Hemodynamic Reactivity to Mental Stress in Patients With Coronary Artery Disease

• Type of Material: Article
• Authors: Kasra Moazzami, Emory University; Brian Cheung, Emory University; Samaah Sullivan, Emory University; Anish Shah, Emory University; Zakaria Almuwaqqat, Emory University; Ayman Alkhoder, Emory University; Puja Kiran Mehta, Emory University; Brad Pearce, Emory University; Amit J. Shah, Grady Health System; Afif Martini, Emory University; Malik Obideen, Emory University; Jonathon Nye, Emory University; J. Douglas Bremner, Emory University; Viola Vaccarino, Emory University; Arshed Ali Quyyumi, Emory University
• Language: English
• Date: 2023-10-17
• Publisher: JAMA Network
• Publication Version: Final Published Version
• Copyright Statement: 2023 Moazzami K et al. JAMA Network Open.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): https://doi.org/10.1001/jamanetworkopen.2023.38060
• Title of Journal or Parent Work: JAMA Network Open
• Volume: 6
• Issue: 10
• Start Page: e2338060
• Grant/Funding Information: This work was supported by grants P01 HL101398, R01 HL109413, R01HL109413-S1, P20HL113451, P01HL086773, R56HL126558, R01 HL125246, R01HL136205, T32. HL130025, K23HL127251, and K24HL077506 from the National Heart, Lung, and Blood Institute of the NIH.
• Keywords: mental stress; oronary artery disease; cardiology; hemodynamic reactivity
• Research Categories: Health Sciences, Epidemiology; Health Sciences, Mental Health

Abstract

Importance The clinical significance of hemodynamic reactivity to mental stress in the population with coronary artery disease (CAD) is unclear. Objective To investigate the association between hemodynamic reactivity to mental stress and the risk of adverse cardiovascular events in patients with stable CAD. Design, Setting, and Participants This cohort study included individuals with stable CAD from 2 prospective studies from a university-based hospital network: the Mental Stress Ischemia Prognosis Study (MIPS) and the Myocardial Infarction and Mental Stress Study 2 (MIMS2). Participants were enrolled between June 2011 and March 2016 and followed up for a median of 6.0 (IQR, 5.6-6.0) years in MIPS and 4.6 (IQR, 3.8-5.3) years in MIMS2. Data were analyzed from December 1, 2022, to February 15, 2023. Exposures The rate-pressure product (RPP) was calculated as the mean systolic blood pressure times the mean heart rate at rest. Rate-pressure product reactivity was calculated as the maximum RPP during a standardized mental stress test minus the RPP at rest. Main Outcomes and Measures The primary outcome was a composite of cardiovascular death or nonfatal myocardial infarction. The secondary end point additionally included hospitalizations for heart failure. Results From the total of 938 individuals from the pooled cohort (mean [SD] age, 60.2 [10.1] years; 611 [65.1%] men), 631 participated in MIPS and 307 in MIMS2. A total of 373 individuals (39.8%) were Black, 519 (55.3%) were White, and 46 (4.9%) were of unknown race or ethnicity. The RPP increased by a mean (SD) of 77.1% (23.1%) during mental stress (mean [SD] absolute change, 5651 [2878]). For every SD decrease in RPP reactivity with mental stress, the adjusted hazard ratios for the primary and secondary end points were 1.30 (95% CI, 1.04-1.72) and 1.30 (95% CI, 1.06-1.56), respectively, in MIPS and 1.41 (95% CI, 1.06-1.97) and 1.21 (95% CI, 1.02-1.60), respectively, in MIMS2. In the pooled sample, when RPP reactivity to mental stress was added to a model including traditional clinical risk characteristics, model discrimination for adverse events improved (increase in C statistic of 5% for the primary end point; P = .009). Conclusions and Relevance In this cohort study of individuals with stable CAD, a blunted cardiovascular reactivity to mental stress was associated with adverse outcomes. Future studies are needed to assess the clinical utility of mental stress reactivity testing in this population.