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CLINICAL STUDIES

Relationship among mental stress–induced ischemia and ischemia during daily life and during exercise: the Psychophysiologic Investigations of Myocardial Ischemia (PIMI) Study

Peter H. Stone, MD, FACC^*, David S. Krantz, PhD, Robert P. McMahon, PhD, A. David Goldberg, MD, FACC, Lewis C. Becker, MD, FACC^||, Bernard R. Chaitman, MD, FACC^¶, Herman A. Taylor, MD, FACC^||||, Jerome D. Cohen, MD^#, Kenneth E. Freedland, PhD^¶¶, Barry D. Bertolet, MD, FACC, Cecil Coughlan, MD^**, Carl J. Pepine, MD, FACC, Peter G. Kaufmann, PhD, David S. Sheps, MD, FACC for the PIMI Study Group

^* Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts, USA
University of the Health Sciences Dept of Medical and Clinical Psychology, Bethesda, Maryland, USA
Maryland Medical Research Institute, Baltimore, Maryland, USA
Henry Ford Hospital, Division of Cardiology, Detroit, Michigan, USA
^|| Johns Hopkins University, Baltimore, Maryland, USA
^¶ St. Louis University, Division of Cardiology, St. Louis, Missouri, USA
^# Health Sciences Center, St. Louis, Missouri, USA
^** University of Alabama Medical Center, Cardiology Division, Birmingham, Alabama, USA
University of Florida, Health Science Center, Gainesville, Florida, USA
National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
Division of Cardiology, East Tennessee State University, James H. Quillen College of Medicine, Johnson City, Tennessee, USA
^|||| Jackson Medical Mall, Jackson, Milwaukee, USA
^¶¶ Washington University, St. Louis, Missouri, USA

Manuscript received October 30, 1997; revised manuscript received December 11, 1998, accepted January 20, 1999.

Reprint requests and correspondence: Dr. Peter H. Stone, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115. PIMI Clinical Coordinating Center, Maryland Medical Research Institute, 600 Wyndhurst Avenue, Baltimore, Maryland 21210, USA

OBJECTIVES

The purposes of this database study were to determine: 1) the relationship between mental stress–induced ischemia and ischemia during daily life and during exercise; 2) whether patients who exhibited daily life ischemia experienced greater hemodynamic and catecholamine responses to mental or physical stress than patients who did not exhibit daily life ischemia, and 3) whether patients who experienced daily life ischemia could be identified on the basis of laboratory-induced ischemia using mental or exercise stress testing.

BACKGROUND

The relationships between mental stress–induced ischemia in the laboratory and ischemia during daily life and during exercise are unclear.

METHODS

One hundred ninety-six stable patients with documented coronary disease and a positive exercise test underwent mental stress testing and bicycle exercise testing. Radionuclide ventriculography and electrocardiographic (ECG) monitoring were performed during the mental stress and bicycle tests. Patients underwent 48 h of ambulatory ECG monitoring. Hemodynamic and catecholamine responses were obtained during mental stress and bicycle tests.

RESULTS

Ischemia (reversible left ventricular dysfunction or ST segment depression 1 mm) developed in 106 of 183 patients (58%) during the mental stress test. There were no significant differences in clinical characteristics of patients with, compared with those without, mental stress–induced ischemia. Patients with mental stress ischemia more often had daily life ischemia than patients without mental stress ischemia, but their exercise tests were similar. Patients with daily life ischemia had higher ejection fraction and cardiac output, and lower systemic vascular resistance during mental stress than patients without daily life ischemia. Blood pressure and catecholamine levels at rest and during the mental stress tests were not different in patients with, compared with those without, daily life ischemia. Patients with daily life ischemia had a higher ejection fraction at rest and at peak bicycle exercise compared with patients without daily life ischemia, but there were no other differences in peak hemodynamic or catecholamine responses to exercise. The presence of ST segment depression during routine daily activities was best predicted by ST segment depression during mental or bicycle exercise stress, although ST segment depression was rare during mental stress.

CONCLUSIONS

Patients with daily life ischemia exhibit a heightened generalized response to mental stress. ST segment depression in response to mental or exercise stress is more predictive of ST segment depression during routine daily activities than other laboratory-based ischemic markers. Therapeutic management strategies might therefore focus on patients with these physiologic responses to stress and on whether lessening such responses reduces ischemia.

Abbreviations and Acronyms   AECG = ambulatory electrocardiographic   BP = blood pressure   CAD = coronary artery disease   CO = cardiac output   ECG = electrocardiographic   EDV = end-diastolic volume   EF = ejection fraction   ESV = end-systolic volume   ETT = exercise treadmill test   HR = heart rate   kpm = kilo pond meters   LV = left ventricular   MI = myocardial infarction   PIMI = Psychophysiologic Investigations of Myocardial Ischemia   RPP = rate–pressure product   RVG = radionuclide ventriculography   SV = stroke volume   SVR = systemic vascular resistance

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