Uncovering the Relationship Between Mental Stress and CV Events

Mental stress–induced changes in early diastolic and systolic myocardial annular velocity may be predictive of major adverse cardiovascular (CV) events, according to findings published in November 2017 in the American Journal of Cardiology. Led by Duke psychiatrist Wei Jiang, MD, the study is the first to use changes in myocardial annular velocity during mental stress as a predictor of prognosis in patients with clinically stable coronary artery disease (CAD).

The results are part of a planned secondary analysis of data from the Responses of Mental Stress-Induced Myocardial Ischemia to Escitalopram Treatment (REMIT) trial, a randomized, double-blind, placebo-controlled study of patients with clinically stable CAD.

The primary outcome of the REMIT study was the seminal finding reported in 2013 that mental stress–
induced ischemia occurs more frequently than exercise-induced ischemia in patients with clinically stable CAD. The results helped overturn the belief that mental stress–induced ischemia is relatively uncommon and tends to only occur in people with exercise-induced ischemia, Jiang says. The 2013 trial also revealed that women are more susceptible than men to mental stress–induced ischemia and that selective serotonin reuptake inhibitors have the potential to reduce rates of the condition.

Notable outcomes of an earlier predefined secondary analysis of the trial included the findings that depression and mental stress–induced platelet aggregation—2 factors known to play a role in increasing the risk of CAD—are associated with a higher probability of mental stress–induced ischemia. Jiang says future studies will examine mental stress–induced metabolite levels in the blood.

Taken together, these studies are an important step toward elucidating the underlying mechanisms by which mental stress can lead to major adverse CV events and, Jiang hopes, will help clinicians develop better approaches to prevention.

“These studies demonstrate how important it is for clinicians to understand the connection between significant emotional stress and pathophysiologic processes,” she explains. “We can’t just say, ‘Oh, this patient’s chest pain or shortness of breath are just a somatic symptom of mental problems’; there is a pathologic process underlying these symptoms, and if it’s not taken care of appropriately, these patients are more likely to die of heart attack, stroke, or heart failure.”

Jiang says that ideally these patients would undergo a mental stress test. However, although these types of stress tests are well validated by research, at present they aren’t available in a clinical setting. Her ultimate goal is to bring mental stress tests into the clinic so that clinicians can better help patients reduce their risk of major adverse CV events.