heart Association, 2013
Mental stress-induced myocardial ischemia (MSIMI) is associated with adverse prognosis in patients with coronary artery disease (CAD), yet the mechanisms underlying this phenomenon remain unclear. We hypothesized that compared with exercise/pharmacological stress-induced myocardial ischemia (PSIMI) that is secondary to the atherosclerotic burden of CAD, MSIMI is primarily due to vasomotor changes. Patients with angiographically documented CAD underwent 99mTc-sestamibi myocardial perfusion imaging at rest and following both mental and physical stress testing, performed on separate days. The severity and extent of CAD were quantified using the Gensini and Sullivan scores. Peripheral arterial tonometry (Itamar Inc) was used to assess the digital microvascular tone during mental stress as a ratio of pulse wave amplitude during speech compared with baseline. Measurements were made in a discovery sample (n = 225) and verified in a replication sample (n = 159). In the pooled (n = 384) samp...
Mental stress-induced myocardial ischemia in women with angina and normal coronary angiograms
Journal of Nuclear Cardiology, 2006
Background Coronary artery disease is frequent in postmenopausal women. Silent myocardial ischemia has been induced with mental stress testing. Methods and Results To evaluate whether mental stress can induce ischemia in women with typical angina and normal coronary angiography, postmenopausal patients (n = 16) were studied. Each underwent technetium 99m methoxyisobutylisonitrile myocardial scintigraphy (exercise stress/rest/mental stress protocol), brachial artery endothelial function measurement by ultrasonography, and 24-hour ambulatory electrocardiographic recording (Holter). During mental stress testing, 6 patients (group I) had reversible perfusion defects on myocardial scintigraphy whereas the other 10 patients (group II) did not. Group I patients exhibited endothelial dysfunction more frequently than those in group II (83% vs 20%). Myocardial scintigraphy showed anteroapical/septal ischemia in 5 patients and inferoapical ischemia in one other patient, with both types of stress. Among group II patients, none showed a reversible perfusion defect during physical or mental stress. No group I patients had evidence of ischemia by Holter monitoring, whereas 2 of 10 group II patients did. Conclusion In postmenopausal women with typical angina and normal coronary arteries, mental stress may provoke myocardial ischemia, which can be concordant with ischemia induced by exercise stress, and is associated with endothelial dysfunction.
Mental stress–induced myocardial ischemia: Moving forward
Journal of Nuclear Cardiology, 2007
See related article, p. 308 The article by Hassan et al 1 in this issue of the Journal is the latest description of a phenomenonmental stress-induced myocardial ischemia (MSIMI)that has been growing in recognition in the cardiology community. This clinical presentation has been historically and consistently explored and brought to the attention of our peers by the efforts of those engaged in clinical research using nuclear cardiology approaches. Among the first descriptions of this form of provoked ischemia in the laboratory was that of Deanfield et al, 2 who used rubidium 82 to image myocardial perfusion via positron emission tomography. This study reported that 12 of 16 patients evidenced a flow defect during the performance of a mental arithmetic task. Of note, the defect associated with mental arithmetic was comparable in size and location to that observed during exercise, although in many cases there were enough differences in the extent and severity of the observed defect to indicate possible differences between MSIMI and exerciseinduced myocardial ischemia in underlying pathophysiology. More recent work has identified the importance of impaired myocardial blood flow, particularly in the microvascular bed, with regard to MSIMI, 3-5 as well as the prognostic significance of this phenomenon. 6-8 Indeed, in the PIMI (Psychophysiological Investigations of Myocardial Ischemia) multicenter study, the investigators found a 3-fold rate ratio of death at 5 years among those who demonstrated MSIMI in the laboratory, as compared with those who did not, controlling for standard risk factors for death. 9 Other work has identified anger, as well as the ease with which one experiences this emotion when under stress, as a vulnerability marker
International journal of cardiac imaging, 1998
Transient ischemic episodes at rest in patients with coronary artery disease have been attributed to mental stress. The means to monitor and record cardiac function changes due to mental stress is now available by utilizing the nuclear VEST. Eight, patients with angiographically documented coronary artery disease and 8 normal volunteers underwent a 4 hour session of continuous monitoring and recording of the left ventricular function, electrocardiogram, and blood pressure during exercise and mental stress. In the normal group, all subjects showed the expected normal response to exercise with an increase in ejection fraction, heart rate and blood pressure. During mental stress two subjects (25%) showed transient episodes of ejection fraction decrease that were not associated with chest pain, ST changes or significant changes in blood pressure. In the group of coronary artery disease patients, five (63%) had an ischemic response to exercise by electrocardiographic and radionuclide ven...