Endothelial dysfunction and fingertip vasoconstrictive reaction in response to mental stress can help predict subjects with CAD at greater risk of developing MSIMI

Int J Cardiol. 2017 May 25. pii: S0167-5273(17)31257-3. doi: 10.1016/j.ijcard.2017.05.093. [Epub ahead of print]

Hemodynamic, catecholamine, vasomotor and vascular responses:
Determinants of myocardial ischemia during mental stress.

Hammadah M1, Alkhoder A1, Al Mheid I1, Wilmot K1, Isakadze N1, Abdulhadi N1, Chou D2, Obideen M1, O’Neal WT1, Sullivan S2, Tahhan AS1, Kelli HM1, Ramadan R1, Pimple P2, Sandesara P1, Shah AJ3, Ward L2, Ko YA4, Sun Y2, Uphoff I1, Pearce B2, Garcia EV5, Kutner M4, Bremner JD6, Esteves F5, Sheps DS7, Raggi P8, Vaccarino V9, Quyyumi AA10.

Author information

1
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States.
2
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
3
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Atlanta VA Medical Center, Decatur, GA, United States.
4
Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
5
Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States.
6
Atlanta VA Medical Center, Decatur, GA, United States; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, United States.
7
University of Florida Health Science Center, Department of Medicine, Division of Cardiovascular Medicine, United States.
8
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
9
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
10
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States. Electronic address: aquyyum@emory.edu.

Abstract

AIMS:

Mental stress-induced myocardial ischemia (MSIMI) in patients with coronary artery disease (CAD) is associated with adverse cardiovascular outcomes. We aim to assess hemodynamic, neuro-hormonal, endothelial, vasomotor and vascular predictors of MSIMI.

METHODS AND RESULTS:

We subjected 660 patients with stable CAD to 99mTc sestamibi myocardial perfusion imaging at rest, with mental (speech task) and with conventional (exercise/pharmacological) stress. Endothelium-dependent flow-mediated dilation (FMD), microvascular reactivity [reactive hyperemia index (RHI)] and arterial stiffness [pulse wave velocity (PWV)] were measured at rest and 30-min after mental stress. The digital microvascular vasomotor response during mental stress was assessed using peripheral arterial tonometry (PAT). A total of 106(16.1%) patients had MSIMI. Mental stress was accompanied by significant increases in rate-pressure-product (heart rate x systolic blood pressure; RPP), epinephrine levels and PWV, and significant decreases in FMD and PAT ratio denoting microvascular constriction. In comparison to those with no MSIMI, patients with MSIMI had higher hemodynamic and digital vasoconstrictive responses (p 0.05 for both), but did not differ in epinephrine, endothelial or macrovascular responses. Only presence of ischemia during conventional stress (OR of 7.1, 95%CI of 4.2, 11.9), high hemodynamic response (OR for RPP response≥vs<ROC cutoff of 1.8, 95%CI of 1.1, 2.8), and high digital vasoconstriction (OR for PAT ratio<vs≥ROC cutoff of 2.1, 95%CI of 1.3, 3.3) were independent predictors of MSIMI.

CONCLUSION:

Ischemia during conventional stress testing and hemodynamic and vasoconstrictive responses to mental stress can help predict subjects with CAD at greater risk of developing MSIMI.

KEYWORDS:

Arterial stiffness; Catecholamines; Conventional stress test; Endothelial dysfunction; Mental stress; Myocardial ischemia; Peripheral arterial tonometry; Vasoconstriction

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