Abstract
Background and hypothesis: Many episodes of ischemia in daily life are silent occurring during sedentary activities and may be related to mental stress. In 35 patients with stable angina and positive exercise test awaiting bypass surgery, we investigated whether laboratory mental stress tests would trigger ischemia of a comparable severity to that occurring in daily life and attempted to elucidate some of the underlying mechanisms.
Methods: All patients underwent exercise testing, personality assessment, 2‐day Holter monitoring, and laboratory mental stress tests while on their usual medications.
Results: Only four patients (12%) had positive mental stress test (ST depression ≥0.1 mV). All episodes were silent and usually associated with fast heart rate (>90 beats/min). In contrast, ambulatory ischemia was common (average duration of 51 min per 24 h), and at least one episode was recorded in 27 patients (77%) including the 4 with positive test. Patients with positive mental stress test had a higher heart rate during testing (124 ± 24 vs. 86 ± 16 beats/min, p<0.01), and a shorter exercise time and time to 1 mm ST depression on cycle ergometry than those with negative mental stress test. None of the four patients were on beta blockers. There was no difference in personality inventory between the two groups. Comparisons between patients with and without positive mental stress test revealed no difference in the duration and frequency of ambulatory ischemia, or in the occurrence of silent ischemia. However, the heart rate at onset of ambulatory ischemia tended to be higher in the patients with positive mental stress test (96 ± 9 vs. 62 ± 43, p = 0.07). Further subgroup analysis in patients without beta blockers (4 mental stress test positive and 18 negative) showed similar results.
Conclusions: Laboratory mental stress test is a weak inducer of ischemia detected by electrocardiographic monitoring in patients with frequent ambulatory ischemia. Wall motion evaluation during mental stress test may improve sensitivity. While larger scale studies may determine its clinical role, the present study illustrated that patients with heightened heart rate response to mental stress were identified in whom beta blockers could be the drug of choice.
Full Text
The Full Text of this article is available as a PDF (534.6 KB).
References
- 1. Schang S, Pepine C: Transient asymptomatic ST segment depression during daily activity. Am J Cardiol 1977; 39: 396–402. [DOI] [PubMed] [Google Scholar]
- 2. Cecchi A, Dovellini E, Marchi F, Pucci P, Santoro G, Fazzini P: Silent myocardial ischemia during ambulatory electrocardiographic monitoring in patients with effort angina. J Am Coll Cardiol 1983; 1: 934–939. [DOI] [PubMed] [Google Scholar]
- 3. Freeman L, Nixon P, Sallabank P, Reavely D: Psychological stress and silent myocardial ischemia. Am Heart J 1987; 114: 477–482. [DOI] [PubMed] [Google Scholar]
- 4. Bairey CN, Krantz DS, Rozanski A: Mental stress as an acute trigger of ischemic left ventricular dysfunction and blood pressure elevation in coronary artery disease. Am J Cardiol 1990; 66: 28G–31G. [DOI] [PubMed] [Google Scholar]
- 5. Barry J, Selewyn AP, Nabel EG, Rocco MB, Mead K, Campell S, Rebecca G: Frequency of ST‐segment depression produced by mental stress in stable angina pectoris from coronary artery disease. Am J Cardiol 1988; 61: 989–993. [DOI] [PubMed] [Google Scholar]
- 6. Rozanski A, Bairey CN, Krantz DS, Friedman J, Resser KJ, Morell M, Hilton‐Chalfen S, Hestrin L, Bietondof J, Berman DS: Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med 1988; 318: 1005–1012. [DOI] [PubMed] [Google Scholar]
- 7. Deanfield JE, Shea M, Kensett M, Horlock P, Wilson RA, deLandsheere CM, Selwyn AP: Silent ischemia due to mental stress. Lancet 1984; 2: 1001–1005. [DOI] [PubMed] [Google Scholar]
- 8. Burg MM, Jain D, Soufer R, Kerns RD, Zaret BL: Role of behavioral and psychological factors in mental‐stress induced silent left ventricular dysfunction in coronary artery disease. J Am Coll Cardiol 1993; 22: 440–448. [DOI] [PubMed] [Google Scholar]
- 9. Deanfield J, Shea M, Wilson R, Horlock P, deLandsheere C, Selwyn A: Direct effects of smoking on the heart: Silent ischemic disturbances of coronary flow. Am J Cardiol 1986; 57: 1005–1009. [DOI] [PubMed] [Google Scholar]
- 10. Barry J, Mead K, Nabel EG, Rocco MB, Campbell S, Fenton T, Mudge GH, Selwyn AP: Effect of smoking on the activity of ischemic heart disease. J Am Med Assoc 1989; 261: 398–402. [PubMed] [Google Scholar]
- 11. Deanfield J, Shea M, Ribiero P, deLandsheere CM, Wilson RA, Horlock P, Selwyn AP: Transient ST‐segment depression as a marker of myocardial ischemia during daily life. Am J Cardiol 1984; 54: 1195–1200. [DOI] [PubMed] [Google Scholar]
- 12. Gottdiener JS, Krantz DS, Howell RH, Hecht GM, Klein J, Falconer JJ, Rozanski A: Induction of silent myocardial ischemia with mental stress testing: Relation to the triggers of ischemia during daily life activities and to ischemic functional severity. J Am Coll Cardiol 1994; 24: 1645–1651. [DOI] [PubMed] [Google Scholar]
- 13. Pepine CJ, Cohn PF, Deedwania PC, Gibson RS, Handberg E, Hill JA, Miller E, Marks RG, Thandani U: Effect of treatment on outcome in mildly symptomatic patients with ischemia during daily life. The Atenolol Silent Ischemia Study (ASIST). Circulation 1994; 90: 762–768. [DOI] [PubMed] [Google Scholar]
- 14. Knatterud GL, Bourassa MG, Pepine CJ, Geller NL, Sopko G, Chaitman BR, Pratt C, Stone PH, Davies RF, Rogers WJ, Deanfield JE, Goldberg AD, Ouyang AD, Mueller H, Sharof B, Day P, Selwyn AP, Conti R, for the ACIP investigators : Effects of treatment strategies to suppress ischemia in patients with coronary artery diesease: 12‐week results of the Asymptomatic Cardiac Ischemic Pilot (ACIP) study. J Am Coll Cardiol 1994; 24: 11–20. [DOI] [PubMed] [Google Scholar]
- 15. Haynes SG, Levine S, Scotch NA, Feinleib M, Kannel WB: The relationship of psychosocial factors to coronary heart disease in the Framingham study. I. Methods and risk factors. Am J Epidemiol 1978; 107: 362–383. [DOI] [PubMed] [Google Scholar]
- 16. Coumarelos C: Hostility, anger and aggression: Their differentiation and their relationship to essential hypertension and myocardial infarction. Doctoral dissertation 1990. University of New South Wales, Sydney, Australia.
- 17. Spielberger CD, Jacobs G, Russels S, Crane RS: Assessment of anger: The State Trait Anger Scale In Advances in Personality Assessment, Vol. 2 (Eds. Butcher JN, Spielberger CD.). p. 159–187. Hillsdale, N.J.: Lea. [Google Scholar]
- 18. Gumbrielle T, Freedman SB, Fogarty L, Ogasawara S, Sobb P, Kelly DT: Efficacy, safety and duration of nitrate‐free interval to prevent tolerance to transdermal nitroglycerin in effort angina. Eur Heart J 1992; 13: 671–678. [DOI] [PubMed] [Google Scholar]
- 19. Turner JR, Caroll D, Courtley H: Cardiac and metabolic responses to “space invader:” An instance of metabolically exaggerated cardiac adjustment. Psychophysiology 1983; 20: 544–549. [DOI] [PubMed] [Google Scholar]
- 20. Yeung AC, Vekshtein VI, Krantz DS, Vita JA, Ryan TJ, Ganz P, Selwyn AP: The effect of atherosclerosis on the vasomotor response of coronary arteries to mental stress. N Engl J Med 1991; 325: 1551–1556. [DOI] [PubMed] [Google Scholar]
- 21. Yeung AC, Raby KE, Ganz P, Selwyn AP: New insights into management of myocardial ischemia. Am J Cardiol 1992; 70: 8G–13G. [DOI] [PubMed] [Google Scholar]
- 22. Becker LC, Pepine CJ, Bonsall R, Cohen JD, Goldberg AD, Coghlan C, Forman S, Sheps DS, Kaufmann PG, the PIMI investigators : Left ventricular, peripheral vascular and neurohumoral response to mental stress in normal middle aged men and women. Circulation 1995; 92: I–677. [DOI] [PubMed] [Google Scholar]
- 23. Stone P, Krantz D, McMahon R, Goldberg D, Becker L, Taylor H, Cohen J, Freedland K, Bertolet B, Kauffman P, Sheps D, for the PIMI Investigators : Relationship between mental stress‐induced ischemia and ischemia during routine daily activities and daily exercise: A PIMI database study. Circulation 1995; 92: I–677. [Google Scholar]
- 24. Davies RF, Habibi H, Klinke WP, Dessain P, Dadeau C, Phaneuf DC, Lepage S, Raman S, Herbert M, Foris K, Linden W, Butters JA, for the Canadian Amlodipine/Atenolol in Silent Ischemia Study (CASIS) Investigators : Effect of amlodipine, atenolol and their combination on myocardial ischemia during treadmill exercise and ambulatory monitoring. J Am Coll Cardiol 1995; 25: 619–625. [DOI] [PubMed] [Google Scholar]
- 25. Portegies MC, Sijbring P, Gobel EJ, Viersma JW, Lie KI: Efficacy of metoprolol and diltiazem in treating silent myocardial ischemia. Am J Cardiol 1994; 74: 1095–1098. [DOI] [PubMed] [Google Scholar]
- 26. Sheps DS, Ballenger MN, De Gent GE, Krittayaphong R, Dittman E, Maixner W, McCartney W, Golden RN, Koch G, Light KC: Psychophysical responses to a speech stressor: Correlation of plasma beta‐endorphin levels at rest and after psychological stress with thermally measured pain threshold in patients with coronary artery disease. J Am Coll Cardiol 1995; 25: 1499–1503. [DOI] [PubMed] [Google Scholar]