Association of Emotional States with Heart Rate Variability in Patients with Suspected Ischemic Heart Disease: Relevant to Cardiac Symptoms During Daily Life

Objective: Autonomic nervous system dysregulation has been linked to cardiovascular disease risk. Both long-term and short-term emotional distress have also been associated with adverse cardiovascular outcomes. However, the relationship between acute emotional states and autonomic regulation in patients with ischemic heart disease remains unclear. This study examines the association between in-the-moment emotional states with short-term heart rate variability (HRV) indices of autonomic activity and their contribution to cardiac symptoms during daily life activities. Methods: Patients referred for diagnostic myocardial perfusion imaging (MPI) for inducibility of myocardial ischemia underwent 24-hour ecological momentary assessments (EMA) of emotional states and cardiac symptoms using electronic diaries via their mobile phones. Ambulatory ECG-based HRV indices (repeated 10-minute epochs and 24 hours) were matched with the EMA assessments. Associations were analyzed using General Estimation Equation models. Results: A total of 175 EMA assessments were obtained in 26 patients (mean age=66.5±9.3 years, 7 (26.9%) women). Negative emotional states were associated with HRV indices (lower standard deviation of normal-to-normal intervals and low-frequency power) and higher heart rate. Negative emotional states were associated with anginal complaints (B=0.167 [95%CI=0.067;0.268], P <0.001) and shortness of breath (B=0.136 [95%CI=0.071;0.202], P <0.001). Lower HRV indices were also associated with these cardiac symptoms. Ischemia during MPI was negatively correlated with 24-hour low-frequency HRV, but not with negative emotions or cardiac symptoms during daily life. Conclusions: Negative emotions are related to potentially adverse changes in autonomic regulation, contributing cardiac symptoms. These results highlight the value of in-the-moment emotional states for understanding autonomic dysregulation and cardiovascular symptoms.