小柯机器人

美国埃默里大学医学院Arshed A. Quyyumi团队研究了精神应激诱导的心肌缺血与冠心病患者心血管事件的相关性。相关论文于2021年11月9日发表在《美国医学会杂志》上。

精神应激性心肌缺血是冠心病患者公认的一种现象，但其在当今医学界的临床意义尚未研究。

为了比较精神应激诱导或常规应激诱导心肌缺血与冠心病患者不良心血管事件的相关性，研究组对佐治亚州亚特兰大市一所大学医院网络的2项稳定型冠心病患者前瞻性队列研究进行了汇总分析：精神应激缺血预后研究（MIPS）和心肌梗死和精神应激研究2（MIMS2）。参与者于2011年6月至2016年3月期间入组，最后随访日期为2020年2月。研究组通过标准化精神压力测试（公开演讲任务）和常规（运动或药理学）压力测试（使用单光子发射计算机断层扫描）来诱发心肌缺血。主要结局是心血管死亡或首次/复发性非致命性心肌梗死。次要终点还包括因心力衰竭住院。

全部样本库的918名患者平均年龄为60岁，34%为女性，其中618名参与MIPS，300名参与MIMS2。147名患者（16%）患有精神应激诱导缺血，281名患者（31%）患有常规应激诱导缺血，96名患者（10%）同时患有这两种疾病。在为期5年的中位随访中，156名参与者出现了主要结局。

精神应激性缺血的患者中主要结局合并发生率为6.9例/100患者-年，在没有精神应激性缺血的患者为2.6例/100患者-年。精神应激诱导缺血患者与非精神应激诱导缺血患者的多变量校正危险比（HR）为2.5。与无缺血的患者相比（事件发生率为2.3例/100患者-年），单纯精神应激诱导缺血患者的风险显著增加（事件发生率为4.8例/100患者-年），同时患有精神应激缺血和常规应激缺血患者的风险也显著增加（事件发生率为8.1例/100患者-年）。

单纯常规应激性缺血患者的风险没有显著增加（事件发生率为3.1例/100患者-年）。与单纯常规应激性缺血患者相比，同时患有精神应激性缺血和常规应激性缺血患者的风险较高（HR为2.7）。次要终点出现在319名参与者中。精神应激性缺血患者的事件发生率为12.6例/100患者-年，而没有精神应激性缺血的患者为5.6例/100患者-年，校正HR为2.0。

研究结果表明，在稳定型冠心病患者中，与无精神应激诱导的缺血相比，精神应激诱导的缺血与心血管死亡或非致命性心肌梗死的风险增加显著相关。

附：英文原文

Title: Association of Mental Stress–Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease

Author: Viola Vaccarino, Zakaria Almuwaqqat, Jeong Hwan Kim, Muhammad Hammadah, Amit J. Shah, Yi-An Ko, Lisa Elon, Samaah Sullivan, Anish Shah, Ayman Alkhoder, Bruno B. Lima, Brad Pearce, Laura Ward, Michael Kutner, Yingtian Hu, Tené T. Lewis, Ernest V. Garcia, Jonathon Nye, David S. Sheps, Paolo Raggi, J. Douglas Bremner, Arshed A. Quyyumi

Issue&Volume: 2021/11/09

Abstract:

Importance  Mental stress–induced myocardial ischemia is a recognized phenomenon in patients with coronary heart disease (CHD), but its clinical significance in the contemporary clinical era has not been investigated.

Objective  To compare the association of mental stress–induced or conventional stress–induced ischemia with adverse cardiovascular events in patients with CHD.

Design, Setting, and Participants  Pooled analysis of 2 prospective cohort studies of patients with stable CHD from a university-based hospital network in Atlanta, Georgia: 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 (last follow-up, February 2020).

Exposures  Provocation of myocardial ischemia with a standardized mental stress test (public speaking task) and with a conventional (exercise or pharmacological) stress test, using single-photon emission computed tomography.

Main Outcomes and Measures  The primary outcome was a composite of cardiovascular death or first or recurrent nonfatal myocardial infarction. The secondary end point additionally included hospitalizations for heart failure.

Results  Of the 918 patients in the total sample pool (mean age, 60 years; 34% women), 618 participated in MIPS and 300 in MIMS2. Of those, 147 patients (16%) had mental stress–induced ischemia, 281 (31%) conventional stress ischemia, and 96 (10%) had both. Over a 5-year median follow-up, the primary end point occurred in 156 participants. The pooled event rate was 6.9 per 100 patient-years among patients with and 2.6 per 100 patient-years among patients without mental stress–induced ischemia. The multivariable adjusted hazard ratio (HR) for patients with vs those without mental stress–induced ischemia was 2.5 (95% CI, 1.8-3.5). Compared with patients with no ischemia (event rate, 2.3 per 100 patient-years), patients with mental stress–induced ischemia alone had a significantly increased risk (event rate, 4.8 per 100 patient-years; HR, 2.0; 95% CI, 1.1-3.7) as did patients with both mental stress ischemia and conventional stress ischemia (event rate, 8.1 per 100 patient-years; HR, 3.8; 95% CI, 2.6-5.6). Patients with conventional stress ischemia alone did not have a significantly increased risk (event rate, 3.1 per 100 patient-years; HR, 1.4; 95% CI, 0.9-2.1). Patients with both mental stress ischemia and conventional stress ischemia had an elevated risk compared with patients with conventional stress ischemia alone (HR, 2.7; 95% CI, 1.7-4.3). The secondary end point occurred in 319 participants. The event rate was 12.6 per 100 patient-years for patients with and 5.6 per 100 patient-years for patients without mental stress–induced ischemia (adjusted HR, 2.0; 95% CI, 1.5-2.5).

Conclusions and Relevance  Among patients with stable coronary heart disease, the presence of mental stress–induced ischemia, compared with no mental stress–induced ischemia, was significantly associated with an increased risk of cardiovascular death or nonfatal myocardial infarction. Although these findings may provide insights into mechanisms of myocardial ischemia, further research is needed to assess whether testing for mental stress–induced ischemia has clinical value.

DOI: 10.1001/jama.2021.17649

Source: https://jamanetwork.com/journals/jama/article-abstract/2785948

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