Mental stress-induced myocardial ischaemia

### Learning objectives The management of angina is determined by symptoms and cardiovascular risk, together guiding further assessment in order to detect significant underlying coronary artery disease (CAD). The current National Institute for Health and Care Excellence guidelines require that symptoms are precipitated by physical exertion to be defined as typical angina.1 There are, however, a number of other stressors that may induce myocardial ischaemia, including cold exposure2 and mental stress. In the first detailed description of angina pectoris in the medical literature in 1772, William Heberden noted “it is increased by disturbance of the mind”.3 Mental stress-induced myocardial ischaemia (MSIMI) is a recognised phenomenon, but in the absence of an evidence base it is not routinely explored during either the clinical consultation or subsequent investigations. Significant uncertainties remain; in particular, how does MSIMI differ from exercise-induced myocardial ischaemia, and does it hold any particular significance for patients with ischaemic heart disease? Numerous observational studies have suggested that exposure to both acute and chronic mental stress is associated with an increased incidence of adverse cardiac events. Natural disasters, including earthquakes4–7 and hurricanes,8 have been linked with increases in cardiac mortality immediately after the event. There was a 71% increase in cardiac deaths on the day of the Northridge earthquake and a 35% increase in hospital admissions for myocardial infarction over the ensuing week.5 Similar findings are reported with unnatural events including in civilian communities under threat of imminent missile attack9 and with major sporting competitions.10–13 During the 2006 FIFA World Cup in Germany, the incidence of acute cardiac events was 2.7 times higher on match days involving the German national team.14 In those known to have …