Research Finds Link Between Mental Stress-Induced Myocardial Ischemia and Severe Cardiovascular Outcomes

November 9, 2021

A recent study led by researchers at the Emory Rollins School of Public Health and Emory School of Medicine found mental stress-induced myocardial ischemia in patients with stable coronary heart disease to be significantly associated with an increased risk in cardiovascular events, including death, non-fatal heart attacks, and heart failure. Viola Vaccarino, MD, PhD, professor of epidemiology, was lead author on the study published in JAMA.

The researchers conducted a pooled analysis of 918 participants with stable coronary heart disease and performed both a conventional stress test (exercise-based or pharmacological) as well as a mental stress test procedure (requiring participants to complete a public speaking exercise) to determine if mental stress had an effect on myocardial ischemia (reductions of blood  flow to the heart) in patients with coronary heart disease. All patients were measured for mental stress–induced ischemia and conventional stress ischemia using myocardial perfusion imaging with single-photon emission computed tomography.

The researchers found that myocardial ischemia provoked by an acute psychological stressor was associated with over twofold increased risk of adverse events during the five-year period studied. This association was independent of and larger than that of myocardial ischemia induced by a conventional stress test (like a treadmill test). When examined separately, ischemia with mental stress alone, but not with conventional stress alone, carried increased risk, and patients who developed ischemia with both stressors showed an almost fourfold increase in risk.

“These results suggest that ischemia with mental stress contributes substantially to the outcome of patients with heart disease,” says Vaccarino. “Up to now, we knew little about the prognostic significance of this phenomenon in the modern era using current imaging techniques. These data highlight the importance of emotional factors on the morbidity and mortality of patients with heart disease, and have substantial implications for our understanding of the link between psychological stress and coronary heart disease."

She continues, "This evidence underscores a compelling need to include stress and mental health indicators in the risk assessment of patients with coronary heart disease, in contrast to the current practice of mainly addressing conventional risk factors and atherosclerotic disease. Stress and mental health factors are amenable to medical and lifestyle intervention, for example stress management training, and in some cases, medications as well.”

Arshed Quyyumi, MD, professor of medicine, co-led the study and states, "These results are consistent with recent evidence linking stress-related changes in vascular function and brain activity to adverse outcomes in patients with coronary disease. Further studies are urgently needed to ascertain the utility of recognizing and treating myocardial ischemia in the clinical setting.”

Additional Emory authors on the article include: Zakaria Almuwaqqat, MD, cardiology fellow; Amit J. Shah, MD, assistant professor of epidemiology and medicine/cardiology; Yi-An Ko, PhD, assistant professor of biostatistics; Lisa Elon, MPH, staff statistician; Brad Pearce, PhD, associate professor of epidemiology; Laura Ward, MPH, assistant professor of biostatistics; Michael Kutner, PhD, professor of biostatistics; Tené T. Lewis, PhD, associate professor of epidemiology; Ernest V Garcia, PhD, professor of radiology; Jonathon Nye, PhD, associate professor of radiology; and J. Douglas Bremner, MD, professor of psychiatry.

The study was funded by the National Institutes of Health.