Association of Mental Stress–Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease

医学 危险系数 内科学 心肌梗塞 心脏病学 缺血 冠状动脉疾病 压力测试(软件) 前瞻性队列研究 置信区间 计算机科学 程序设计语言
作者
Viola Vaccarino,Zakaria Almuwaqqat,Jeong Hwan Kim,Muhammad Hammadah,Amit Shah,Yi‐An Ko,Lisa Elon,Samaah Sullivan,Anish S. Shah,Ayman Alkhoder,Bruno B. Lima,Brad D. Pearce,Laura Ward,Michael Kutner,Yingtian Hu,Tené T. Lewis,Ernest Garcia,Jonathon A. Nye,David S. Sheps,Paolo Raggi,J. Douglas Bremner,Arshed A. Quyyumi
出处
期刊:JAMA [American Medical Association]
卷期号:326 (18): 1818-1818 被引量:75
标识
DOI:10.1001/jama.2021.17649
摘要

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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