Mental Stress-Induced-Myocardial Ischemia in Young Patients With Recent Myocardial Infarction: Sex Differences and Mechanisms
- PMID: 29459465
- PMCID: PMC5822741
- DOI: 10.1161/CIRCULATIONAHA.117.030849
Mental Stress-Induced-Myocardial Ischemia in Young Patients With Recent Myocardial Infarction: Sex Differences and Mechanisms
Abstract
Background: Mental stress-induced myocardial ischemia (MSIMI) is frequent in patients with coronary artery disease and is associated with worse prognosis. Young women with a previous myocardial infarction (MI), a group with unexplained higher mortality than men of comparable age, have shown elevated rates of MSIMI, but the mechanisms are unknown.
Methods: We studied 306 patients (150 women and 156 men) ≤61 years of age who were hospitalized for MI in the previous 8 months and 112 community controls (58 women and 54 men) frequency matched for sex and age to the patients with MI. Endothelium-dependent flow-mediated dilation and microvascular reactivity (reactive hyperemia index) were measured at rest and 30 minutes after mental stress. The digital vasomotor response to mental stress was assessed using peripheral arterial tonometry. Patients received 99mTc-sestamibi myocardial perfusion imaging at rest, with mental (speech task) and conventional (exercise/pharmacological) stress.
Results: The mean age of the sample was 50 years (range, 22-61). In the MI group but not among controls, women had a more adverse socioeconomic and psychosocial profile than men. There were no sex differences in cardiovascular risk factors, and among patients with MI, clinical severity tended to be lower in women. Women in both groups showed a higher peripheral arterial tonometry ratio during mental stress but a lower reactive hyperemia index after mental stress, indicating enhanced microvascular dysfunction after stress. There were no sex differences in flow-mediated dilation changes with mental stress. The rate of MSIMI was twice as high in women as in men (22% versus 11%, P=0.009), and ischemia with conventional stress was similarly elevated (31% versus 16%, P=0.002). Psychosocial and clinical risk factors did not explain sex differences in inducible ischemia. Although vascular responses to mental stress (peripheral arterial tonometry ratio and reactive hyperemia index) also did not explain sex differences in MSIMI, they were predictive of MSIMI in women only.
Conclusions: Young women after MI have a 2-fold likelihood of developing MSIMI compared with men and a similar increase in conventional stress ischemia. Microvascular dysfunction and peripheral vasoconstriction with mental stress are implicated in MSIMI among women but not among men, perhaps reflecting women's proclivity toward ischemia because of microcirculatory abnormalities.
Keywords: ischemia; microcirculation; sex; stress; vascular function.
© 2018 American Heart Association, Inc.
Conflict of interest statement
Comment in
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Risk factors: Mental stress puts women's hearts at risk.Nat Rev Cardiol. 2018 Mar 13;15(4):198. doi: 10.1038/nrcardio.2018.23. Nat Rev Cardiol. 2018. PMID: 29532795 No abstract available.
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Response by Vaccarino et al to Letter Regarding Article, "Mental Stress-Induced-Myocardial Ischemia in Young Patients With Recent Myocardial Infarction: Sex Differences and Mechanisms".Circulation. 2018 Jul 31;138(5):548-549. doi: 10.1161/CIRCULATIONAHA.118.035546. Epub 2018 Jul 30. Circulation. 2018. PMID: 30532315 Free PMC article. No abstract available.
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Letter by Singh and Mian Regarding Article, "Mental Stress-Induced-Myocardial Ischemia in Young Patients With Recent Myocardial Infarction: Sex Differences and Mechanisms".Circulation. 2018 Jul 31;138(5):546-547. doi: 10.1161/CIRCULATIONAHA.118.034499. Circulation. 2018. PMID: 30571527 No abstract available.
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