Prevalence and Clinical Characteristics of Mental Stress–Induced Myocardial Ischemia in Patients With Coronary Heart Disease
Key result
Mental stress triggers myocardial ischemia more frequently than exercise stress testing in stable CAD, affecting ~43%.
- P=0.002
- n=310
Why the study?
Mental stress-induced myocardial ischemia carries poor prognosis in coronary heart disease, but previous studies primarily evaluated patients with exercise-induced myocardial ischemia.
Does mental stress testing induce myocardial ischemia more frequently than exercise stress testing in patients with clinically stable coronary heart disease?
Key Points
- To evaluate the prevalence and clinical characteristics of mental stress-induced myocardial ischemia in patients with clinically stable coronary heart disease.
- Assessed 310 patients with clinically stable coronary heart disease enrolled in the REMIT trial (NCT00574847) who underwent a battery of 3 mental stress tests followed by a treadmill exercise stress test.
- Stress-induced ischemia was defined by echocardiography and electrocardiography as the development or worsening of regional wall motion abnormality, left ventricular ejection fraction reduction ≥ 8%, or ST-segment depression ≥ 1 mm.
- Mental stress-induced ischemia occurred in 43.45% of patients compared with 33.79% for exercise-induced ischemia (p = 0.002).
- Patients who were women (OR: 1.88, 95% CI: 1.04 to 3.42, p = 0.04), not married (OR: 1.99, 95% CI: 1.19 to 3.36, p = 0.009), or living alone (OR: 2.24, 95% CI: 1.19 to 4.20, p = 0.01) were significantly more likely to develop mental stress-induced ischemia.
- Compared with married men, unmarried men (OR: 2.57, 95% CI: 1.33 to 4.97, p = 0.005) and married women (OR: 3.18, 95% CI: 1.22 to 8.32, p = 0.02) had a significantly higher risk for mental stress-induced ischemia.
Study Design
Type
Cross-Sectional (n=310)
Multicenter
No
Structured PICO
Does mental stress testing induce myocardial ischemia more frequently than exercise stress testing in patients with clinically stable coronary heart disease?
P
Population
310 adult patients with clinically stable coronary heart disease who underwent mental and exercise stress testing to evaluate myocardial ischemia.
E
Exposure
Mental stress testing (mental arithmetic, mirror trace, and anger recall public speech)
C
Comparator
Exercise treadmill testing (standard Bruce protocol)
O
Outcome
Stress-induced myocardial ischemia (defined as development/worsening of regional wall motion abnormality, LVEF reduction ≥8%, and/or horizontal/downsloping ST-segment depression ≥1 mm in ≥2 leads for ≥3 beats)surrogate
Main Result
Absolute Event Rate: 43.45% vs 33.79%
p-value: p=0.002
Mental stress-induced myocardial ischemia is more prevalent than exercise-induced ischemia in patients with stable coronary heart disease, particularly among women, unmarried men, and individuals living alone.
Limitations
- Small number of women
- Intercorrelations of demographic variables
- Not designed to evaluate Takotsubo cardiomyopathy-like manifestations
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“These studies demonstrate how important it is for clinicians to understand the connection between significant emotional stress and pathophysiologic processes. We can't just say, 'Oh, this patient's chest pain or shortness of breath are just a somatic symptom of mental problems'; there is a pathologic process underlying these symptoms, and if it's not taken care of appropriately, these patients are more likely to die of heart attack, stroke, or heart failure.”
“I'd be very cautious about the 'married women' are at higher risk than unmarried women for mental stress induced myocardial ischemia (MSIMI), because the sample size was quite small for this analysis. I think it is safe to state the married men seem to be protected from having MSIMI. The role of marriage in women in terms of MSIMI need to be further investigated.”
Implication
Mental stress ischemia exceeds exercise ischemia in stable CHD; cross-sectional data leave open whether mental stress testing improves risk stratification.
Abstract
OBJECTIVES: The goal of this study was to evaluate the prevalence and clinical characteristics of mental stress-induced myocardial ischemia. BACKGROUND: Mental stress-induced myocardial ischemia is prevalent and a risk factor for poor prognosis in patients with coronary heart disease, but past studies mainly studied patients with exercise-induced myocardial ischemia. METHODS: Eligible patients with clinically stable coronary heart disease, regardless of exercise stress testing status, underwent a battery of 3 mental stress tests followed by a treadmill test. Stress-induced ischemia, assessed by echocardiography and electrocardiography, was defined as: 1) development or worsening of regional wall motion abnormality; 2) left ventricular ejection fraction reduction ≥ 8%; and/or 3) horizontal or downsloping ST-segment depression ≥ 1 mm in 2 or more leads lasting for ≥ 3 consecutive beats during at least 1 mental test or during the exercise test. RESULTS: Mental stress-induced ischemia occurred in 43.45%, whereas exercise-induced ischemia occurred in 33.79% (p = 0.002) of the study population (N = 310). Women (odds ratio [OR]: 1.88), patients who were not married (OR: 1.99), and patients who lived alone (OR: 2.24) were more likely to have mental stress-induced ischemia (all p < 0.05). Multivariate analysis showed that compared with married men or men living with someone, unmarried men (OR: 2.57) and married women (OR: 3.18), or living alone (male OR: 2.25 and female OR: 2.72, respectively) had higher risk for mental stress-induced ischemia (all p < 0.05). CONCLUSIONS: Mental stress-induced ischemia is more common than exercise-induced ischemia in patients with clinically stable coronary heart disease. Women, unmarried men, and individuals living alone are at higher risk for mental stress-induced ischemia. (Responses of Myocardial Ischemia to Escitalopram Treatment [REMIT]; NCT00574847).
Discussion
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Cite This Study
Jiang et al. (2013) conducted a cross-sectional in clinically stable coronary heart disease (n=310). Mental stress testing vs. Exercise stress testing was evaluated on Stress-induced myocardial ischemia (p=0.002). Mental stress-induced ischemia occurred in 43.45% of patients with clinically stable coronary heart disease, compared to 33.79% for exercise-induced ischemia (p = 0.002).