According to pooled registry data, the deleterious impact of mental stress on CV health may be a widespread and underappreciated risk factor in patients with stable CAD. The study’s lead author, Viola Vaccarino, MD, Ph.D. (Emory University, Atlanta, GA), told TCTMD, “We were able to demonstrate that ischemia induced by mental stress is an important prognostic indicator in the current era, meaning that patients who have this kind of response have a substantial increase in the risk of subsequent coronary events, including death.”
The study’s CAD patients with evidence of ischemia caused by both mental stress and traditional (exercise or pharmacological) stress testing had the highest risk of all. According to a scientific statement released by the American Heart Association recently, stress is a recognized cause of acute occurrences following an initial MI. Myocardial perfusion imaging was done during typical exercise or physiologic stress testing, as well as a public speaking challenge designed to produce mental stress.
Overall, 16 percent of patients experienced mental stress-induced ischemia, 31% experienced traditional stress ischemia, and 10% experienced both forms of ischemia. After a median follow-up of 5 years, patients with vs. without mental stress-induced ischemia had a higher rate of CV death or MI (adjusted HR 2.5; 95 percent CI 1.8-3.5) and a higher rate of the secondary endpoint of HF hospitalization (adjusted HR 2.0; 95 percent CI 1.5-2.5). Patients who had both mental stress ischemia and conventional stress ischemia had the highest risk of CV mortality or MI (HR 3.8; 95% CI 2.6-5.6), followed by those who only had mental stress ischemia (HR 2.0; 95% CI 1.1-3.7).
Is it changeable? The fact that mental stress was an independent predictor of events and actually had a bigger effect than traditional stress-induced ischemia, “adds to our understanding of ischemia in general.” She went on to say that the next phase in this study will be to figure out how the findings may be applied clinically. One of the most crucial future questions, according to Bravo and Cappola, is whether mental-stress ischemia is therapeutically adjustable, and whether screening for and treating it improves outcomes.
In their editorial, they add, “Answers to these critical questions will help establish whether mental stress should become an actionable clinical item in the care of people with known or suspected coronary heart disease.” Vaccarino told TCTMD that standard practice guidelines and preventive management focus on CV risk factors, with little mention of mental health and the need to assist patients with these concerns.