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Osei J, Vaccarino V, Wang M, Shah AS, Lampert RJ, Li LY, Ko YA, Pearce BD, Kutner M, Garcia E, Piccinelli M, Raggi P, Bremner JD, Quyyumi AA, Sun YV, Ahmed H, Haddad G, Daaboul O, Roberts T, Stefanos L, Correia L, Shah AJ. Stress-Induced Autonomic Dysfunction is Associated With Mental Stress-Induced Myocardial Ischemia in Patients With Coronary Artery Disease. Circ Cardiovasc Imaging 2024; 17:e016596. [PMID: 38868952 PMCID: PMC11187646 DOI: 10.1161/circimaging.124.016596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/30/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Mental stress-induced myocardial ischemia (MSIMI) is associated with adverse cardiovascular outcomes in individuals with coronary artery disease, but the mechanisms underlying this phenomenon are unknown. We examined the relationship between stress-induced autonomic dysfunction, measured by low heart rate variability (HRV) in response to stress, and MSIMI in patients with stable coronary artery disease. We hypothesized that stress-induced autonomic dysfunction is associated with higher odds of MSIMI. METHODS In 735 participants with stable coronary artery disease, we measured high- and low-frequency HRV in 5-minute intervals before and during a standardized laboratory-based speech stressor using Holter monitoring. HRV at rest and stress were categorized into low HRV (first quartile) versus high HRV (second to fourth quartiles); the low category was used as an indicator of autonomic dysfunction. Multivariable logistic regression models were used to examine the association of autonomic dysfunction with MSIMI. RESULTS The mean age was 58 (SD, ±10) years, 35% were women, 44% were Black participants, and 16% developed MSIMI. Compared with high HRV during stress, low HRV during stress (both high and low frequencies) was associated with higher odds of MSIMI after adjusting for demographic and clinical factors (odds ratio for high-frequency HRV, 2.1 [95% CI, 1.3-3.3]; odds ratio for low-frequency HRV, 2.1 [95% CI, 1.3-3.3]). Low-frequency HRV at rest was also associated with MSIMI but with slightly reduced effect estimates. CONCLUSIONS In individuals with coronary artery disease, mental stress-induced autonomic dysfunction may be a mechanism implicated in the causal pathway of MSIMI.
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Affiliation(s)
- Jeffery Osei
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maggie Wang
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anish S. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel J. Lampert
- Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Louis Y. Li
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ernest Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marina Piccinelli
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Hashir Ahmed
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George Haddad
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Obada Daaboul
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tatum Roberts
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lewam Stefanos
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Luis Correia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Vaccarino V, Bremner JD. Stress and cardiovascular disease: an update. Nat Rev Cardiol 2024:10.1038/s41569-024-01024-y. [PMID: 38698183 DOI: 10.1038/s41569-024-01024-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/05/2024]
Abstract
Psychological stress is generally accepted to be associated with an increased risk of cardiovascular disease (CVD), but results have varied in terms of how stress is measured and the strength of the association. Additionally, the mechanisms and potential causal links have remained speculative despite decades of research. The physiological responses to stress are well characterized, but their contribution to the development and progression of CVD has received little attention in empirical studies. Evidence suggests that physiological responses to stress have a fundamental role in the risk of CVD and that haemodynamic, vascular and immune perturbations triggered by stress are especially implicated. Stress response physiology is regulated by the corticolimbic regions of the brain, which have outputs to the autonomic nervous system. Variation in these regulatory pathways might explain interindividual differences in vulnerability to stress. Dynamic perturbations in autonomic, immune and vascular functions are probably also implicated as CVD risk mechanisms of chronic, recurring and cumulative stressful exposures, but more data are needed from prospective studies and from assessments in real-life situations. Psychological assessment remains insufficiently recognized in clinical care and prevention. Although stress-reduction interventions might mitigate perceived stress levels and potentially reduce cardiovascular risk, more data from randomized trials are needed.
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Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Department of Radiology and Diagnostic Imaging, Emory University School of Medicine, Atlanta, GA, USA
- Veterans Administration Medical Center, Decatur, GA, USA
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Pederiva VC, de Castro A, Belló-Klein A, Araujo ASDR, Turck P. Vascular Response of Triiodothyronine on Isolated Aortic Rings: Contribution of Redox Mechanisms. Arq Bras Cardiol 2024; 121:e20230236. [PMID: 38695407 PMCID: PMC11098570 DOI: 10.36660/abc.20230236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 10/28/2023] [Accepted: 01/18/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Vascular dysfunction constitutes the etiology of many diseases, such as myocardial infarction and hypertension, with the disruption of redox homeostasis playing a role in the imbalance of the vasomotor control mechanism. Our group previously has shown that thyroid hormones exert protective effects on the aortic tissue of infarcted rats by improving angiogenesis signaling. OBJECTIVE Investigate the role of triiodothyronine (T3) on vascular response, exploring its effects on isolated aortas and whether there is an involvement of vascular redox mechanisms. METHODS Isolated aortic rings (intact- and denuded-endothelium) precontracted with phenylephrine were incubated with T3 (10-8, 10-7, 10-6, 10-5, and 10-4 M), and tension was recorded using a force-displacement transducer coupled with an acquisition system. To assess the involvement of oxidative stress, aortic rings were preincubated with T3 and subsequently submitted to an in vitro reactive oxygen species (ROS) generation system. The level of significance adopted in the statistical analysis was 5%. RESULTS T3 (10-4 M) promoted vasorelaxation of phenylephrine precontracted aortic rings in both intact- and denuded-endothelium conditions. Aortic rings preincubated in the presence of T3 (10-4 M) also showed decreased vasoconstriction elicited by phenylephrine (1 µM) in intact-endothelium preparations. Moreover, T3 (10-4 M) vasorelaxation effect persisted in aortic rings preincubated with NG-nitro-L-arginine methylester (L-NAME, 10 µM), a nonspecific NO synthase (NOS) inhibitor. Finally, T3 (10-4 M) exhibited, in vitro, an antioxidant role by reducing NADPH oxidase activity and increasing SOD activity in the aorta's homogenates. CONCLUSION T3 exerts dependent- and independent-endothelium vasodilation effects, which may be related to its role in maintaining redox homeostasis.
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Affiliation(s)
- Viviane Cristina Pederiva
- Universidade Federal do Rio Grande do SulDepartamento de FisiologiaLaboratório de Fisiologia CardiovascularPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - Departamento de Fisiologia, Laboratório de Fisiologia Cardiovascular, Porto Alegre, RS – Brasil
| | - Alexandre de Castro
- Universidade Federal do Rio Grande do SulDepartamento de FisiologiaLaboratório de Fisiologia CardiovascularPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - Departamento de Fisiologia, Laboratório de Fisiologia Cardiovascular, Porto Alegre, RS – Brasil
| | - Adriane Belló-Klein
- Universidade Federal do Rio Grande do SulDepartamento de FisiologiaLaboratório de Fisiologia CardiovascularPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - Departamento de Fisiologia, Laboratório de Fisiologia Cardiovascular, Porto Alegre, RS – Brasil
| | - Alex Sander da Rosa Araujo
- Universidade Federal do Rio Grande do SulDepartamento de FisiologiaLaboratório de Fisiologia CardiovascularPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - Departamento de Fisiologia, Laboratório de Fisiologia Cardiovascular, Porto Alegre, RS – Brasil
| | - Patrick Turck
- Universidade Federal do Rio Grande do SulDepartamento de FisiologiaLaboratório de Fisiologia CardiovascularPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul - Departamento de Fisiologia, Laboratório de Fisiologia Cardiovascular, Porto Alegre, RS – Brasil
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Martin ZT, Shah AJ, Ko YA, Sheikh SAA, Daaboul O, Haddad G, Goldberg J, Smith NL, Lewis TT, Quyyumi AA, Bremner JD, Vaccarino V. Exaggerated Peripheral and Systemic Vasoconstriction During Trauma Recall in Posttraumatic Stress Disorder: A Co-Twin Control Study. Biol Psychiatry 2023:S0006-3223(23)01791-2. [PMID: 38142719 PMCID: PMC11192861 DOI: 10.1016/j.biopsych.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/23/2023] [Accepted: 12/14/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Individuals with posttraumatic stress disorder (PTSD) face an increased risk of cardiovascular disease, but the mechanisms linking PTSD to cardiovascular disease remain incompletely understood. We used a co-twin control study design to test the hypothesis that individuals with PTSD exhibit augmented peripheral and systemic vasoconstriction during a personalized trauma recall task. METHODS In 179 older male twins from the Vietnam Era Twin Registry, lifetime history of PTSD and current (last month) PTSD symptoms were assessed. Participants listened to neutral and personalized trauma scripts while peripheral vascular tone (Peripheral Arterial Tone ratio) and systemic vascular tone (e.g., total vascular conductance) were measured. Linear mixed-effect models were used to assess the within-pair relationship between PTSD and vascular tone indices. RESULTS The mean age of participants was 68 years, and 19% had a history of PTSD. For the Peripheral Arterial Tone ratio analysis, 32 twins were discordant for a history of PTSD, and 46 were discordant for current PTSD symptoms. Compared with their brothers without PTSD, during trauma recall, participants with a history of PTSD had greater increases in peripheral (β = -1.01, 95% CI [-1.72, -0.30]) and systemic (total vascular conductance: β = -1.12, 95% CI [-1.97, -0.27]) vasoconstriction after adjusting for cardiovascular risk factors. Associations persisted after adjusting for antidepressant medication use and heart rate and blood pressure during the tasks. Analysis of current PTSD symptom severity showed consistent results. CONCLUSIONS PTSD is associated with exaggerated peripheral and systemic vasoconstrictor responses to traumatic stress reminders, which may contribute to elevated risk of cardiovascular disease.
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Affiliation(s)
- Zachary T Martin
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Amit J Shah
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Emory University School of Medicine, Emory University, Atlanta, Georgia; Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, Georgia
| | - Yi-An Ko
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Obada Daaboul
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - George Haddad
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jack Goldberg
- Seattle Epidemiologic Research and Information Center, U.S. Department of Veterans Affairs Office of Research and Development, Seattle, Washington
| | - Nicholas L Smith
- Seattle Epidemiologic Research and Information Center, U.S. Department of Veterans Affairs Office of Research and Development, Seattle, Washington
| | - Tené T Lewis
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arshed A Quyyumi
- Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - J Douglas Bremner
- Emory University School of Medicine, Emory University, Atlanta, Georgia; Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, Georgia
| | - Viola Vaccarino
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Emory University School of Medicine, Emory University, Atlanta, Georgia.
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Moazzami K, Garcia M, Sullivan S, Lewis TT, Bremner JD, Razavi AC, Shallenberger L, Sun YV, Raggi P, Shah AJ, Quyyumi AA, Vaccarino V. Association Between Symptoms of Chronic Psychological Distress and Myocardial Ischemia Induced by Mental Stress in Patients With Coronary Artery Disease. J Am Heart Assoc 2023; 12:e030305. [PMID: 37929719 PMCID: PMC10727402 DOI: 10.1161/jaha.123.030305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/15/2023] [Indexed: 11/07/2023]
Abstract
Background Mental stress-induced myocardial ischemia is a frequent phenomenon in patients with coronary artery disease and is associated with a greater risk of future cardiovascular events. The association between chronic symptoms of psychological distress and mental stress-induced ischemia is not clear. Methods and Results We used a composite score of psychological distress derived from symptoms of depression, posttraumatic stress disorder, anxiety, anger, and perceived general stress. Participants underwent myocardial perfusion imaging with both mental (public speaking task) and conventional (exercise or pharmacological) stress testing. Overall, 142 (15.9%) patients experienced mental stress-induced myocardial ischemia. After adjusting for demographic factors, medical history, and medication use, patients in the highest tertile of psychological distress score had 35% higher odds of having mental stress-induced ischemia compared to those in the lowest tertile (odds ratio [OR], 1.35 [95% CI, 1.06-2.22]). Stratified analyses showed that the association between psychological distress score and mental stress-induced myocardial ischemia was significantly associated only within the subgroup of patients with a prior myocardial infraction, with patients with a prior myocardial infarction in the highest tertile having a 93% higher odds of developing myocardial ischemia with mental stress (95% CI, 1.07-3.60). There was no significant association between psychological distress and conventional stress-induced ischemia (OR, 1.19 [95% CI, 0.87-1.63]). Conclusions Among patients with a history of myocardial infarction, a higher level of psychosocial distress is associated with mental stress-induced myocardial ischemia but not with ischemia induced by a conventional stress test.
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Affiliation(s)
- Kasra Moazzami
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Grady Health SystemAtlantaGA
| | - Mariana Garcia
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
| | - Samaah Sullivan
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public HealthThe University of Texas Health Science CenterHoustonTX
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - J. Douglas Bremner
- Atlanta VA Medical CenterDecaturGA
- Department of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaGA
| | - Alexander C. Razavi
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Lucy Shallenberger
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Paolo Raggi
- Mazankowski Alberta Heart InstituteUniversity of AlbertaEdmontonAlbertaCanada
| | - Amit J. Shah
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
- Atlanta VA Medical CenterDecaturGA
| | - Arshed A. Quyyumi
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
| | - Viola Vaccarino
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research InstituteAtlantaGA
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
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Zhang S, Li Y, Zhu W, Zhang L, Lei L, Tian X, Chen K, Shi W, Cong B. Endoplasmic reticulum stress induced by turbulence of mitochondrial fusion and fission was involved in stressed cardiomyocyte injury. J Cell Mol Med 2023; 27:3313-3325. [PMID: 37593898 PMCID: PMC10623534 DOI: 10.1111/jcmm.17901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/25/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023] Open
Abstract
Mitochondria are sensitive organelles that sense intrinsic and extrinsic stressors and maintain cellular physiological functions through the dynamic homeostasis of mitochondrial fusion and fission. Numerous pathological processes are associated with mitochondrial fusion and fission disorders. However, the molecular mechanism by which stress induces cardiac pathophysiological changes through destabilising mitochondrial fusion and fission is unclear. Therefore, this study aimed to investigate whether the endoplasmic reticulum stress signalling pathway initiated by the turbulence of mitochondrial fusion and fission under stressful circumstances is involved in cardiomyocyte damage. Based on the successful establishment of the classical stress rat model of restraint plus ice water swimming, we measured the content of serum lactate dehydrogenase. We used haematoxylin-eosin staining, special histochemical staining, RT-qPCR and western blotting to clarify the cardiac pathology, ultrastructural changes and expression patterns of mitochondrial fusion and fission marker proteins and endoplasmic reticulum stress signalling pathway proteins. The results indicated that mitochondrial fusion and fission markers and proteins of the endoplasmic reticulum stress JNK signalling pathway showed significant abnormal dynamic changes with the prolongation of stress, and stabilisation of mitochondrial fusion and fission using Mdivi-1 could effectively improve these abnormal expressions and ameliorate cardiomyocyte injury. These findings suggest that stress could contribute to pathological cardiac injury, closely linked to the endoplasmic reticulum stress JNK signalling pathway induced by mitochondrial fusion and fission turbulence.
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Affiliation(s)
- Shengnan Zhang
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Yingmin Li
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Weihao Zhu
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Lihua Zhang
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Lei Lei
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Xiaofei Tian
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Ke Chen
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Weibo Shi
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
| | - Bin Cong
- Department of Forensic MedicineHebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular IdentificationShijiazhuangChina
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Okoh AK, Young A, Garcia M, Sullivan S, Almuwaqqat Z, Hu Y, Liu C, Moazzami K, Uphoff I, Lima BB, Ko YA, Elon L, Jajeh N, Rout P, Gupta S, Shah AJ, Bremner JD, Lewis T, Quyyumi A, Vaccarino V. Racial Differences in Mental Stress-Induced Transient Endothelial Dysfunction and Its Association With Cardiovascular Outcomes. Psychosom Med 2023; 85:431-439. [PMID: 37053106 PMCID: PMC10239336 DOI: 10.1097/psy.0000000000001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE This study aimed to investigate differences in transient endothelial dysfunction (TED) with mental stress in Black and non-Black individuals with coronary heart disease (CHD), and their potential impact on cardiovascular outcomes. METHODS We examined 812 patients with stable CHD between June 2011 and March 2016 and followed through February 2020 at a university-affiliated hospital network. Flow-mediated vasodilation (FMD) was assessed before and 30 minutes after mental stress. TED was defined as a lower poststress FMD than prestress FMD. We compared prestress FMD, post-stress FMD, and TED between Black and non-Black participants. In both groups, we examined the association of TED with an adjudicated composite end point of cardiovascular death or nonfatal myocardial infarction (first and recurring events) after adjusting for demographic, clinical, and socioeconomic factors. RESULTS Prestress FMD was lower in Black than non-Black participants (3.7 [2.8] versus 4.9 [3.8], p < .001) and significantly declined with mental stress in both groups. TED occurred more often in Black (76%) than non-Black patients (67%; multivariable-adjusted odds ratio = 1.6, 95% confidence interval = 1.5-1.7). Over a median (interquartile range) follow-up period of 75 (65-82) months, 142 (18%) patients experienced either cardiovascular death or nonfatal myocardial infarction. Black participants had a 41.9% higher risk of the study outcome than non-Black participants (95% confidence interval = 1.01-1.95). TED with mental stress explained 69% of this excess risk. CONCLUSIONS Among CHD patients, Black individuals are more likely than non-Black individuals to develop endothelial dysfunction with mental stress, which in turn explains a substantial portion of their excess risk of adverse events.
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Affiliation(s)
- Alexis K Okoh
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - An Young
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Mariana Garcia
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zakaria Almuwaqqat
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Chang Liu
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Kasra Moazzami
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Irina Uphoff
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Bruno B. Lima
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Nour Jajeh
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Pratik Rout
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Shishir Gupta
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Atlanta VA Medical Center, Decatur, GA
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Tene Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Arshed Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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Saxon C, Freeman S, Burke J. Cardiac tamponade-mediated generalized coronary vasospasm presenting as an inferior ST-segment elevation myocardial infarction: a case report. Eur Heart J Case Rep 2023; 7:ytad220. [PMID: 37193072 PMCID: PMC10182336 DOI: 10.1093/ehjcr/ytad220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/14/2022] [Accepted: 04/24/2023] [Indexed: 05/18/2023]
Abstract
Background Coronary vasospasm is a rare cause of ST-segment elevation myocardial infarction (STEMI) and can be precipitated by numerous inciting factors including endogenous catecholamines. Differentiating coronary vasospasm from an acute atherothrombotic event is diagnostically challenging and requires a careful clinical history combined with electrocardiographic and angiographic abnormalities to make the diagnosis and guide therapy. Case Summary We report a case of cardiogenic shock secondary to cardiac tamponade leading to an endogenous catecholamine surge resulting in profound arterial vasospasm and STEMI. The patient presented with chest pain and inferior ST segment elevations prompting emergent coronary angiography, demonstrating subtotal occlusion of the right coronary artery, severe proximal left anterior descending coronary artery stenosis, and diffusely stenosed aortoiliac vessels. Emergent transthoracic echocardiogram revealed a large pericardial effusion and hemodynamics consistent with cardiac tamponade. Pericardiocentesis resulted in dramatic hemodynamic improvement with immediate normalization of ST segments. Repeat coronary angiography performed one day later showed no angiographically significant coronary or peripheral arterial stenosis. Discussion This is the first reported case of simultaneous coronary and peripheral arterial vasospasm presenting as inferior STEMI caused by endogenous catecholamines from cardiac tamponade. Several clues suggest coronary vasospasm including the discordant electrocardiography (ECG) and coronary angiographic findings as well as diffusely stenosed aortoiliac vessels. Diffuse vasospasm was confirmed when repeat angiography performed after pericardiocentesis demonstrated angiographic resolution of coronary and peripheral arterial stenosis. Though rare, circulating endogenous catecholamines resulting in diffuse coronary vasospasm may present as STEMI and should be considered based on the clinical history, ECG findings, and coronary angiography.
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Affiliation(s)
- Cara Saxon
- Corresponding author. Tel: 303-724-1784,
| | - Scott Freeman
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
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Bremner JD, Piccinelli M, Garcia EV, Moncayo VM, Elon L, Nye JA, Cooke CD, Washington BP, Ortega RA, Desai SR, Okoh AK, Cheung B, Soyebo BO, Shallenberger LH, Raggi P, Shah AJ, Daaboul O, Jajeh MN, Ziegler C, Driggers EG, Murrah N, De Cecco CN, van Assen M, Krafty RT, Quyyumi AA, Vaccarino V. A Pilot Study of Neurobiological Mechanisms of Stress and Cardiovascular Risk. MEDICAL RESEARCH ARCHIVES 2023; 11:3787. [PMID: 37484871 PMCID: PMC10361343 DOI: 10.18103/mra.v11i4.3787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Objective Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk. Methods Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [18F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain, heart, adipose tissue and aorta with mental stress. Results Patients with mental stress-induced ischemia showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group as a whole, activity increase with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (r=0.69, p=0.038; and r=0.69, p=0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (r=0.71, p=0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Activity in other brain areas not implicated in stress did not show similar correlations. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (r=0.85, p=0.004). Conclusions These findings suggest a link between brain response to stress in key areas mediating emotion and peripheral organs involved in inflammation and hematopoietic activity, as well as myocardial ischemia, in Coronary Heart Disease patients.
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Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Marina Piccinelli
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Ernest V. Garcia
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Valeria M. Moncayo
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Lisa Elon
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Jonathon A. Nye
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - C. David Cooke
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Brianna P. Washington
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Rebeca Alvarado Ortega
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Shivang R. Desai
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Alexis K. Okoh
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Brian Cheung
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Britt O. Soyebo
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | | | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Amit J. Shah
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Obada Daaboul
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | | | - Carrie Ziegler
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | | | - Nancy Murrah
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Carlo N. De Cecco
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
- Department Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
| | - Marly van Assen
- Department Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Robert T. Krafty
- Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Arshed A. Quyyumi
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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10
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Deng F, Li X, Tang C, Chen J, Fan B, Liang J, Zhen X, Tao R, Zhang S, Cong Z, Du W, Zhao H, Xu L. Mechanisms of Xiong-Pi-Fang in treating coronary heart disease associated with depression: A systematic pharmacology strategy and in vivo pharmacological validation. JOURNAL OF ETHNOPHARMACOLOGY 2022; 298:115631. [PMID: 35987411 DOI: 10.1016/j.jep.2022.115631] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/18/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Coronary heart disease (CHD) and depression are very common and often co-existing disorders. Xiong-Pi-Fang (XPF), a therapeutic classical traditional Chinese medicine (TCM) formula, has shown satisfactory efficacy in treating CHD associated with depression. However, its mechanism of action is still unknown. PURPOSE To employ a systematic pharmacology approach for identifying the action mechanisms of XPF in treating CHD associated with depression. METHODS We used a systematic pharmacology approach to identify the potential active mechanisms of XPF in treating CHD with depression. Potential active compounds in XPF and the diseases targets were screened using relevant databases to build corresponding pathways, following the experiments that were conducted to confirm whether the presumptive results of systemic pharmacology were correct. RESULTS Network pharmacology predicted 42 key targets and 20 signaling pathways involved in XPF-mediated treatment, with IL-6/JAK2/STAT3/HIF-1α/VEGF-A pathway significantly affected. The common influences were hypothalamic-pituitary-adrenal axis (HPA axis) and glucocorticoid signaling, validated through chronic unexpected mild stress (CUMS) with isoprenaline (ISO) for inducing CHD within the depression model in rats. In addition, XPF intake reduced depressive-like behaviors and improved ECG ischemic changes. Furthermore, XPF exerted some anti-inflammatory effects by inhibiting the interleukin-6 (IL-6) induced phosphorylation of janus kinase 2 (JAK2) and signal transducer and activator of transcription 3 (STAT3), ultimately downregulating hypoxia-inducible factor 1-α (HIF-1α) and vascular endothelial growth factor-A (VEGF-A) activation. The dysfunctional HPA axis feedback loop was also regulated, which enhanced the glucocorticoid receptor (GR) expression. In contrast, it improved glucocorticoid resistance by reducing the mineralocorticoid receptor expression. CONCLUSIONS Suppressing IL-6 release and maintaining the HPA feedback loop balance could be the primary mechanism of XPF against CHD with depression. The significance of the IL-6 and HPA axis identified indicates their potential as essential targets for CHD therapy with depression.
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Affiliation(s)
- Fangjuan Deng
- Graduate School, Tianjin University of TCM, Tianjin, 301617, China
| | - Xiaofeng Li
- Department of Cardiology, The Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 300150, China
| | - Cheng Tang
- School of Pharmacy, Tianjin Medical University, Tianjin, 300070, China
| | - Jinhong Chen
- Graduate School, Tianjin University of TCM, Tianjin, 301617, China
| | - Boya Fan
- Graduate School, Tianjin University of TCM, Tianjin, 301617, China
| | - Jiayu Liang
- Graduate School, Tianjin University of TCM, Tianjin, 301617, China
| | - Xin Zhen
- Graduate School, Tianjin University of TCM, Tianjin, 301617, China
| | - Rui Tao
- Department of TCM, Tianjin University of TCM, Tianjin, 301617, China
| | - Shaoqiang Zhang
- Department of Cardiology, The Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 300150, China
| | - Zidong Cong
- Department of Cardiology, The Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 300150, China
| | - Wuxun Du
- Department of Cardiology, The Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 300150, China.
| | - Hucheng Zhao
- Department of Aeronautics and Astronautics, Tsinghua University, Beijing, 100084, China.
| | - Liang Xu
- School of Pharmacy, Tianjin Medical University, Tianjin, 300070, China; Tianjin Medical College, Tianjin, 300222, China.
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11
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Damman P, Elias-Smale SE, Jansen TPJ, Konst RE, Dimitriu-Leen AC, Hartzema M, van Royen N, Maas AHEM. Contemporary and future invasive coronary vasomotor function testing and treatment in patients with ischaemia with no obstructive coronary arteries. Eur Heart J Suppl 2022; 24:H18-H24. [PMID: 36382006 PMCID: PMC9650459 DOI: 10.1093/eurheartjsupp/suac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In the current review, we emphasize the importance of diagnostics and therapy in patients with ischaemia with no obstructive coronary arteries (INOCA). The importance of the diagnostic coronary function test (CFT) procedure is described, including future components including angiography-derived physiology and invasive continuous thermodilution. Furthermore, the main components of treatment are discussed. Future directions include the national registration ensuring a high quality of INOCA care, besides a potential source to improve our understanding of pathophysiology in the various phenotypes of coronary vascular dysfunction, the diagnostic CFT procedure, and treatment.
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Affiliation(s)
- Peter Damman
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Suzette E Elias-Smale
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Regina E Konst
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | | | - Mariëlle Hartzema
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center , Nijmegen , the Netherlands
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12
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Mental Stress and Cardiovascular Health-Part I. J Clin Med 2022; 11:jcm11123353. [PMID: 35743423 PMCID: PMC9225328 DOI: 10.3390/jcm11123353] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/05/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022] Open
Abstract
Epidemiological studies have shown that a substantial proportion of acute coronary events occur in individuals who lack the traditional high-risk cardiovascular (CV) profile. Mental stress is an emerging risk and prognostic factor for coronary artery disease and stroke, independently of conventional risk factors. It is associated with an increased rate of CV events. Acute mental stress may develop as a result of anger, fear, or job strain, as well as consequence of earthquakes or hurricanes. Chronic stress may develop as a result of long-term or repetitive stress exposure, such as job-related stress, low socioeconomic status, financial problems, depression, and type A and type D personality. While the response to acute mental stress may result in acute coronary events, the relationship of chronic stress with increased risk of coronary artery disease (CAD) is mainly due to acceleration of atherosclerosis. Emotionally stressful stimuli are processed by a network of cortical and subcortical brain regions, including the prefrontal cortex, insula, amygdala, hypothalamus, and hippocampus. This system is involved in the interpretation of relevance of environmental stimuli, according to individual’s memory, past experience, and current context. The brain transduces the cognitive process of emotional stimuli into hemodynamic, neuroendocrine, and immune changes, called fight or flight response, through the autonomic nervous system and the hypothalamic–pituitary–adrenal axis. These changes may induce transient myocardial ischemia, defined as mental stress-induced myocardial ischemia (MSIMI) in patients with and without significant coronary obstruction. The clinical consequences may be angina, myocardial infarction, arrhythmias, and left ventricular dysfunction. Although MSIMI is associated with a substantial increase in CV mortality, it is usually underestimated because it arises without pain in most cases. MSIMI occurs at lower levels of cardiac work than exercise-induced ischemia, suggesting that the impairment of myocardial blood flow is mainly due to paradoxical coronary vasoconstriction and microvascular dysfunction.
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13
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Sara JDS, Toya T, Ahmad A, Clark MM, Gilliam WP, Lerman LO, Lerman A. Mental Stress and Its Effects on Vascular Health. Mayo Clin Proc 2022; 97:951-990. [PMID: 35512885 PMCID: PMC9058928 DOI: 10.1016/j.mayocp.2022.02.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 01/13/2023]
Abstract
Coronary artery disease continues to be a major cause of morbidity and mortality despite significant advances in risk stratification and management. This has prompted the search for alternative nonconventional risk factors that may provide novel therapeutic targets. Psychosocial stress, or mental stress, has emerged as an important risk factor implicated in a higher incidence of cardiovascular events, and although our understanding of this far ranging and interesting phenomenon has developed greatly over recent times, there is still much to be learned regarding how to measure mental stress and how it may impact physical health. With the current coronavirus disease 2019 global pandemic and its incumbent lockdowns and social distancing, understanding the potentially harmful biological effects of stress related to life-changing events and social isolation has become even more important. In the current review our multidisciplinary team discusses stress from a psychosocial perspective and aims to define psychological stress as rigorously as possible; discuss the pathophysiologic mechanisms by which stress may mediate cardiovascular disease, with a particular focus to its effects on vascular health; outline existing methods and approaches to quantify stress by means of a vascular biomarker; outline the mechanisms whereby psychosocial stressors may have their pathologic effects ultimately transduced to the vasculature through the neuroendocrine immunologic axis; highlight areas for improvement to refine existing approaches in clinical research when studying the consequences of psychological stress on cardiovascular health; and discuss evidence-based therapies directed at reducing the deleterious effects of mental stress including those that target endothelial dysfunction. To this end we searched PubMed and Google Scholar to identify studies evaluating the relationship between mental or psychosocial stress and cardiovascular disease with a particular focus on vascular health. Search terms included "myocardial ischemia," "coronary artery disease," "mental stress," "psychological stress," "mental∗ stress∗," "psychologic∗ stress∗," and "cardiovascular disease∗." The search was limited to studies published in English in peer-reviewed journals between 1990 and the present day. To identify potential studies not captured by our database search strategy, we also searched studies listed in the bibliography of relevant publications and reviews.
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Key Words
- cad, coronary artery disease
- cbt, cognitive behavioral therapy
- cvd, cardiovascular disease
- fmd, flow-mediated dilatation
- il, interleukin
- mi, myocardial infarction
- ms, mental stress
- msimi, mental stress induced myocardial ischemia
- pat, peripheral arterial tonometry
- ped, peripheral endothelial dysfunction
- pet, positron emission tomography
- rh, reactive hyperemia
- ses, socioeconomic status
- tnf, tumor necrosis factor
- vsmc, vascular smooth muscle cells
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Affiliation(s)
| | - Takumi Toya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ali Ahmad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Wesley P Gilliam
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Lliach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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14
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Almuwaqqat Z, Wittbrodt MT, Moazzami K, Nye JA, Lima BB, Shah AJ, Alkhalaf J, Pearce B, Sun YV, Quyyumi AA, Vaccarino V, Bremner JD. Neural correlates of stress and leucocyte telomere length in patients with coronary artery disease. J Psychosom Res 2022; 155:110760. [PMID: 35217318 PMCID: PMC8940678 DOI: 10.1016/j.jpsychores.2022.110760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Accelerated biological aging, as indicated by telomere shortening, is associated with CAD pathogenesis. In a cross-sectional study, we investigated neural correlates of acute psychological stress and short telomeres in patients with CAD. METHODS Individuals with CAD (N = 168) underwent a validated mental stress protocol including public speaking and mental arithmetic. Imaging of the brain with [O-15] water and high-resolution positron emission tomography (HR-PET) was performed during mental stress and control conditions. Blood flow during stressful tasks (average of speech and arithmetic) and control tasks were assessed. Telomere length in peripheral leucocytes was measured by quantitative polymerase chain reaction and expressed as Telomere/Single Copy Gene (T/S) ratio. Voxel-wise regression models were constructed to assess the association between brain areas and activity during rest and mental stress after adjustments for demographic factors and clinical characteristics. RESULTS The mean (SD) age of the sample was 62 (8) years, and 69% were men. Increased activation with mental stress in the lingual gyrus, cerebellum and superior and inferior frontal gyri were associated with reduced telomere length; 1.6 higher voxel activation of these areas was associated with 0.1 T/S-units reduction in telomere length (P < 0.005). Additionally, during neutral counting and speaking tasks, brain activity in the precentral, middle and superior frontal and middle temporal gyri was inversely associated with telomere length. Results remained consistent after adjustment for demographic and clinical risk factors. CONCLUSION Increased stress-induced activity in brain areas mediating the stress response was associated with shortened telomere length in CAD patients.
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Affiliation(s)
- Zakaria Almuwaqqat
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Matthew T Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, United States of America
| | - Kasra Moazzami
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Jonathan A Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Bruno B Lima
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America; Atlanta VA Medical Center, Decatur, Georgia
| | - Jamil Alkhalaf
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Yan V Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, United States of America; Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America; Atlanta VA Medical Center, Decatur, Georgia.
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15
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Mehta PK, Sharma A, Bremner JD, Vaccarino V. Mental Stress-Induced Myocardial Ischemia. Curr Cardiol Rep 2022; 24:2109-2120. [PMID: 36322365 PMCID: PMC9628301 DOI: 10.1007/s11886-022-01821-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To summarize recent evidence on mental stress-induced myocardial ischemia (MSIMI), its mechanisms, and clinical significance. RECENT FINDINGS MSIMI can occur in patients with normal cardiac stress testing, is only weakly related to severity of coronary artery disease (CAD), and it is often silent. Among patients with CAD, MSIMI is associated with a twofold increased risk of major adverse cardiovascular events compared to those who do not have MSIMI. Certain groups such as young women with myocardial infarction and those with psychological comorbidities are more susceptible to MSIMI. Abnormal microvascular vasoreactivity and inflammation are implicated mechanisms in MSIMI. Increased brain activity in regions that modulate autonomic reactivity to emotional stress and fear is associated with MSIMI. MSIMI has important prognostic implications in patients with CAD. Stress can no longer be ignored as a risk factor in cardiology care. Clinical trials testing effective strategies to target MSIMI are needed.
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Affiliation(s)
- Puja K. Mehta
- grid.189967.80000 0001 0941 6502Division of Cardiology, Emory Women’s Heart Center and Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA 30322 USA
| | - Ashish Sharma
- grid.259906.10000 0001 2162 9738Internal Medicine Residency Program, Mercer University School of Medicine, Macon, GA USA
| | - J. Douglas Bremner
- grid.189967.80000 0001 0941 6502Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA USA ,grid.414026.50000 0004 0419 4084Atlanta VA Medical Center, Decatur, GA USA
| | - Viola Vaccarino
- grid.189967.80000 0001 0941 6502Division of Cardiology, Emory Women’s Heart Center and Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA 30322 USA ,grid.189967.80000 0001 0941 6502Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
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16
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Wehrum T, Dragonu I, Strecker C, Hennemuth A, Hennig J, Reinhard T, Harloff A. Influence of Pulse Wave Velocity on Atherosclerosis and Blood Flow Reversal in the Aorta: A 4-Dimensional Flow Magnetic Resonance Imaging Study in Acute Stroke Patients and Matched Controls. J Thorac Imaging 2022; 37:42-48. [PMID: 33492047 DOI: 10.1097/rti.0000000000000580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aortic stiffness is associated with a higher incidence of cardiovascular events including stroke. The primary aim of this study was to evaluate whether increased pulse wave velocity (PWV), a marker of stiffness, is an independent predictor of aortic atheroma. The secondary aim was to test whether increased PWV reinforces retrograde blood flow from the descending aorta (DAo), a mechanism of stroke. METHODS We performed a cross-sectional case-control study with prospective data acquisition. In all, 40 stroke and 60 ophthalmic patients matched for age and cardiovascular risk factors were included. Multicontrast magnetic resonance imaging (MRI) protocol of the aorta tailored to allow a detailed plaque analysis using 3-dimensional (D) T1-weighted bright blood, T2-weighted and proton density-weighted black blood, and hemodynamic assessment using 4D flow MRI was applied. Individual PWV was calculated based on 4D flow MRI data using the time-to-foot of the blood flow waveform. The extent of maximum retrograde blood flow from the proximal DAo into the arch was quantified. RESULTS PWV was higher in stroke patients compared with controls (7.62±2.59 vs. 5.96±2.49 m/s; P=0.005) and in patients with plaques (irrespective of thickness) compared with patients without plaques (7.47±2.89 vs. 5.62±1.89 m/s; P=0.002). Increased PWV was an independent predictor of plaque prevalence and contributed significantly to a predictor model explaining 36.5% (Nagelkerke R2) of the variance in plaque presence. Maximum retrograde flow extent from the proximal DAo was not correlated with PWV. CONCLUSIONS Aortic stiffness was higher in stroke patients and associated with a higher prevalence of plaques. Increased PWV was an independent predictor of plaque presence. Accordingly, regional PWV seems to be a valuable biomarker for the assessment and management of aortic atherosclerosis. However, no association was found for increased retrograde flow extent from the DAo.
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Affiliation(s)
| | - Iulius Dragonu
- Departments of Neurology
- Radiology-Medical Physics, Medical Center
| | | | - Anja Hennemuth
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Thomas Reinhard
- Eye Center, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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17
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Mehta PK, Wei J, Shufelt C, Quesada O, Shaw L, Bairey Merz CN. Gender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV Medicine. Front Cardiovasc Med 2021; 8:744788. [PMID: 34869650 PMCID: PMC8635525 DOI: 10.3389/fcvm.2021.744788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/13/2021] [Indexed: 12/30/2022] Open
Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men, yet women continue to have delays in diagnosis and treatment. The lack of recognition of sex-specific biological and socio-cultural gender-related differences in chest pain presentation of CAD may, in part, explain these disparities. Sex and gender differences in pain mechanisms including psychological susceptibility, the autonomic nervous system (ANS) reactivity, and visceral innervation likely contribute to chest pain differences. CAD risk scores and typical/atypical angina characterization no longer appear relevant and should not be used in women and men. Women more often have ischemia with no obstructive CAD (INOCA) and myocardial infarction, contributing to diagnostic and therapeutic equipoise. Existing knowledge demonstrates that chest pain often does not relate to obstructive CAD, suggesting a more thoughtful approach to percutaneous coronary intervention (PCI) and medical therapy for chest pain in stable obstructive CAD. Emerging knowledge regarding the central and ANS and visceral pain processing in patients with and without angina offers explanatory mechanisms for chest pain and should be investigated with interdisciplinary teams of cardiologists, neuroscientists, bio-behavioral experts, and pain specialists. Improved understanding of sex and gender differences in chest pain, including biological pathways as well as sociocultural contributions, is needed to improve clinical care in both women and men.
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Affiliation(s)
- Puja K Mehta
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute and Emory Women's Heart Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart Institute, Cincinnati, OH, United States
| | - Leslee Shaw
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
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Bremner JD, Wittbrodt MT, Gurel NZ, Shandhi MH, Gazi AH, Jiao Y, Levantsevych OM, Huang M, Beckwith J, Herring I, Murrah N, Driggers EG, Ko YA, Alkhalaf ML, Soudan M, Shallenberger L, Hankus AN, Nye JA, Park J, Woodbury A, Mehta PK, Rapaport MH, Vaccarino V, Shah AJ, Pearce BD, Inan OT. Transcutaneous Cervical Vagal Nerve Stimulation in Patients with Posttraumatic Stress Disorder (PTSD): A Pilot Study of Effects on PTSD Symptoms and Interleukin-6 Response to Stress. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021; 6:100190. [PMID: 34778863 PMCID: PMC8580056 DOI: 10.1016/j.jadr.2021.100190] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is a highly disabling condition associated with alterations in multiple neurobiological systems, including increases in inflammatory and sympathetic function, responsible for maintenance of symptoms. Treatment options including medications and psychotherapies have limitations. We previously showed that transcutaneous Vagus Nerve Stimulation (tcVNS) blocks inflammatory (interleukin (IL)-6) responses to stress in PTSD. The purpose of this study was to assess the effects of tcVNS on PTSD symptoms and inflammatory responses to stress. METHODS Twenty patients with PTSD were randomized to double blind active tcVNS (N=9) or sham (N=11) stimulation in conjunction with exposure to personalized traumatic scripts immediately followed by active or sham tcVNS and measurement of IL-6 and other biomarkers of inflammation. Patients then self administered active or sham tcVNS twice daily for three months. PTSD symptoms were measured with the PTSD Checklist (PCL) and the Clinician Administered PTSD Scale (CAPS), clinical improvement with the Clinical Global Index (CGI) and anxiety with the Hamilton Anxiety Scale (Ham-A) at baseline and one-month intervals followed by a repeat of measurement of biomarkers with traumatic scripts. After three months patients self treated with twice daily open label active tcVNS for another three months followed by assessment with the CGI. RESULTS Traumatic scripts increased IL-6 in PTSD patients, an effect that was blocked by tcVNS (p<.05). Active tcVNS treatment for three months resulted in a 31% greater reduction in PTSD symptoms compared to sham treatment as measured by the PCL (p=0.013) as well as hyperarousal symptoms and somatic anxiety measured with the Ham-A p<0.05). IL-6 increased from baseline in sham but not tcVNS. Open label tcVNS resulted in improvements measured with the CGI compared to the sham treatment period p<0.05). CONCLUSIONS These preliminary results suggest that tcVNS reduces inflammatory responses to stress, which may in part underlie beneficial effects on PTSD symptoms.
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Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
- Atlanta VA Medical Center, Decatur, Georgia
| | - Matthew T. Wittbrodt
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nil Z. Gurel
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - MdMobashir H. Shandhi
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Asim H. Gazi
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Yunshen Jiao
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Oleksiy M. Levantsevych
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Minxuan Huang
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Joy Beckwith
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Isaias Herring
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nancy Murrah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Emily G. Driggers
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - MhmtJamil L. Alkhalaf
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Majd Soudan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lucy Shallenberger
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Allison N. Hankus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jonathon A. Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Jeanie Park
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Anna Woodbury
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Puja K. Mehta
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Mark H. Rapaport
- Huntsman Mental Health Institute, Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, Utah
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Amit J. Shah
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Bradley D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
- Coulter Department of Bioengineering, Georgia Institute of Technology, Atlanta, Georgia
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Meeder JG, Hartzema-Meijer MJ, Jansen TPJ, Konst RE, Damman P, Elias-Smale SE. Outpatient Management of Patients With Angina With No Obstructive Coronary Arteries: How to Come to a Proper Diagnosis and Therapy. Front Cardiovasc Med 2021; 8:716319. [PMID: 34796207 PMCID: PMC8592903 DOI: 10.3389/fcvm.2021.716319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/22/2021] [Indexed: 12/28/2022] Open
Abstract
Two-thirds of women and one-third of men who undergo a clinically indicated coronary angiography for stable angina, have no obstructive coronary artery disease (CAD). Coronary vascular dysfunction is a highly prevalent underlying cause of angina in these so called “Angina with No Obstructive Coronary Arteries (ANOCA)” patients, foremost in middle aged women. Coronary vascular dysfunction encompasses various endotypes, namely epicardial and microvascular coronary spasms, impaired vasodilatation, and increased microvascular resistance. ANOCA patients, especially those with underlying coronary vascular dysfunction, have an adverse cardiovascular prognosis, poor physical functioning, and a reduced quality of life. Since standard ischemia detection tests and coronary angiograms are not designed to diagnose coronary vascular dysfunction, this ischemic heart disease is often overlooked and hence undertreated. But adequate diagnosis is vital, so that treatment can be started to reduce symptoms, reduce healthcare costs and improve quality of life and cardiovascular prognosis. The purpose of this review is to give a contemporary overview of ANOCA with focus on coronary vascular dysfunction. We will provide a possible work-up of patients suspected of coronary vascular dysfunction in the outpatient clinical setting, based on the latest scientific insights and international consensus documents. We will discuss the value of ischemia detection testing, and non-invasive and invasive methods to diagnose coronary vascular dysfunction. Furthermore, we will go into pharmacological and non-pharmacological therapeutic options including anti-anginal regimens and lifestyle interventions.
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Affiliation(s)
- Joan G Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, Netherlands
| | | | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
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20
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Vaccarino V, Almuwaqqat Z, Kim JH, Hammadah M, Shah AJ, Ko YA, Elon L, Sullivan S, Shah A, Alkhoder A, Lima BB, Pearce B, Ward L, Kutner M, Hu Y, Lewis TT, Garcia EV, Nye J, Sheps DS, Raggi P, Bremner JD, Quyyumi AA. Association of Mental Stress-Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease. JAMA 2021; 326:1818-1828. [PMID: 34751708 PMCID: PMC8579237 DOI: 10.1001/jama.2021.17649] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Mental stress-induced myocardial ischemia is a recognized phenomenon in patients with coronary heart disease (CHD), but its clinical significance in the contemporary clinical era has not been investigated. OBJECTIVE To compare the association of mental stress-induced or conventional stress-induced ischemia with adverse cardiovascular events in patients with CHD. DESIGN, SETTING, AND PARTICIPANTS Pooled analysis of 2 prospective cohort studies of patients with stable CHD from a university-based hospital network in Atlanta, Georgia: the Mental Stress Ischemia Prognosis Study (MIPS) and the Myocardial Infarction and Mental Stress Study 2 (MIMS2). Participants were enrolled between June 2011 and March 2016 (last follow-up, February 2020). EXPOSURES Provocation of myocardial ischemia with a standardized mental stress test (public speaking task) and with a conventional (exercise or pharmacological) stress test, using single-photon emission computed tomography. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of cardiovascular death or first or recurrent nonfatal myocardial infarction. The secondary end point additionally included hospitalizations for heart failure. RESULTS Of the 918 patients in the total sample pool (mean age, 60 years; 34% women), 618 participated in MIPS and 300 in MIMS2. Of those, 147 patients (16%) had mental stress-induced ischemia, 281 (31%) conventional stress ischemia, and 96 (10%) had both. Over a 5-year median follow-up, the primary end point occurred in 156 participants. The pooled event rate was 6.9 per 100 patient-years among patients with and 2.6 per 100 patient-years among patients without mental stress-induced ischemia. The multivariable adjusted hazard ratio (HR) for patients with vs those without mental stress-induced ischemia was 2.5 (95% CI, 1.8-3.5). Compared with patients with no ischemia (event rate, 2.3 per 100 patient-years), patients with mental stress-induced ischemia alone had a significantly increased risk (event rate, 4.8 per 100 patient-years; HR, 2.0; 95% CI, 1.1-3.7) as did patients with both mental stress ischemia and conventional stress ischemia (event rate, 8.1 per 100 patient-years; HR, 3.8; 95% CI, 2.6-5.6). Patients with conventional stress ischemia alone did not have a significantly increased risk (event rate, 3.1 per 100 patient-years; HR, 1.4; 95% CI, 0.9-2.1). Patients with both mental stress ischemia and conventional stress ischemia had an elevated risk compared with patients with conventional stress ischemia alone (HR, 2.7; 95% CI, 1.7-4.3). The secondary end point occurred in 319 participants. The event rate was 12.6 per 100 patient-years for patients with and 5.6 per 100 patient-years for patients without mental stress-induced ischemia (adjusted HR, 2.0; 95% CI, 1.5-2.5). CONCLUSIONS AND RELEVANCE Among patients with stable coronary heart disease, the presence of mental stress-induced ischemia, compared with no mental stress-induced ischemia, was significantly associated with an increased risk of cardiovascular death or nonfatal myocardial infarction. Although these findings may provide insights into mechanisms of myocardial ischemia, further research is needed to assess whether testing for mental stress-induced ischemia has clinical value.
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Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zakaria Almuwaqqat
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeong Hwan Kim
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Muhammad Hammadah
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Atlanta VA Medical Center, Decatur, Georgia
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anish Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ayman Alkhoder
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bruno B. Lima
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ernest V. Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathon Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David S. Sheps
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, Gainesville
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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21
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van der Meer RE, Maas AH. The Role of Mental Stress in Ischaemia with No Obstructive Coronary Artery Disease and Coronary Vasomotor Disorders. Eur Cardiol 2021; 16:e37. [PMID: 34721671 PMCID: PMC8532004 DOI: 10.15420/ecr.2021.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/12/2021] [Indexed: 01/22/2023] Open
Abstract
Ischaemic heart disease has been estimated to affect 126.5 million people globally. Approximately 70% of patients with angina and suspected myocardial ischaemia show no signs of obstructed coronary arteries after coronary angiography, but may still demonstrate ischaemia. Ischaemia with no obstructive coronary artery disease (INOCA) is increasingly acknowledged as a serious condition because of its association with poor quality of life and elevated risk for cardiovascular events. The negative effects of psychological stress on INOCA are gaining more attention. Psychological stress is associated with adverse cardiovascular outcomes such as mental stress-induced myocardial ischaemia. Psychological stress includes anxiety, depression, anger and personality disturbances. Coronary microvascular dysfunction and coronary arterial spasm are phenotypes of coronary vasomotor disorders that are triggered by psychological distress and depression, thereby increasing cardiovascular disease risk. Coronary vasomotor disorders are often co-existent in INOCA patients and might be considered as a contributing factor to mental stress-associated adverse cardiovascular outcomes. Additionally, psychological stress induces endothelial dysfunction more often in (young) women with INOCA than in men. Overall, many studies demonstrate an association between mental stress, coronary microvascular dysfunction and coronary vasospasm in patients with INOCA - especially women. Future research on stress-reducing therapies that target coronary vasomotor disorders in patients with INOCA is needed. This is particularly the case in young adolescents, in whom this type of ischaemic heart disease is increasing.
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Affiliation(s)
| | - Angela Hem Maas
- Department of Cardiology, Radboud University Medical Center Nijmegen, the Netherlands
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22
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Sara JDS, Ahmad A, Toya T, Suarez Pardo L, Lerman LO, Lerman A. Anxiety Disorders Are Associated With Coronary Endothelial Dysfunction in Women With Chest Pain and Nonobstructive Coronary Artery Disease. J Am Heart Assoc 2021; 10:e021722. [PMID: 34459240 PMCID: PMC8649259 DOI: 10.1161/jaha.121.021722] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Anxiety disorders are the most prevalent mental disorders and are an emerging risk factor for coronary artery disease and its complications. We determine the relationship between having a clinical diagnosis of an anxiety disorder and coronary endothelial dysfunction (CED) using invasive coronary reactivity testing across both sexes. Methods and Results Patients presenting with chest pain and nonobstructive coronary artery disease (stenosis <40%) at coronary angiography underwent an invasive assessment of CED. Patients were categorized as having a clinical diagnosis of an anxiety disorder at the time of coronary angiography by chart review. The frequency of CED was compared between patients with versus without an anxiety disorder and after stratifying patients by sex. Between 1992 and 2020, 1974 patients (mean age, 51.3 years; 66.2% women) underwent invasive coronary reactivity testing, of which 550 (27.9%) had a documented anxiety disorder at the time of angiography. There was a significantly higher proportion of patients with any type of CED in those with an anxiety disorder in all patients (343 [62.7%] versus 790 [56.4%]; P=0.011) that persisted in women but not in men. After adjusting for covariables, anxiety was significantly associated with any CED among all patients (odds ratio [95% CI], 1.36 [1.10–1.68]; P=0.004), and after stratifying by sex in women but not in men. Conclusions Anxiety disorders are significantly associated with CED in women presenting with chest pain and nonobstructive coronary artery disease. Thus, CED may represent a mechanism underpinning the association between anxiety disorders and coronary artery disease and its complications, highlighting the role of anxiety as a potential therapeutic target to prevent cardiovascular events.
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Affiliation(s)
- Jaskanwal D S Sara
- Department of Cardiovascular Medicine Mayo College of Medicine Rochester MN
| | - Ali Ahmad
- Department of Cardiovascular Medicine Mayo College of Medicine Rochester MN
| | - Takumi Toya
- Department of Cardiovascular Medicine Mayo College of Medicine Rochester MN
| | | | - Lilach O Lerman
- Department of Psychiatry and Psychology Mayo Clinic Rochester MN.,Division of Nephrology and Hypertension Mayo Clinic Rochester MN
| | - Amir Lerman
- Department of Cardiovascular Medicine Mayo College of Medicine Rochester MN
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23
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Sara JDS, Lerman LO, Lerman A. The endothelium is a key player in the vascular response to acute mental stress. Eur Heart J 2021; 42:4089-4091. [PMID: 34374756 DOI: 10.1093/eurheartj/ehab510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Lliach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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24
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McKinnon II, Shah AJ, Lima B, Moazzami K, Young A, Sullivan S, Almuwaqqat Z, Garcia M, Elon L, Bremner JD, Raggi P, Quyyumi AA, Vaccarino V, Lewis TT. Everyday Discrimination and Mental Stress-Induced Myocardial Ischemia. Psychosom Med 2021; 83:432-439. [PMID: 34080584 PMCID: PMC8225242 DOI: 10.1097/psy.0000000000000941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Mental stress-induced myocardial ischemia (MSIMI), a transient myocardial ischemic response to mental stress, is associated with poorer outcomes among patients with coronary heart disease and is more likely to occur among women. However, predictors of MSIMI are not well explored. The current study investigated the association between experiences of everyday discrimination and MSIMI among patients with recent myocardial ischemia and contrasted the results with conventional stress-induced myocardial ischemia (CSIMI). We examined sex differences in associations. METHODS We studied 295 post-MI patients (145 women, 150 men). Provocation of myocardial ischemia with mental stress (speech task) and conventional stress (exercise or pharmacologic) was assessed by myocardial perfusion imaging. Frequency of exposure to everyday discrimination was assessed via questionnaire using the Everyday Discrimination Scale (EDS). RESULTS The mean age was 51 years in both women and men, and the EDS score ranged from 10 to 38 (mean [standard deviation] = 17 [6] years). After multivariable analysis, each standard deviation increase in the EDS score (more frequent exposure) was associated with an increased odds of MSIMI (odds ratio [OR] = 1.57 [1.10-2.23]). The EDS score was not associated with CSIMI (OR = 0.86 [0.64-1.17]). Women demonstrated a twofold increase (OR = 1.96 [1.13-3.38], p = .02) in the adjusted odds of MSIMI, with each standard deviation increase in the EDS score compared with a 1.4-fold increase (OR = 1.40 [0.80-2.44], p = .24) among men; however, interaction was not statistically significant. CONCLUSIONS Among post-MI patients, everyday discrimination was positively associated with occurrence of MSIMI, but not with CSIMI; associations were more pronounced among women.
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Affiliation(s)
- Izraelle I. McKinnon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur, Georgia
| | - Bruno Lima
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - An Young
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zakaria Almuwaqqat
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Mariana Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Lisa Elon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Paolo Raggi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Arshed A. Quyyumi
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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25
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Brain-heart connections in stress and cardiovascular disease: Implications for the cardiac patient. Atherosclerosis 2021; 328:74-82. [PMID: 34102426 PMCID: PMC8254768 DOI: 10.1016/j.atherosclerosis.2021.05.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/05/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022]
Abstract
The influence of psychological stress on the physiology of the cardiovascular system, and on the etiology and outcomes of cardiovascular disease (CVD) has been the object of intense investigation. As a whole, current knowledge points to a "brain-heart axis" that is especially important in individuals with pre-existing CVD. The use of acute psychological stress provocation in the laboratory has been useful to clarify the effects of psychological stress on cardiovascular physiology, immune function, vascular reactivity, myocardial ischemia, neurobiology and cardiovascular outcomes. An emerging paradigm is that dynamic perturbations of physiological and molecular pathways during stress or negative emotions are important in influencing cardiovascular outcomes, and that some patient subgroups, such as women, patients with an early-onset myocardial infarction, and patients with adverse psychosocial exposures, may be at especially high risk for these effects. This review summarizes recent knowledge on mind-body connections in CVD among cardiac patients and highlights important pathways of risk which could become the object of future intervention efforts. As a whole, this research suggests that an integrated study of mind and body is necessary to fully understand the determinants and consequences of CVD.
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26
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Moazzami K, Wittbrodt MT, Lima BB, Kim JH, Almuwaqqat Z, Shah AJ, Hajjar I, Goldstein FC, Levey AI, Nye JA, Bremner JD, Vaccarino V, Quyyumi AA. Neurobiological Pathways Linking Acute Mental Stress to Impairments in Executive Function in Individuals with Coronary Artery Disease. J Alzheimers Dis Rep 2021; 5:99-109. [PMID: 33782663 PMCID: PMC7990469 DOI: 10.3233/adr-200287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Individuals with coronary artery disease (CAD) have worse executive function compared to the general population but the mechanisms are unknown. OBJECTIVE To investigate the role of acute mental stress (MS) on the executive function of patients with CAD. METHODS Participants with stable CAD underwent acute MS testing with simultaneous peripheral vascular function measurements and brain imaging using high resolution-positron emission tomography. Digital pulse wave amplitude was continuously measured using peripheral artery tonometry (PAT, Itamar Inc). Stress/rest PAT ratio (sPAT) of pulse wave amplitude during MS/baseline was calculated as a measure of microvascular constriction during MS. Plasma levels of catecholamine and interleukin-6 were assessed at baseline and after MS. Executive function was assessed both at baseline and at 2 years follow-up using the Trail Making Test parts A and B. RESULTS We studied 389 individuals with brain data available for 148 participants. Of this population follow-up cognitive assessments were performed in 226 individuals (121 with brain imaging). After multivariable adjustment for baseline demographics, risk factors, and medication use, a lower sPAT, indicating greater vasoconstriction, a higher inferior frontal lobe activation with MS, and increases in norepinephrine and IL-6 levels with MS were all independently associated with greater time to complete Trail B test.-38.4pt. CONCLUSION In response to acute MS, greater peripheral vasoconstriction, higher inferior frontal lobe brain activation, and increases in the levels of norepinephrine and IL-6 are associated with worse executive function.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeong Hwan Kim
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA,Atlanta VA Medical Center, Decatur, GA, USA
| | - Ihab Hajjar
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, USA,
Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Felicia C. Goldstein
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, USA,
Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Allan I. Levey
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, USA,
Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathon A. Nye
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA,
Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA,
Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA,Correspondence to: Arshed A. Quyyumi, MD, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road N.E. Suite 507, Atlanta, GA 30322, USA. Tel.: +1 404 727 3655; Fax: +1 404 712 8785; E-mail:
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Moazzami K, Sullivan S, Lima BB, Kim JH, Hammadah M, Almuwaqqat Z, Shah AJ, Hajjar I, Goldstein FC, Levey AI, Bremner JD, Quyyumi AA, Vaccarino V. Mental stress-induced myocardial ischemia and cognitive impairment in coronary atherosclerosis. J Psychosom Res 2021; 141:110342. [PMID: 33360843 PMCID: PMC7857648 DOI: 10.1016/j.jpsychores.2020.110342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/10/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To understand if presence of mental stress-induced myocardial ischemia (MSIMI) is associated with higher prevalence of cognitive impairment at baseline and its decline over time. METHODS A cohort of participants with stable coronary atherosclerosis underwent acute mental stress testing using a series of standardized speech/arithmetic stressors. The stress/rest digital vasomotor response to mental stress (sPAT) was assessed to measure microvascular constriction during mental stress. Patients received 99mTc-sestamibi myocardial perfusion imaging at rest, with mental stress and with conventional (exercise/pharmacological) stress. Cognitive function was assessed both at baseline and at a 2 year follow-up using the Trail Making Test parts A and B and the verbal and visual memory subtests of the Wechsler Memory Scale. RESULTS We studied 486 individuals (72% male, 32.1% Black, 62 ± 9 (mean ± SD) years old). After multivariable adjustment for baseline demographics, risk factors, and medication use, presence of MSIMI was associated with 21% and 20% slower completion of Trail-A and Trail-B, respectively (p for all <0.01). After a 2-year follow-up period, presence of MSIMI was associated with a 33% slower completion of Trail-B, denoting cognitive decline (B = 0.33, 95% CI, 0.04, 0.62). A lower sPAT, indicating greater vasoconstriction, mediated the association between MSIMI and worsening Trail-B performance by 18.2%. Ischemia with a conventional stress test was not associated with any of the cognitive tests over time. CONCLUSION MSIMI is associated with slower visuomotor processing and worse executive function at baseline and with greater decline in these abilities over time.
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Affiliation(s)
- Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Jeong Hwan Kim
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Muhammad Hammadah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Zakaria Almuwaqqat
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America,Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ihab Hajjar
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, United States of America,Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, United States of America,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, United States of America
| | - Felicia C. Goldstein
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, United States of America,Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Allan I. Levey
- Department of Neurology, Emory University School of Medicine, Emory University, Atlanta, GA, United States of America,Goizuetta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, United States of America
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA, United States of America,Department of Radiology and Imaging Sciences, Emory University School of Medicine, United States of America,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America; Emory Clinical Cardiovascular Research Institute, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America.
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Sun H, Li X, Lou J, Zhang Y, Jiang Y, Fang J. Acupuncture and related therapies for treating stable angina pectoris: A protocol of an overview of systematic reviews and meta-analysis. Medicine (Baltimore) 2020; 99:e23701. [PMID: 33371115 PMCID: PMC7748361 DOI: 10.1097/md.0000000000023701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Stable angina pectoris (SAP) is a global health challenge. Multiple previous systematic reviews (SRs) have been conducted to assess the effectiveness of acupuncture and related therapies on SAP. We will carry out a comprehensive overview to map, synthesize, and assess the all the available evidence of acupuncture and related therapies on SAP. METHODS We will search 7 databases, including China National Knowledge Infrastructure (CNKI) and Chinese Biomedical Literature Database (CBM), WanFang Database, the Cochrane Library, PubMed, EMbase, MEDLINE. SRs and meta-analyses (MAs) of acupuncture and related therapies on SAP will be screened for eligibility. Systematic reviews, qualification evaluation, data extraction, methodological quality, and evidence quality evaluation will be conducted in pairs. The outcomes of interest include: frequency of angina attack, changes in nitroglycerin use, intensity of anginal pain, depression assessment, changes of the electrocardiogramme (ECG), anxiety assessment, results of the Six-Minute Walk Test (6-MWT), overall effectiveness, the Seattle Angina Questionnaire (SAQ), and adverse events. Where appropriate, the evidence will be synthesized based on the outcomes and patient subgroups. RESULTS This overview will be published in a peer-reviewed journal. CONCLUSION This overview is expected to provide a reliable and valuable evidence of acupuncture for treating SAP. ETHICS AND COMMUNICATION Given that this is an overview of published research, patient consent and ethical approval are not needed. The findings of this study will be disseminated through conference presentations and publication in peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42020164466.
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Affiliation(s)
- Haiju Sun
- Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Hangzhou City, Zhejiang Province
| | - Xiaoyu Li
- Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Hangzhou City, Zhejiang Province
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jiali Lou
- Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Hangzhou City, Zhejiang Province
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Yajun Zhang
- Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Hangzhou City, Zhejiang Province
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Yongliang Jiang
- Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Hangzhou City, Zhejiang Province
| | - Jianqiao Fang
- Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Hangzhou City, Zhejiang Province
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The effects of repeated binge drinking on arterial stiffness and urinary norepinephrine levels in young adults. J Hypertens 2020; 38:111-117. [PMID: 31503138 DOI: 10.1097/hjh.0000000000002223] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the effect of repeated binge drinking and moderate alcohol consumption in young adults on arterial stiffness and sympathetic activity. METHODS We enrolled 49 healthy young adults, free of cardiovascular diseases (25 men; age: 23.5 ± 0.4 years; BMI: 23.4 ± 0.4 kg/m; mean ± S.E). Individuals included were those with a history of repeated binge drinking (>2 years duration; n = 20), drank at moderate levels (MODs, >5 years duration; n = 16) and abstained from alcohol (last 2-3 years; n = 13). Arterial stiffness was assessed using carotid to femoral pulse wave velocity (cfPWV) and sympathetic activity was assessed using 24-h urinary norepinephrine levels. Also measured was aortic SBP and augmentation index (AIx), a measure of wave reflection. RESULTS Binge drinkers and MODs had higher cfPWV than alcohol abstainers (0.6 and 0.5 m/s, respectively; P ≤ 0.04). In addition, binge drinkers had higher urinary norepinephrine levels than MODs and alcohol abstainers (P < 0.05). Higher cfPWV were correlated with higher norepinephrine levels (r = 0.35. P = 0.02). Aortic SBP (P = 0.2) and AIx (P = 0.96) were similar among binge drinkers, MODs and alcohol abstainers. CONCLUSION Our findings suggest that repeated exposure to alcohol, regardless of drinking pattern, may increase aortic arterial stiffness in healthy young adults. In addition, sympathetic activation, reflected by increased 24-h urinary norepinephrine levels, may contribute to alcohol-induced arterial stiffening in young adults.
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Bremner JD, Gurel NZ, Jiao Y, Wittbrodt MT, Levantsevych OM, Huang M, Jung H, Shandhi MH, Beckwith J, Herring I, Rapaport MH, Murrah N, Driggers E, Ko YA, Alkhalaf ML, Soudan M, Song J, Ku BS, Shallenberger L, Hankus AN, Nye JA, Park J, Vaccarino V, Shah AJ, Inan OT, Pearce BD. Transcutaneous vagal nerve stimulation blocks stress-induced activation of Interleukin-6 and interferon-γ in posttraumatic stress disorder: A double-blind, randomized, sham-controlled trial. Brain Behav Immun Health 2020; 9:100138. [PMID: 34589887 PMCID: PMC8474180 DOI: 10.1016/j.bbih.2020.100138] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 01/02/2023] Open
Abstract
Posttraumatic stress disorder (PTSD) is a highly disabling condition associated with alterations in multiple neurobiological systems, including increases in inflammatory function. Vagus nerve stimulation (VNS) decreases inflammation, however few studies have examined the effects of non-invasive VNS on physiology in human subjects, and no studies in patients with PTSD. The purpose of this study was to assess the effects of transcutaneous cervical VNS (tcVNS) on inflammatory responses to stress. Thirty subjects with a history of exposure to traumatic stress with (N = 10) and without (N = 20) PTSD underwent exposure to stressful tasks immediately followed by active or sham tcVNS and measurement of multiple biomarkers of inflammation (interleukin-(IL)-6, IL-2, IL-1β, Tumor Necrosis Factor alpha (TNFα) and Interferon gamma (IFNγ) over multiple time points. Stressful tasks included exposure to personalized scripts of traumatic events on day 1, and public speech and mental arithmetic (Mental Stress) tasks on days 2 and 3. Traumatic scripts were associated with a pattern of subjective anger measured with Visual Analogue Scales and increased IL-6 and IFNγ in PTSD patients that was blocked by tcVNS (p < .05). Traumatic stress had minimal effects on these biomarkers in non-PTSD subjects and there was no difference between tcVNS or sham. No significant differences were seen between groups in IL-2, IL-1β, or TNFα. These results demonstrate that tcVNS blocks behavioral and inflammatory responses to stress reminders in PTSD.
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Affiliation(s)
- J. Douglas Bremner
- Departments of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Departments of Radiology, and Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Nil Z. Gurel
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Yunshen Jiao
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Matthew T. Wittbrodt
- Departments of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Minxuan Huang
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Hewon Jung
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - MdMobashir H. Shandhi
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Joy Beckwith
- Departments of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Isaias Herring
- Departments of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark H. Rapaport
- Departments of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nancy Murrah
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Emily Driggers
- Departments of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Yi-An Ko
- Departments of Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, GA, USA
| | | | - Majd Soudan
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Jiawei Song
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Benson S. Ku
- Departments of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Lucy Shallenberger
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Allison N. Hankus
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Jonathon A. Nye
- Departments of Radiology, and Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeanie Park
- Departments of Renal Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Viola Vaccarino
- Departments of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Amit J. Shah
- Departments of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
- Coulter Department of Bioengineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Bradley D. Pearce
- Departments of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
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Harris KM, Jacoby DL, Lampert R, Soucier RJ, Burg MM. Psychological stress in heart failure: a potentially actionable disease modifier. Heart Fail Rev 2020; 26:561-575. [PMID: 33215323 DOI: 10.1007/s10741-020-10056-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 10/24/2022]
Abstract
Psychological stress is common in patients with heart failure, due in part to the complexities of effective disease self-management and progressively worsening functional limitations, including frequent symptom exacerbations and hospitalizations. Emerging evidence suggests that heart failure patients who experience higher levels of stress may have a more burdensome disease course, with diminished quality of life and increased risk for adverse events, and that multiple behavioral and pathophysiological pathways are involved. Furthermore, the reduced quality of life associated with heart failure can serve as a life stressor for many patients. The purpose of this review is to summarize the current state of the science concerning psychological stress in patients with heart failure and to discuss potential pathways responsible for the observed effects. Key knowledge gaps are also outlined, including the need to understand patterns of exposure to various heart failure-related and daily life stressors and their associated effects on heart failure symptoms and pathophysiology, to identify patient subgroups at increased risk for stress exposure and disease-related consequences, and the effect of stress specifically for patients who have heart failure with preserved ejection fraction. Stress is a potentially modifiable factor, and addressing these gaps and advancing the science of stress in heart failure is likely to yield important insights about actionable pathways for improving patient quality of life and outcomes.
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Affiliation(s)
- Kristie M Harris
- Yale School of Medicine, Department of Internal Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA. .,VA Connecticut Healthcare System, Department of Cardiology, West Haven, CT, USA.
| | - Daniel L Jacoby
- Yale School of Medicine, Department of Internal Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Rachel Lampert
- Yale School of Medicine, Department of Internal Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Richard J Soucier
- Saint Francis Hospital and Medical Center, Trinity Health of New England, Hartford, CT, USA
| | - Matthew M Burg
- Yale School of Medicine, Department of Internal Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, Department of Cardiology, West Haven, CT, USA.,Yale School of Medicine, Department of Anesthesiology, New Haven, CT, USA
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Sullivan S, Young A, Hammadah M, Lima BB, Levantsevych O, Ko YA, Pearce BD, Shah AJ, Kim JH, Moazzami K, Driggers EG, Haffar A, Ward L, Herring I, Hankus A, Lewis TT, Mehta PK, Bremner JD, Raggi P, Quyyumi A, Vaccarino V. Sex differences in the inflammatory response to stress and risk of adverse cardiovascular outcomes among patients with coronary heart disease. Brain Behav Immun 2020; 90:294-302. [PMID: 32916271 PMCID: PMC7872132 DOI: 10.1016/j.bbi.2020.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 12/18/2022] Open
Abstract
Stress may contribute to progression of coronary heart disease (CHD) through inflammation, especially among women. Thus, we sought to examine whether increased inflammatory response to stress among patients with CHD is associated with a greater risk of cardiovascular events and whether this risk is higher in women. We examined inflammatory biomarkers known to increase with mental stress (speech task), including interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and matrix metallopeptidase-9 (MMP-9) among 562 patients with stable CHD. Inflammatory response, the difference between post-stress and resting values, was examined as a predictor of major adverse cardiovascular events (MACE) using subdistribution hazards models for competing risks adjusting for demographics, cardiovascular risk factors, and medications. MACE was defined as a composite endpoint of cardiovascular death, myocardial infarction, unstable angina with revascularization, and heart failure. All biomarkers were standardized. The mean age was 63 years (range 34-79) and 24% were women. During a median follow-up of 3 years, 71 patients experienced MACE. Overall, there was no significant association between inflammatory response to stress and risk of MACE, but there were sex-based interactions for IL-6 (p = 0.001) and MCP-1 (p = 0.01). The risk of MACE increased 56% (HR: 1.56; 95% CI: 1.21, 2.01; p = 0.001) and 30% (HR: 1.30; 95% 1.09, 1.55; p = 0.004) for each standard deviation increase in IL-6 and MCP-1 response to mental stress for women, respectively, while there was no association among men. Increased inflammation in response to stress is associated with future adverse cardiovascular outcomes among women with CHD.
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Affiliation(s)
- Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
| | - An Young
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Oleksiy Levantsevych
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States,Atlanta VA Medical Center, Decatur, Georgia, 30322, United States
| | - Jeong Hwan Kim
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Emily G. Driggers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Ammer Haffar
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | | | - Allison Hankus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Puja K. Mehta
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia, 30322, United States,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Arshed Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, United States
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Mehta PK, Bess C, Elias-Smale S, Vaccarino V, Quyyumi A, Pepine CJ, Bairey Merz CN. Gender in cardiovascular medicine: chest pain and coronary artery disease. Eur Heart J 2020; 40:3819-3826. [PMID: 31713592 DOI: 10.1093/eurheartj/ehz784] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/26/2019] [Accepted: 10/23/2019] [Indexed: 01/10/2023] Open
Abstract
Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality among women and men yet women are more often underdiagnosed, have a delay in diagnosis, and/or receive suboptimal treatment. An implicit gender-bias with regard to lack of recognition of sex-related differences in presentation of IHD may, in part, explain these differences in women compared with men. Indeed, existing knowledge demonstrates that angina does not commonly relate to obstructive coronary artery disease (CAD). Emerging knowledge supports an inclusive approach to chest pain symptoms in women, as well as a more thoughtful consideration of percutaneous coronary intervention for angina in stable obstructive CAD, to avoid chasing our tails. Emerging knowledge regarding the cardiac autonomic nervous system and visceral pain pathways in patients with and without obstructive CAD offers explanatory mechanisms for angina. Interdisciplinary investigation approaches that involve cardiologists, biobehavioural specialists, and anaesthesia/pain specialists to improve angina treatment should be pursued.
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Affiliation(s)
- Puja K Mehta
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Suite 505, Atlanta, GA, USA
| | - Courtney Bess
- J. Willis Hurst Internal Residency Program, Emory University, 49 Jesse Hill Jr Drive, FOB Building, 4th floor, Box #92, Atlanta, GA, USA
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Geert grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, CNR Building, Room 3041, Atlanta, GA, USA
| | - Arshed Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Suite 505, Atlanta, GA, USA
| | - Carl J Pepine
- Divsion of Cardiology, University of Florida, 1329 SW 6th Street, PO Box 100288, Gainesville, FL, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA, USA
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Research progress regarding the diagnosis and treatment of mental stress-induced myocardial ischemia. Anatol J Cardiol 2020; 24:126-136. [PMID: 32870175 PMCID: PMC7585978 DOI: 10.14744/anatoljcardiol.2020.69447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myocardial ischemia resulting from psychological stress [mental stress-induced myocardial ischemia (MSIMI)] refers to the condition wherein psychosocial and psychological stimulations cause myocardial ischemia in patients with coronary heart disease, which is different from drug-induced myocardial ischemia. Therefore, this condition often escapes diagnosis, portends clinical risk, and affects the quality of life of MSIMI survivors. MSIMI is closely related to the poor prognosis of cardiovascular diseases, especially in young women, according to recent randomized, controlled trials (RCTs) on MSIMI. These RCTs involved different sample sizes, interventional measures, and detection techniques. Moreover, differences exist regarding the prevalence rate, distribution characteristics, possible pathogenesis, and clinical significance. Nevertheless, currently, the diagnostic criteria, pathogenesis, and treatment of MSIMI are still in the clinical exploration stage. Hence, considering recent RCTs, this paper summarizes the research status of MSIMI from the aspects of pathogenesis, diagnosis, and treatment strategies to provide a theoretical basis for the follow-up diagnostic methods and treatment guidelines for MSIMI.
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Saito Y, Shoji T, Tateishi K, Kitahara H, Fujimoto Y, Kobayashi Y. Mental Health Status in Patients Undergoing Intracoronary Acetylcholine Provocation Test. Adv Ther 2020; 37:3807-3815. [PMID: 32651740 DOI: 10.1007/s12325-020-01424-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Previous studies showed the relation of mental distress such as anxiety and depression to coronary vasoconstriction and myocardial ischemia. However, the mental health status of patients suspected to have vasospastic angina is unclear. METHODS A total of 99 patients underwent intracoronary acetylcholine (ACh) provocation tests for the diagnosis of vasospastic angina and mental health assessment using the 12-item General Health Questionnaire (GHQ-12) and State-Trait Anxiety Inventory Form Y (STAI Y-2). Patients with binary GHQ-12 ≥ 4 were defined as having poor mental health. RESULTS Median GHQ-12 and STAI Y-2 were 3 [1, 6] and 44 [36, 50]. Forty-one (41%) patients had binary GHQ-12 ≥ 4, and 48 (48%) had positive ACh provocation tests. The number of provoked vasospasms and rate of electrocardiographic change and chest pain during ACh tests were not significantly different between patients with and without GHQ-12 ≥ 4. The incidence of positive ACh provocation test was similar between the two groups (49% vs. 48%, p = 1.00). The multivariable analysis indicated that younger age, no history of percutaneous coronary intervention and no diabetes mellitus were factors associated with higher GHQ-12 and/or STAI Y-2 scores. CONCLUSIONS More than 40% of patients who underwent ACh provocation tests had poor mental condition. No impact of mental distress on positive ACh tests was found in this study.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Toshihiro Shoji
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Konst RE, Meeder JG, Wittekoek ME, Maas AHEM, Appelman Y, Piek JJ, van de Hoef TP, Damman P, Elias-Smale SE. Ischaemia with no obstructive coronary arteries. Neth Heart J 2020; 28:66-72. [PMID: 32780334 PMCID: PMC7419395 DOI: 10.1007/s12471-020-01451-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Ischaemia with no obstructive coronary arteries (INOCA) is a common ischaemic heart disease with a female preponderance, mostly due to underlying coronary vascular dysfunction comprising coronary microvascular dysfunction and/or epicardial coronary vasospasm. Since standard ischaemia detection tests and coronary angiograms are not suitable to diagnose coronary vascular dysfunction, INOCA is often overlooked in current cardiology practice. Future research, including large outcome trials, is much awaited. Yet, adequate diagnosis is possible and treatment options are available and vital to reduce symptoms and most probably improve cardiovascular prognosis. This review intends to give a brief overview of the clinical presentation, underlying pathophysiology, and the diagnostic and treatment options in patients with suspected INOCA.
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Affiliation(s)
- R E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | | | - A H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Y Appelman
- Department of Cardiology, Amsterdam UMC, Location VUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J Piek
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - T P van de Hoef
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - P Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S E Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands.
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Tu M, Jiang Y, Yu J, Liao B, Fang J. Acupuncture for treating chronic stable angina pectoris-associated anxiety and depression: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21583. [PMID: 32756214 PMCID: PMC7402712 DOI: 10.1097/md.0000000000021583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There are numerous studies worldwide on the use of acupuncture as complementary therapy for chronic stable angina pectoris (CSAP). However, the high morbidity of CSAP-associated anxiety and depression is often overlooked. This protocol of systematic review and meta-analysis aims to assess whether acupuncture is effective as a complementary therapy for anxiety and depression in patients with CSAP. METHODS The following 8 databases will be searched from inception to February 2020 with no language restrictions: PubMed, Excerpt Medical Database, Web of Science, the Cochrane Library, Chinese Biomedical Database, China National Knowledge Infrastructure, VIP Database and Wanfang Database. Eligible randomized controlled trials and controlled clinical trials will be included. Study selection, data extraction, and risk of bias assessment will be performed independently by 2 reviewers, differences will be resolved by the third reviewer. The primary outcomes include the level of anxiety or depression measured by qualified scales, angina attack frequency, and angina pain intensity. Revman 5.3 software will be used to perform the assessment of the risk of bias and data synthesis. The review will grade the quality of the evidence based on the Grading of Recommendation, Assessment, Development, and Evaluation system. RESULTS This systematic review and meta-analysis will provide reliable evidence about the effect and safety of acupuncture as a complementary therapy for CSAP-associated anxiety and depression. CONCLUSION The conclusion of this study will be published in a peer-reviewed journal. ETHICS AND DISSEMINATION This review will not involve private information of participants, so the ethical approval will not be required. The results will be disseminated in a peer-reviewed journal or conference presentation. Important protocol modifications will be updated on PROSPERO. PROSPERO REGISTRATION NUMBER CRD42020165492.
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Affiliation(s)
- Mingqi Tu
- Department of Neurobiology and Acupuncture Research, the Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province
| | - Yongliang Jiang
- Department of Neurobiology and Acupuncture Research, the Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province
| | - Jie Yu
- Department of Neurobiology and Acupuncture Research, the Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province
- Department of Acupuncture and Massage, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Binjun Liao
- Department of Neurobiology and Acupuncture Research, the Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province
| | - Jianqiao Fang
- Department of Neurobiology and Acupuncture Research, the Third Clinical Medical College, Zhejiang Chinese Medical University, Key Laboratory of Acupuncture and Neurology of Zhejiang Province
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Lima BB, Hammadah M, Kim JH, Uphoff I, Shah A, Levantsevych O, Almuwaqqat Z, Moazzami K, Sullivan S, Ward L, Kutner M, Ko YA, Sheps DS, Bremner JD, Quyyumi AA, Vaccarino V. Association of Transient Endothelial Dysfunction Induced by Mental Stress With Major Adverse Cardiovascular Events in Men and Women With Coronary Artery Disease. JAMA Cardiol 2020; 4:988-996. [PMID: 31509180 PMCID: PMC6739728 DOI: 10.1001/jamacardio.2019.3252] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance Acute mental stress can result in transient endothelial dysfunction, but the prognostic relevance of this phenomenon is unknown. Objective To determine the association between mental stress-induced impairment in endothelium-dependent relaxation as assessed by brachial artery flow-mediated vasodilation and adverse cardiovascular outcomes among individuals with stable coronary artery disease. Design, Setting, and Participants This cohort study was conducted at a university-affiliated hospital network between June 2011 and August 2014. A cohort of individuals with stable coronary artery disease were included. Data analysis took place from November 2018 to May 2019. Exposures Study participants were subjected to a laboratory mental stress task (public speaking). Main Outcomes and Measures Flow-mediated vasodilation was measured before and 30 minutes after a public-speaking mental stress task. We examined the association of the rest (prestress), poststress, and δ flow-mediated vasodilation (poststress minus prestress levels) with an adjudicated composite end point of adverse events, including cardiovascular death, myocardial infarction, unstable angina leading to revascularization, and heart failure hospitalization, after adjusting for sociodemographic factors, medical history, and depression. Results A total of 569 patients were included (mean [SD] age, 62.6 [9.3] years; 420 men [73.8%]). Flow-mediated vasodilation decreased from a mean (SD) of 4.8% (3.7%) before mental stress to 3.9% (3.6%) after mental stress (a 23% reduction; P < .001), and 360 participants (63.3%) developed transient endothelial dysfunction (a decrease in flow-mediated vasodilation). During a median (interquartile range) follow-up period of 3.0 (2.9-3.1) years, 74 patients experienced a major adverse cardiovascular event. The presence of transient endothelial dysfunction with mental stress was associated with a 78% increase (subdistribution hazard ratio [sHR], 1.78 [95% CI, 1.15-2.76]) in the incidence of major adverse cardiovascular event. Both the δ flow-mediated vasodilation (sHR, 1.15 [95% CI, 1.03-1.27] for each 1% decline) and poststress flow-mediated vasodilation (sHR, 1.14 [95% CI, 1.04-1.24] for each 1% decline) were associated with major adverse cardiovascular event. Risk discrimination statistics demonstrated a significant model improvement after addition of either poststress flow-mediated vasodilation (change in the area under the curve, 0.05 [95% CI, 0.01-0.09]) or prestress plus δ flow-mediated vasodilation (change in the area under the curve, 0.04 [95% CI, 0.00-0.08]) compared with conventional risk factors. Conclusions and Relevance In this study, transient endothelial dysfunction with mental stress was associated with adverse cardiovascular outcomes in patients with coronary artery disease. Endothelial responses to stress represent a possible mechanism through which psychological stress may affect outcomes in patients with coronary artery disease.
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Affiliation(s)
- Bruno B Lima
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Muhammad Hammadah
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeong Hwan Kim
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Irina Uphoff
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amit Shah
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia.,Atlanta VA Medical Center, Decatur, Georgia
| | - Oleksiy Levantsevych
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zakaria Almuwaqqat
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Kasra Moazzami
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Samaah Sullivan
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Laura Ward
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Michael Kutner
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Yi-An Ko
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - David S Sheps
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
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Acute psychological stress, autonomic function, and arterial stiffness among women. Int J Psychophysiol 2020; 155:219-226. [PMID: 32619458 DOI: 10.1016/j.ijpsycho.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/20/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022]
Abstract
This study aimed to investigate the effect of acute psychological stress on autonomic function and arterial stiffness, and to test a mediating role of changes in autonomic function between acute stress and arterial stiffness. Eighty-five healthy female adults were randomized into either an experimental or control group. The Trier Social Stress Test (TSST) was used to induce acute psychological stress. Autonomic function (measured by pre-ejection period [PEP] from cardiac impedance and high frequency [HF] of heart rate variability [HRV]) and arterial stiffness (measured by carotid and femoral pulse wave velocity [cfPWV] and augmentation index [AIx]) were assessed before and after the TSST. The mean age of the participants was 28.78 (±9.84) years old. Experimental group participants had a significant increase in cfPWV (p = .025) and AIx (p = .017) following the stressor, compared with those in the control group, after controlling for age, body mass index, and systolic blood pressure. However, no significant group differences were observed in changes in PEP (p = .181) and HF (p = .058). Changes in PEP and HF were neither associated with changes in cfPWV (p = .975 and p = .654, respectively), nor in AIx (p = .376 and p = .323, respectively). The results suggest that even a brief period of mild to moderate stress, which does not cause sustainable changes in autonomic function, may still exert significant adverse effects on arterial stiffness. The changes in arterial stiffness were not related to changes in autonomic function. Future experimental studies with several measurement points are recommended to identify distinct effects of stress on autonomic function and arterial stiffness.
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Vaccarino V, Badimon L, Bremner JD, Cenko E, Cubedo J, Dorobantu M, Duncker DJ, Koller A, Manfrini O, Milicic D, Padro T, Pries AR, Quyyumi AA, Tousoulis D, Trifunovic D, Vasiljevic Z, de Wit C, Bugiardini R. Depression and coronary heart disease: 2018 position paper of the ESC working group on coronary pathophysiology and microcirculation. Eur Heart J 2020; 41:1687-1696. [PMID: 30698764 PMCID: PMC10941327 DOI: 10.1093/eurheartj/ehy913] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/25/2018] [Accepted: 01/03/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road Northeast, Atlanta, GA, 30322, USA
- Department of Medicine (Cardiology), Emory University School of Medicine, 1518 Clifton Road Northeast, Atlanta, GA, 30322, USA
| | - Lina Badimon
- Cardiovascular Program (ICCC), IR-Hospital de la Santa Creu i Sant Pau. CiberCV-Institute Carlos III. Autonomous University of Barcelona, C/ Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive Northeast, Atlanta, GA, 30329, USA
- Department of Radiology, Emory University School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA, 30322, USA
- Atlanta Veterans Administration Medical Center, 670 Clairmont Road, Decatur, GA, 30033, USA
| | - Edina Cenko
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Judit Cubedo
- Cardiovascular Program (ICCC), IR-Hospital de la Santa Creu i Sant Pau. CiberCV-Institute Carlos III. Autonomous University of Barcelona, C/ Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain
| | - Maria Dorobantu
- Cardiology Department, University of Medicine and Pharmacy ‘Carol Davila’ of Bucharest, Emergency Clinical Hospital of Bucharest, Calea Floreasca 8, Sector 1, Bucuresti, 014461, Romania
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus MC, University Medical Center, Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Akos Koller
- Institute of Natural Sciences, University of Physical Education, Alkotas street, 44, 1123, Budapest, Hungary
- Department of Physiology, New York Medical College, Valhalla, NY, 10595, USA
| | - Olivia Manfrini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Davor Milicic
- Department for Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb, Kispaticeva 12, HR-10000, Zagreb, Croatia
| | - Teresa Padro
- Cardiovascular Program (ICCC), IR-Hospital de la Santa Creu i Sant Pau. CiberCV-Institute Carlos III. Autonomous University of Barcelona, C/ Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain
| | - Axel R Pries
- Department of Physiology, Charitè-University Medicine, Thielallee 71, D-14195, Berlin, Germany
| | - Arshed A Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, 1518 Clifton Road Northeast, Atlanta, GA, 30322, USA
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, University of Athens Medical School, Vasilissis Sofias 114, TK 115 28, Athens, Greece
| | - Danijela Trifunovic
- Department of Cardiology, University Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Zorana Vasiljevic
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Cor de Wit
- Institut für Physiologie, Universität zu Lübeck and Deutsches Zentrumfür Herz-Kreislauf-Forschung (DZHK), Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Raffaele Bugiardini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
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Abstract
OBJECTIVE This study aimed to investigate the relationship between waist circumference as a measure of abdominal obesity and brain responses to stress among patients with coronary artery disease (CAD). METHODS Patients with CAD (N = 151) underwent acute mental stress tasks in conjunction with high-resolution positron emission tomography and radiolabeled water imaging of the brain. Brain responses to mental stress were correlated with waist circumference. RESULTS Waist circumference was positively correlated with increased activation in the right and left frontal lobes (β values ranging from 2.81 to 3.75 in the paracentral, medial, and superior gyri), left temporal lobe, left hippocampal, left amygdala, left uncus, and left anterior and posterior cingulate gyri (β values ranging from 2.93 to 3.55). Waist circumference was also negatively associated with the left and right parietal lobes, right superior temporal gyrus, and right insula and precuneus (β values ranging from 2.82 to 5.20). CONCLUSION Increased brain activation in the brain regions involved in the stress response and autonomic regulation of the cardiovascular system during psychological stress may underlie stress-induced overeating and abdominal obesity in patients with CAD.
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Lima BB, Hammadah M, Pearce BD, Shah A, Moazzami K, Kim JH, Sullivan S, Levantsevych O, Lewis TT, Weng L, Elon L, Li L, Raggi P, Bremner JD, Quyyumi A, Vaccarino V. Association of Posttraumatic Stress Disorder With Mental Stress-Induced Myocardial Ischemia in Adults After Myocardial Infarction. JAMA Netw Open 2020; 3:e202734. [PMID: 32286655 PMCID: PMC7156990 DOI: 10.1001/jamanetworkopen.2020.2734] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE Posttraumatic stress disorder (PTSD) is prevalent among patients who survived an acute coronary syndrome and is associated with adverse outcomes, but the mechanisms underlying these associations are unclear. OBJECTIVE To evaluate the association of PTSD with mental stress-induced myocardial ischemia among individuals who survived a myocardial infarction (MI). DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included 303 patients aged 18 to 60 years enrolled from a university-affiliated network. Participants had a verified history of MI within 8 months. Data were collected from June 2011 to March 2016, and data analysis was conducted from March to June 2019. EXPOSURES A clinical diagnosis of PTSD (lifetime and current) was obtained using the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), and PTSD symptom subscales were assessed with the civilian version of the PTSD Symptom Checklist. MAIN OUTCOMES AND MEASURES Patients received technetium 99m-labeled sestamibi myocardial perfusion imaging at rest, with mental stress (ie, a speech task) and conventional stress (ie, exercise or pharmacologic). A summed difference score (ie, the difference between stress and rest scores) was used to assess ischemia under both stress conditions. RESULTS Among 303 participants (148 [48.8%] women; 198 [65.3%] African American; mean [SD] age, 51 [7] years), the prevalence of PTSD was 14.5% (44 patients). Patients with PTSD had a higher rate of ischemia with mental stress than those without PTSD (12 of 44 [27.3%] vs 38 of 259 [14.7%]; P = .04) and more than twice the mean number of ischemic segments (1.2 [95% CI, 0.5-1.8] vs 0.5 [95% CI, 0.3-0.7]; P < .001), but there was no difference in conventional stress ischemia (10 of 44 [22.7%] vs 60 of 259 [23.2%]; P = .91). Increasing levels of PTSD symptoms were associated with higher odds of ischemia with mental stress (adjusted odds ratio [OR] per 5-point score increase, 1.18; 95% CI 1.04-1.35; P = .01) but not with conventional stress (adjusted OR per 5-point score increase, 1.05; 95% CI, 0.92-1.21; P = .47). Reexperiencing trauma was the symptom cluster most robustly associated with the presence of ischemia with mental stress (adjusted OR per 5-point score increase, 1.87; 95% CI 1.21-2.91; P = .005), followed by avoidance and numbing (adjusted OR per 5-point score increase, 1.51; 95% CI, 1.07-2.14; P = .02). CONCLUSIONS AND RELEVANCE In this study of young and middle-aged individuals with MI, with a large representation of women and patients from racial/ethnic minority groups, PTSD was associated with the development of myocardial ischemia with mental stress. A higher ischemic response to mental stress represents a potential pathway associating PTSD with adverse outcomes after MI.
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Affiliation(s)
- Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Muhammad Hammadah
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Amit Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Atlanta VA Medical Center, Decatur, Georgia
| | - Kasra Moazzami
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeong Hwan Kim
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Oleksiy Levantsevych
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lei Weng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lian Li
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - J. Douglas Bremner
- Atlanta VA Medical Center, Decatur, Georgia
- Departments of Psychiatry, Emory University School of Medicine, Atlanta, Georgia
- Behavioral Sciences and Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Bremner JD, Wittbrodt MT, Shah AJ, Pearce BD, Gurel NZ, Inan OT, Raggi P, Lewis TT, Quyyumi AA, Vaccarino V. Confederates in the Attic: Posttraumatic Stress Disorder, Cardiovascular Disease, and the Return of Soldier's Heart. J Nerv Ment Dis 2020; 208:171-180. [PMID: 32091470 PMCID: PMC8214871 DOI: 10.1097/nmd.0000000000001100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Da Costa originally described Soldier's Heart in the 19th Century as a syndrome that occurred on the battlefield in soldiers of the American Civil War. Soldier's Heart involved symptoms similar to modern day posttraumatic stress disorder (PTSD) as well as exaggerated cardiovascular reactivity felt to be related to an abnormality of the heart. Interventions were appropriately focused on the cardiovascular system. With the advent of modern psychoanalysis, psychiatric symptoms became divorced from the body and were relegated to the unconscious. Later, the physiology of PTSD and other psychiatric disorders was conceived as solely residing in the brain. More recently, advances in psychosomatic medicine led to the recognition of mind-body relationships and the involvement of multiple physiological systems in the etiology of disorders, including stress, depression PTSD, and cardiovascular disease, has moved to the fore, and has renewed interest in the validity of the original model of the Soldier's Heart syndrome.
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Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta
- Department of Radiology, Emory University School of Medicine, Emory University, Atlanta
- Atlanta VA Medical Center, Decatur
| | - Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta
| | - Amit J. Shah
- Atlanta VA Medical Center, Decatur
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
| | - Bradley D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Nil Z. Gurel
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
- Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Arshed A. Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
| | - Viola Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
- Department of Epidemiology, Rollins School of Public Health, Emory University
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Effect of nutritive and non-nutritive sweeteners on hemodynamic responses to acute stress: a randomized crossover trial in healthy women. Nutr Diabetes 2020; 10:1. [PMID: 32066654 PMCID: PMC7026094 DOI: 10.1038/s41387-019-0104-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 12/06/2019] [Accepted: 12/17/2019] [Indexed: 12/28/2022] Open
Abstract
Background The mechanisms by which chronic stress increases the risk of non-communicable diseases remain poorly understood. On one hand, chronic stress may increase systemic vascular resistance (SVR) and blood pressure, which may lead to blood vessels injury and altered myocardial perfusion. On the other hand, chronic stress may promote the overconsumption of sugar-containing foods and favor obesity. There is indeed evidence that sweet foods are preferentially consumed to alleviate stress responses. The effects of nutritive and non-nutritive sweeteners (NNS) on hemodynamic stress responses remain however largely unknown. Objective/design This study aimed at comparing the effects of sucrose-containing and NNS-containing drinks, as compared to unsweetened water, on hemodynamic responses to acute stress in twelve healthy female subjects. Acute stress responses were elicited by a 30-min mental stress (5-min Stroop’s test alternated with 5-min mental arithmetic) and a 3-min cold pressure test (CPT), each preceded by a resting baseline period. Hemodynamic stress responses were investigated by the repeated measurement of mean arterial pressure and the continuous monitoring of cardiac output by thoracic electrical bioimpedance measurement. SVR was selected as a primary outcome because it is a sensitive measure of hemodynamic responses to acute stress procedures. Results With all three drinks, SVR were not changed with mental stress (P = 0.437), but were increased with CPT (P = 0.045). Both mental stress and CPT increased mean arterial pressure and heart rate (all P < 0.001). Cardiac output increased with mental stress (P < 0.001) and remained unchanged with CPT (P = 0.252). No significant differences in hemodynamic responses were observed between water, sucrose and NNS (stress × condition, all P > 0.05). Conclusions These results demonstrate that sucrose and NNS do not alter hemodynamic responses to two different standardized acute stress protocols.
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Gurel NZ, Huang M, Wittbrodt MT, Jung H, Ladd SL, Shandhi MMH, Ko YA, Shallenberger L, Nye JA, Pearce B, Vaccarino V, Shah AJ, Bremner JD, Inan OT. Quantifying acute physiological biomarkers of transcutaneous cervical vagal nerve stimulation in the context of psychological stress. Brain Stimul 2020; 13:47-59. [PMID: 31439323 PMCID: PMC8252146 DOI: 10.1016/j.brs.2019.08.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/24/2019] [Accepted: 08/04/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Stress is associated with activation of the sympathetic nervous system, and can lead to lasting alterations in autonomic function and in extreme cases symptoms of posttraumatic stress disorder (PTSD). Vagal nerve stimulation (VNS) is a potentially useful tool as a modulator of autonomic nervous system function, however currently available implantable devices are limited by cost and inconvenience. OBJECTIVE The purpose of this study was to assess the effects of transcutaneous cervical VNS (tcVNS) on autonomic responses to stress. METHODS Using a double-blind approach, we investigated the effects of active or sham tcVNS on peripheral cardiovascular and autonomic responses to stress using wearable sensing devices in 24 healthy human participants with a history of exposure to psychological trauma. Participants were exposed to acute stressors over a three-day period, including personalized scripts of traumatic events, public speech, and mental arithmetic tasks. RESULTS tcVNS relative to sham applied immediately after traumatic stress resulted in a decrease in sympathetic function and modulated parasympathetic/sympathetic autonomic tone as measured by increased pre-ejection period (PEP) of the heart (a marker of cardiac sympathetic function) of 4.2 ms (95% CI 1.6-6.8 ms, p < 0.01), decreased peripheral sympathetic function as measured by increased photoplethysmogram (PPG) amplitude (decreased vasoconstriction) by 47.9% (1.4-94.5%, p < 0.05), a 9% decrease in respiratory rate (-14.3 to -3.7%, p < 0.01). Similar effects were seen when tcVNS was applied after other stressors and in the absence of a stressor. CONCLUSION Wearable sensing modalities are feasible to use in experiments in human participants, and tcVNS modulates cardiovascular and peripheral autonomic responses to stress.
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Affiliation(s)
- Nil Z Gurel
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
| | - Minxuan Huang
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Matthew T Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Hewon Jung
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Stacy L Ladd
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA; Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Md Mobashir H Shandhi
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, GA, USA
| | - Lucy Shallenberger
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Jonathon A Nye
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Bradley Pearce
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA; Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA; Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA; Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - Omer T Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA; Coulter Department of Bioengineering, Georgia Institute of Technology, Atlanta, GA, USA
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Bremner JD, Fani N, Cheema FA, Ashraf A, Vaccarino V. Effects of a mental stress challenge on brain function in coronary artery disease patients with and without depression. Health Psychol 2019; 38:910-924. [PMID: 31380683 PMCID: PMC6746592 DOI: 10.1037/hea0000742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Coronary artery disease (CAD) patients with comorbid depression show an increase in mortality compared to cardiac patients without depression, but the mechanisms mediating this effect remain obscure. One possible explanation for this finding is that depressed patients with CAD exhibit an increased vulnerability to stress. The purpose of this study was to assess the effects of stress and depression on brain function and to explore its relationship with myocardial ischemia in CAD patients. METHODS Patients with CAD and depression (N = 13) and CAD without depression (N = 15) underwent imaging of the brain with positron emission tomography and [O-15] water and imaging of the heart with single photon emission computed tomography (SPECT) and [Tc-99m] sestamibi under mental stress task and control conditions. RESULTS CAD patients with depression compared to nondepressed showed decreased function with mental stress in the rostral anterior cingulate, the hippocampus, parts of the dorsolateral temporal and parietal cortex, the cerebellum, and the uncus, with increased blood flow in the parahippocampus, visual association cortex, and posterior cingulate. Depressed CAD patients who became ischemic during a mental stress task had relative decreases in the caudal and posterior cingulate, orbitofrontal cortex, and cerebellum, and increased activation in the parietal cortex and precuneus/visual association cortex compared to nonischemic depressed CAD patients. CONCLUSIONS These findings are consistent with dysfunction in a network of brain regions involved in the stress response in patients with comorbid CAD and depression that has direct and indirect links to the heart, suggesting a pathway by which stress and depression could lead to increased risk of heart disease related morbidity and mortality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences
| | | | - Ali Ashraf
- Department of Psychiatry and Behavioral Sciences
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Kim JH, Almuwaqqat Z, Hammadah M, Liu C, Ko YA, Lima B, Sullivan S, Alkhoder A, Abdulbaki R, Ward L, Bremner JD, Sheps DS, Raggi P, Sun YV, Shah AJ, Vaccarino V, Quyyumi AA. Peripheral Vasoconstriction During Mental Stress and Adverse Cardiovascular Outcomes in Patients With Coronary Artery Disease. Circ Res 2019; 125:874-883. [PMID: 31550998 PMCID: PMC7134565 DOI: 10.1161/circresaha.119.315005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
RATIONALE Excessive vasoconstriction in response to mental stress may be a potential mechanism by which acute psychological stress leads to adverse cardiac events. OBJECTIVES We investigated whether excessive digital vasoconstriction during acute mental stress predicts adverse cardiovascular outcomes among patients with coronary artery disease. METHODS AND RESULTS Five hundred forty-nine patients with stable coronary artery disease (age 63±9, 76% male, 29% black) underwent mental stress testing with a standardized public speaking stressor and followed prospectively for cardiovascular end points. Digital pulse wave amplitude was continuously measured using peripheral artery tonometry (PAT, Itamar Inc). Stress/rest PAT ratio (sPAT) of pulse wave amplitude during mental stress/baseline was calculated and dichotomized by the median value into low and high sPAT ratio groups. Upon 3-year follow-up, Fine and Gray's subdistribution hazard ratios were used to examine the association between sPAT ratio and the composite end point of cardiovascular death, myocardial infarction, revascularization, and hospitalization for heart failure. The median sPAT ratio was 0.68 (interquartile range, 0.48-0.88), indicating 32% vasoconstriction with mental stress. Men were more likely to have low sPAT ratio than women (odds ratio, 1.79; P=0.007) while those on β-blockers were less likely to have low sPAT ratio (odds ratio, 0.52; P=0.003). After adjusting for demographic and cardiovascular risk factors, medications, and rate-pressure product change during mental stress, those with low sPAT ratio were at significantly higher risk of adverse outcomes (subdistribution hazard ratio, 1.77 [95% CI, 1.12-2.80]). CONCLUSIONS Greater peripheral vasoconstriction with mental stress, denoted by a low sPAT ratio, is associated with a higher risk of adverse cardiovascular outcomes in patients with coronary artery disease.
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Affiliation(s)
- Jeong Hwan Kim
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Zakaria Almuwaqqat
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Muhammad Hammadah
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Chang Liu
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA.,Department of Biostatistics and Bioinformatics (C.L., Y.-A.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics (C.L., Y.-A.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Bruno Lima
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Samaah Sullivan
- Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ayman Alkhoder
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Rami Abdulbaki
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Laura Ward
- Department of Biostatistics and Bioinformatics (C.L., Y.-A.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA.,Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences (J.D.B.), Emory University School of Medicine, Atlanta, GA.,Atlanta VA Medical Center, Decatur, Georgia (J.D.B., A.J.S.)
| | - David S Sheps
- Department of Epidemiology, University of Florida College of Medicine, Gainesville (D.S.S.)
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Yan V Sun
- Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amit J Shah
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA.,Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA.,Atlanta VA Medical Center, Decatur, Georgia (J.D.B., A.J.S.)
| | - Viola Vaccarino
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA.,Department of Epidemiology (S.S., L.W., Y.V.S., A.J.S., V.V.), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Arshed A Quyyumi
- From the Division of Cardiology, Department of Medicine (J.H.K., Z.A., M.H., C.L., B.L., A.A., R.A., A.J.S., V.V., A.A.Q.), Emory University School of Medicine, Atlanta, GA
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Pulse wave velocity can be accurately measured during transcatheter aortic valve implantation and used for post-procedure risk stratification. J Hypertens 2019; 37:1845-1852. [DOI: 10.1097/hjh.0000000000002141] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Wittbrodt MT, Moazzami K, Lima BB, Alam ZS, Corry D, Hammadah M, Campanella C, Ward L, Quyyumi AA, Shah AJ, Vaccarino V, Nye JA, Bremner JD. Early childhood trauma alters neurological responses to mental stress in patients with coronary artery disease. J Affect Disord 2019; 254:49-58. [PMID: 31103906 PMCID: PMC6592739 DOI: 10.1016/j.jad.2019.05.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/08/2019] [Accepted: 05/11/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Early childhood trauma is known to independently increase adverse outcome risk in coronary artery disease (CAD) patients, although the neurological correlates are not well understood. The purpose of this study was to examine whether early childhood trauma alters neural responses to acute mental stress in CAD patients. METHODS Participants (n = 152) with CAD underwent brain imaging with High Resolution Positron Emission Tomography and radiolabeled water during control (verbal counting, neutral speaking) and mental stress (mental arithmetic, public speaking). Traumatic events in childhood were assessed with the Early Trauma Inventory (ETI-SR-SF) and participants were separated by presence (ETI+) or absence (ETI-) of early childhood trauma. Brain activity during mental stress was compared between ETI+ and ETI-. RESULTS Compared to ETI-, ETI+ experienced greater (p < 0.005) activations during mental stress within the left anterior cingulate, bilateral frontal lobe and deactivations (p < 0.005) within the left insula, left parahippocampal gyrus, right dorsal anterior cingulate, bilateral cerebellum, bilateral fusiform gyrus, left inferior temporal gyrus, and right parietal lobe. Significant (p < 0.005) positive correlations between brain activation and ETI-SR-SF scores were observed within the left hippocampus, bilateral frontal lobe, left occipital cuneus, and bilateral temporal lobe. LIMITATIONS Results in non-CAD samples may differ and ETI may be subject to recall bias. CONCLUSION Early childhood trauma exacerbated activations in stress-responsive limbic and cognitive brain areas with direct and indirect connections to the heart, potentially contributing to adverse outcomes in CAD patients.
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Affiliation(s)
- Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Kasra Moazzami
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Bruno B. Lima
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zuhayr S. Alam
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Daniel Corry
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Muhammad Hammadah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Carolina Campanella
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Arshed A. Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Amit J. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA,Atlanta VA Medical Center, Decatur, GA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Jonathon A. Nye
- Department of Radiology, Emory University School of Medicine
| | - J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA,Department of Radiology, Emory University School of Medicine,Atlanta VA Medical Center, Decatur, GA
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Bremner JD, Campanella C, Khan Z, Shah M, Hammadah M, Wilmot K, Mheid IA, Lima BB, Garcia EV, Nye J, Ward L, Kutner MH, Raggi P, Pearce BD, Shah A, Quyyumi A, Vaccarino V. Brain Correlates of Mental Stress-Induced Myocardial Ischemia. Psychosom Med 2019; 80:515-525. [PMID: 29794945 PMCID: PMC6023737 DOI: 10.1097/psy.0000000000000597] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Coronary artery disease (CAD) is a major cause of morbidity and mortality, and despite important advances in our understanding of this disorder, the underlying mechanisms remain under investigation. Recently, increased attention has been placed on the role of behavioral factors such as emotional stress on CAD risk. Brain areas involved in memory and the stress response, including medial prefrontal cortex, insula, and parietal cortex, also have outputs to the peripheral cardiovascular system. The purpose of this study was to assess the effects of mental stress on brain and cardiac function in patients with CAD. METHODS CAD patients (N = 170) underwent cardiac imaging with [Tc-99m] sestamibi single-photon emission tomography at rest and during a public speaking mental stress task. On another day, they underwent imaging of the brain with [O-15] water positron emission tomography (PET) during mental stress (arithmetic and public speaking) and control conditions. RESULTS Patients with mental stress-induced myocardial ischemia showed increased activation with stress in anterior cingulate, inferior frontal gyrus, and parietal cortex (p < .005). This was seen with both arithmetic stress and public speaking stress. Arithmetic stress was additionally associated with left insula activation, and public speaking with right pre/postcentral gyrus and middle temporal gyrus activation (p < .005). CONCLUSIONS These findings suggest that mental stress-induced myocardial ischemia is associated with activation in brain areas involved in the stress response and autonomic regulation of the cardiovascular system. Altered brain reactivity to stress could possibly represent a mechanism through which stress leads to increased risk of CAD-related morbidity and mortality.
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Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
- Department of Radiology, Emory University School of Medicine, Atlanta, GA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Carolina Campanella
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Zehra Khan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Majid Shah
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Muhammad Hammadah
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Kobina Wilmot
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Ibhar Al Mheid
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Bruno B. Lima
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Ernest V. Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, GA
| | - Jonathon Nye
- Department of Radiology, Emory University School of Medicine, Atlanta, GA
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michael H. Kutner
- Department Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brad D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amit Shah
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - Arshed Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
| | - Viola Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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