Wei Jiang, MD Associate Professor Internal Medicine Psychiatry & Behavioral Sciences Duke University Medical Center,Emotional Distress &Mental Stress Induced Myocardial Ischemia _ An Invisible Killer,Purgason K. Dimensions of Critical Care Nursing. 2006;25:247-53,A 64yo WF presents to a local ER, complaining of 2-h substernal chest pain Mild dyspnea with HR 72 bpm, BP 136/72 mm Hg, RR 20/min, T 97.9F, and O2 saturation 96% on RA No past medical history, postmenopausal, walks daily, and on balanced diet 12-lead EKG shows ST elevation in leads V3-V6, troponin 3.5 ng/dL and CPK 275 m/L, LVEF 40% with moderate ventricle dysfunction, apical akinesis, and preserved basal function by Echocardiograpm The patient received news that her daughter had been severely injured in a car accident several hours before her onset of chest pain,A Typical Case:,“I have always been impressed by the probability of an important relationship between personality attributes, stress coping strategies and heart disease with myocardial infarction in particular. I have witnessed several friends die suddenly this way. They did not smoke, were not overweight, and their cholesterol levels were unremarkable. But I knew them to be under considerable strain as the result of professional and personal stressors, and I have always believed that their lack of insight, resilience, and emotional resourcefulness, along with their characteristic pattern of responding to stress with helpless anger, significantly contributed to their demise.” _An anonymous Cardiologist,A Quote from a Cardiologist,Ampulla cardiomyopathy (Takotusbo cardiomyopathy) -reversible left ventricular dysfunction: with ST segment elevation 8 elderly women and one middle-aged man are studied. All coronary arteriograms are normal, though 7 of them had ST elevation on electrocardiogram. Coronary spasm was positive in only 2 of the 7 patients who received provocation tests Biopsy specimens revealed focal myocyte injury Normal coronary arteriograms during ST elevation and the presence of pathologic myocardial lesions were not consistent with a concept of stunned myocardium. The presence of myocardial lesions suggested that focal and disseminated myocardial damage had occurred.,Kawai, et al. Jpn Circ J 2000;64:237,Autopsy Findings following an Earthquake,Formal autopsy findings from 111 earthquake-related deaths The median extrication time for 99 of 102 victims buried or trapped in collapsed buildings was 2.1 (range 0.1-7.8) days Deaths were cause by blunt injuries, asphyxia and myocardial infarction. Injuries impaired the airway, breathing, circulation, and brain or spinal functions in 10.5, 61.9, 46.6 and 57.1% of the victims, respectively.,Papadopoulos et al. J Surgery. 2004;91:1633-40,Kloner et al J Am Coll Cardiol. 1998;32:553-4,Increased MI following an Earthquake _ U.S.A,Increased MI following an Earthquake _ Japan,Matsuo et al. Int J Hematol 1998; 67: 1239,Tsai et al. Psychosomatics. 45(6):477-82, 2004 Nov-Dec.,Increased MI following an Earthquake _ Taiwan,Mental stress-Induced Myocardial Ischemic Activity,Myocardial Ischemia occurs when the demand on the myocardium is not met by the blood supply High myocardium demandanything increases activities of myocardium, most notably, physical exercise or condition causing elevation of heart rate Low blood supplyconstriction of coronary arteries anatomically or hemodynamically Myocardial Ischemia occurs transiently in relationship of the alteration of the balance between demand and supply,Mechanism of Myocardial Ischemia,Demand HR Double Product,Supply Stenosis Vessel Constriction,Mental Stress-Induced Myocardial Ischemic Activity,Myocardial ischemia induced in the laboratory is, in general, based on the mechanism of increasing myocardium demand, i.e. high systolic blood pressure and rapid heart rate; by means of exercise or pharmacological intervention Myocardial ischemia occurs during daily living not necessarily related to increased physical intensity, it occurs during mental activities as well Myocardial Ischemia may be detected by electrocardiogram in the laboratory and during daily living, and myocardium imaging in laboratory setting Occurrence of myocardial ischemia is associated with poorer prognosis in patients with coronary artery disease,Mental Stress-Induced Myocardial Ischemic Activity,Barry J et al. Am J Cardiol 1988;61:989-93,Total of 372 ischemic episodes,Mental Stress Tasks,Commonly Utilized Mental Tasks in Laboratory Setting: Mental Arithmetic Public Speech Mirror Trace Stroop Color Word Reading Type A Personality Interview Start with a brief introduction, followed by a 30-second preparation. The tasks last 3-5 minutes,Mental Stress-Induced Myocardial Ischemic Activity,Deanfield et al. Lancet 1984;92:2102-8,Deanfield et al. Lancet 1984;92:2102-8,Mental Stress-Induced Myocardial Ischemic Activity,A comparative study among patients with positive exercise testing and normal controls with low IHD probability,