Mental Stress Increases Risk of Secondary Cardiovascular Events

Viola Vaccarino, MD, PhD

While the link between physical stress and secondary cardiovascular events is one that needs no explanation, the results of a new study suggest mental stress may be more likely to predict secondary events after myocardial infarction (MI).

Presented at the American College of Cardiology’s Annual Scientific Session Together with World Congress of Cardiology (ACC.20/WCC), the Emory University-Rollins School of Public Health study found those who endured mental stress-induced myocardial ischemic (MSIMI) events after MI were twice as likely to suffer a secondary event or cardiovascular mortality.

“These data point to the important effect that psychological stress can have on the heart and on the prognosis of patients with heart disease,” said lead investigator Viola Vaccarino, MD, PhD, Wilton Looney Professor of Cardiovascular Research in the department of epidemiology at Emory University Rollins School of Public Health, in a statement. “It gives us tangible proof of how psychological stress, which is not specifically addressed in current clinical guidelines, can actually affect outcomes.”

With data into the impact of mental stress on cardiovascular events lacking, Vaccarino and colleagues sought to assess whether MSIMI was associated with poor outcomes among heart attack survivors. To do so, they conducted an analysis of 306 adults who had been hospitalized for MI within 8 months of enrollment.

All individuals included in the current analysis were recruited from the Atlanta metropolitan area and were 61 years of age or younger. The mean age of the stud cohort was 50 years, 50% were women, and 65% of the cohort was African American. As part of the study design, all participants underwent mental stress testing—in the form of speech giving followed by myocardial perfusion imaging—and conventional stress testing.

The primary endpoint of the study was a composite of the occurrence of a repeat event and cardiovascular death. Endpoints were confirmed through use of an independent medical record review and examination of death records.

Over a follow-up period that lasted a median of 3 years, MSIMI occurred in 16% of patients and conventional ischemia occurred in 35%. During the follow-up period, 28 individuals had a recurrent MI and 2 died from cardiovascular causes. Based on the results, the incidence of the composite endpoint was 20% in those with MSIMI and just 8% in those without MSIMI (HR 2.6, 95%CI, 1.2-5.6).

Additionally, adjustment for demographic and clinical risk factors, as well as depressive symptoms, did not substantially change these associations. Conversely, results indicated conventional stress ischemia was not significantly associated with the outcome (HR 1.4, 95%CI, 0.6-3.0).

Vaccarino and colleagues plan to perform additional research into this area using a larger sample size and longer follow-up period. They also noted multiple limitations within their current analysis including limited sample size, the inability to determine if risk differs by sex or race, and inability to assess whether previous exposure to stressors may have played a role in results.

“Patients who developed ischemia with mental stress had more than two times the risk of having a repeat heart attack or dying from heart disease compared with those who did not develop ischemia during mental stress,” Vaccarino said in the statement. “What this means is that the propensity to have a reduction in blood flow to the heart during acute psychological stress poses substantial future risk to these patients.”

This study, “Mental Stress-Induced Myocardial Ischemia as a Marker for Adverse Cardiovascular Events After MI,” was published online in JACC.