The findings "highlight the importance of emotional factors on the clinical course of patients with heart disease, providing compelling evidence to include stress and mental-health indicators in the risk assessment of these patients," Dr. Viola Vaccarino of Emory University, in Atlanta, told Reuters Health by email.
"Further studies are urgently needed to ascertain the utility of recognizing and treating ischemia provoked by psychological stress in the clinical setting," said Dr. Vaccarino.
The findings stem from a pooled analysis of data on 918 adults (mean age, 60 years; 34% women; 40% Black) with stable CHD from two prospective cohort studies with similar protocols; 618 patients from the Mental Stress Ischemia Prognosis Study (MIPS) and 300 from the Myocardial Infarction and Mental Stress Study 2 (MIMS2).
At baseline, all participants underwent both mental-stress testing with a public speaking challenge and a conventional exercise or pharmacologic stress test, with myocardial perfusion imaging used to detect ischemia. "This design also allowed us to compare the effect of each of the two ischemia types when occurring without the other," Dr. Vaccarino explained.
Overall, 147 participants (16%) had mental-stress-induced ischemia, 281 (31%) had conventional stress ischemia and 96 (10%) had both types of ischemia, Dr. Vaccarino and her colleagues report in JAMA.
During a median follow-up of five years, the primary endpoint of cardiovascular death or myocardial infarction occurred in 156 participants (17%), and the secondary endpoint that also included hospitalization for heart failure occurred in 319 participants (35%).
Mental-stress-induced myocardial ischemia alone was significantly associated with the primary endpoint (pooled adjusted hazard ratio, 2.5; 95% confidence interval, 1.8 to 3.5) and the secondary endpoint (pooled aHR, 2.0; 95% CI, 1.5 to 2.5).
"The findings were consistently observed in each of the two cohorts and applied to first and subsequent events," the authors say.
The presence of both mental-stress-induced and conventional stress myocardial ischemia (compared with no ischemia) was associated a greater than three-fold increased risk for the primary endpoint (HR, 3.8; 95% CI, 2.6 to 5.6), with similar results for the secondary endpoint.
The presence of conventional stress ischemia alone was not significantly associated with increased risk for the primary endpoint (HR, 1.4; 95% CI: 0.9 to 2.1).
"We were indeed surprised to find that mental-stress ischemia is a stronger risk factor than conventional stress ischemia. This suggests that the known association of conventional stress ischemia with adverse cardiac events is in part explained by its co-occurrence with mental-stress ischemia," Dr. Vaccarino told Reuters Health.
"As a whole, this evidence suggests that the value of stress and mental health factors for CHD risk stratification should be investigated, given that they are amenable to medical and lifestyle intervention, including aerobic exercise and stress management training, antidepressants, and beta-blockers and anti-anginal drugs," the researchers write in their paper.
The authors of a JAMA editorial say the findings "largely confirm prior observations from smaller studies and extend the generalizability of the findings to women, Black individuals, and younger individuals with stable CHD, populations that are often underrepresented in biomedical research."
"Sufficient evidence now suggests that mental stress can trigger myocardial infarction, reversible cardiomyopathy and sudden cardiac death in susceptible individuals," write Dr. Paco Bravo and Dr. Thomas Cappola with the University of Pennsylvania Perelman School of Medicine in Philadelphia.
However, they say several clinically relevant questions remain to be answered, including to what extent mental-stress ischemia can be modified; whether screening for and treatment of mental-stress ischemia can improve outcomes; whether or not mental-stress testing is reproducible and feasible in clinical practice; and whether there are additional at-risk groups for whom mental-stress ischemia testing should be considered.
"Answers to these important questions will help determine whether mental stress should become an actionable clinical item in the management of individuals with known or suspected CHD," the editorialists conclude.
SOURCE: https://bit.ly/3bQttYz and https://bit.ly/3F5Lhvz JAMA, online November 9, 2021.
By Megan Brooks
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