Systematic review of mental stress-induced myocardial ischaemia

There is growing evidence that psychosocial stress can influence the natural history of coronary heart disease.1 Epidemiological studies indicate that psychosocial factors both contribute to the development of coronary artery disease (CAD), and increase risk of cardiac dysfunction and the likelihood of cardiac events in susceptible patients with established disease.2,3 An important method of assessing effects on cardiac function is by measuring transient ischaemic responses to standardized mental stress tests. Mental stress-induced myocardial ischaemia (MSIMI) is analogous to exercise stress ischaemia, except that the stimulus is psychological rather than physical. MSIMI has been studied with a number of different imaging techniques and with a range of stressful stimuli. But several investigations have involved small numbers of patients, and the medication status of patients has been variable. This has resulted in diverse findings concerning the prevalence of MSIMI, the conditions in which it is elicited, the type of patients who are most susceptible, the mechanisms underlying the phenomenon, and its clinical significance. In an effort to clarify these issues, we have conducted a systematic review of studies in which myocardial ischaemic responses have been measured in response to standardized mental stressors in the laboratory and clinic. Relevant articles were identified from searches of PubMed (http://www.ncbi.nlm.nih.gov/PubMed)between 1980 and 2002. Only articles in English language peer-reviewed publications were examined. We included studies that examined the link between standardized mental stress tests and myocardial ischaemic responses. Studies involving patients with CAD and healthy volunteers or patients without CAD were included. To ensure comprehensive data location, further searches were made for authors published in this field and review articles were used as sources. The bibliographies of all papers retrieved were hand searched to ensure as many articles as possible were obtained. A number of studies in this field have resulted in multiple publications, …