情绪压抑和精神紧张引起的心肌缺血-一个无形的杀手(英文教学课件)

1、Wei Jiang, MDAssociate Professor Internal Medicine Psychiatry & Behavioral Sciences Duke University Medical CenterEmotional Distress & Mental Stress Induced Myocardial Ischemia _ An Invisible KillerPurgason K. Dimensions of Critical Care Nursing. 2006;25:247-53A 64yo WF presents to a local ER, compl

2、aining of 2-h substernal chest painMild dyspnea with HR 72 bpm, BP 136/72 mm Hg, RR 20/min, T 97.9F, and O2 saturation 96% on RANo past medical history, postmenopausal, walks daily, and on balanced diet12-lead EKG shows ST elevation in leads V3-V6, troponin 3.5 ng/dL and CPK 275 m/L, LVEF 40% with m

3、oderate ventricle dysfunction, apical akinesis, and preserved basal function by EchocardiograpmThe patient received news that her daughter had been severely injured in a car accident several hours before her onset of chest painA Typical Case: “I have always been impressed by the probability of an im

4、portant 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 t

5、o 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 the

6、ir demise.” _An anonymous CardiologistA Quote from a CardiologistAmpulla cardiomyopathy (Takotusbo cardiomyopathy) -reversible left ventricular dysfunction: with ST segment elevation8 elderly women and one middle-aged man are studied. All coronary arteriograms are normal, though 7 of them had ST ele

7、vation on electrocardiogram. Coronary spasm was positive in only 2 of the 7 patients who received provocation testsBiopsy specimens revealed focal myocyte injuryNormal coronary arteriograms during ST elevation and the presence of pathologic myocardial lesions were not consistent with a concept of st

8、unned myocardium. The presence of myocardial lesions suggested that focal and disseminated myocardial damage had occurred.Kawai, et al. Jpn Circ J 2000;64:237Autopsy Findings following an EarthquakeFormal autopsy findings from 111 earthquake-related deathsThe median extrication time for 99 of 102 vi

9、ctims buried or trapped in collapsed buildings was 2.1 (range 0.1-7.8) daysDeaths 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. Papadopo

10、ulos et al. J Surgery. 2004;91:1633-40Kloner et al J Am Coll Cardiol. 1998;32:553-4Increased MI following an Earthquake _ U.S.AIncreased MI following an Earthquake _ JapanMatsuo et al. Int J Hematol 1998; 67: 1239 Tsai et al. Psychosomatics. 45(6):477-82, 2004 Nov-Dec.Increased MI following an Earth

11、quake _ TaiwanMental stress-Induced Myocardial Ischemic ActivityMyocardial 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 rateL

12、ow blood supplyconstriction of coronary arteries anatomically or hemodynamically Myocardial Ischemia occurs transiently in relationship of the alteration of the balance between demand and supplyMechanism of Myocardial IschemiaDemand HR Double ProductSupplyStenosisVessel ConstrictionMental Stress-Ind

13、uced Myocardial Ischemic ActivityMyocardial 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

14、living not necessarily related to increased physical intensity, it occurs during mental activities as wellMyocardial Ischemia may be detected by electrocardiogram in the laboratory and during daily living, and myocardium imaging in laboratory settingOccurrence of myocardial ischemia is associated wi

15、th poorer prognosis in patients with coronary artery disease Mental Stress-Induced Myocardial Ischemic ActivityBarry J et al. Am J Cardiol 1988;61:989-93Total of 372 ischemic episodesMental Stress TasksCommonly Utilized Mental Tasks in Laboratory Setting:Mental ArithmeticPublic SpeechMirror TraceStr

16、oop Color Word ReadingType A Personality Interview Start with a brief introduction, followed by a30-second preparation. The tasks last 3-5 minutes Mental Stress-Induced Myocardial Ischemic ActivityMyocardial Ischemic ActivityMental ArithmeticAngina / + exerciseHealthy ControlAbnormal perfusion75%0ST

17、-depression50% 0Deanfield et al. Lancet 1984;92:2102-8Deanfield et al. Lancet 1984;92:2102-8Mental Stress-Induced Myocardial Ischemic ActivityA comparative study among patients with positive exercise testing and normal controls with low IHD probabilityRozanski et al. NEJM 1988;318:1005Mental Arithme

18、ticPatientsNL ControlsLVWMA72%8%Ischemic ST 23%*Chest pain17%* Those abnormalities occurred exclusively in association with LVWMAMental Stress-Induced Myocardial Ischemic ActivityScintographically Recorded Responsesto Exercise and Mental Arithmetic testingGiubbini et al. Circulation 1991;83:II100Men

19、tal Stress-Induced Myocardial Ischemic ActivityMyocardial Ischemic Activity (N=136)Ischemic MarkerMental Stress-Induced(%)Exercise-Induced(%)WMA43 (34.1)63 (50)LVEF reduction 5%72 (57.1)45 (35.7)LVEF reduction or WMA84 (66.7)86 (68.3)ECG ST change 044 (35.8) WMA = left ventricular segmental wall mot

20、ion abnormalityBlumenthal & Jiang et al. Circulation 1995;92:2102-8Flow mal-distributionHypoperfusionDiastolic dysfunction Systolic dysfunction ECG changes Angina Perfusion ImagingEchocardiographyTissue Doppler EchoCascade of Myocardial IschemiaMental Stress-Induced Myocardial Ischemic ActivityMenta

21、l stress induced myocardial ischemia usually asymptomaticMSIMI does not have to occur in patients without significant stenosis of coronary arteriesPatients with mental stress induced ischemia had increased risk for death or revascularizations over a 5-year follow-up, especially for those whose resti

22、ng LVEF 19RR (95%CI)P valueRR (95%)P valueWMA with at least one MST2.8(1.3-6.0).0070.12(0.03-0.60).009Math7.7(1.2-48.1).0290.01(0.01-0.83).042Speech2.9(1.1-7.5).030.16(0.03-1.0).049Trace2.9(1.2-7.0).0220.15(0.03-0.88).035Reading3.8(0.78-18.8).0980.14(0.01-2.2).163Interview4.5(1.3-15.0).0150.03(0.01-

23、0.60).021Estimated RR of Depression for the Likelihood of MSIMIKop. Psychosomatic Medicine 1999;61:476-487 Mental Stress-Induced Myocardial Ischemic ActivityHemo-dynamic responses to mental stress and exerciseMental Stress-Induced Myocardial Ischemic ActivityRozanski A et al. N eng J med 1988;318:10

24、05-12Mental Stress-Induced Myocardial Ischemic ActivitySBP ReactionBlumenthal JA et al. Circulation 1995;92:2102-8Mental Stress-Induced Myocardial Ischemic ActivityDBP ReactionBlumenthal JA et al. Circulation 1995;92:2102-8Mental Stress-Induced Myocardial Ischemic ActivityHR ReactionBlumenthal JA et

25、 al. Circulation 1995;92:2102-8Mental Stress-Induced Myocardial Ischemic ActivityDouble-product = SBP x HR _ an indicator of myocardium demandMental Stress-Induced Myocardial Ischemic ActivityUniqueness of Coronary CirculationEpicardial coronary arteries give off small tranmural penetrating arteries

26、 into the myocardial layers, i.e. arterioles which terminates in capillary vessels that directly supply cardial myocytes.Non-stenosed epicardial coronary artery plays a minor role in the regulation of coronary vascular resistance Most of the resistance arises from coronary arterioles which opposes c

27、oronary blood flowMicrocirculationDistribution of Coronary Resistance in Coronary BedLarge Epicardial ArteriesMedium-small ArteriesArteriolesCapilariesDiameter1000um100-1000um10-100um10um% total resistance515-2550-6020% length of coronary bed5-1015-2560-75In response to vessel wall injury, alteratio

28、ns of blood flow (shear stress), or chemical stimuli (eg, thrombin or catecholamines), platelets manifest a series of linked functional responses (ie, adhesion, secretion, and aggregation)The surface of activated platelets expresses procoagulant phospholipids and binding sites for FV and FVIII that

29、constitute the platelet coagulation activity referred to as platelet factor 3Hemostatic function is closely related to vWF, that is stored in endothelial cells and platelets. vWF is crucial for both platelet adhesion to injured subendothelial structures and platelet aggregation. In addition, vWF bin

30、ds to and protects FVIII from proteolysisHomeostasis PathwaysDisturbed HomeostasisA hypercoagulable state prior to overt thrombosis resulting from an imbalance between the coagulation and fibrinolysis systems is related to cardiovascular disease progression and acute coronary syndromesDisturbed Home

31、ostasisSearch of literature on coagulation, anticoagulation, and fibrinolysis measures in conjunction with mental stress, psychosocial strain, and psychiatric disorders in MEDLINE from 1966 conducted, identifying 68 articles.Disturbed HomeostasisIn healthy subjects, acute mental stress simultaneousl

32、y activates coagulation (ie, fibrinogen or vWF) and fibrinolysis (ie, tissue-type PA) within a physiological range. In patients with atherosclerosis and impaired endothelial anticoagulant function, however, procoagulant responses to acute stressors may outweigh anticoagulant mechanisms and thereby p

33、romote a hypercoagulable state. Chronic psychosocial stressors (job strain or low socioeconomic status) are related to a hypercoagulable state reflected by increased procoagulant molecules (ie, fibrinogen or factor VII) and by reduced fibrinolytic capacity. There is also some evidence that points to

34、 hypercoagulability in depression. Mental Stress-Induced Myocardial Ischemic ActivitySignificant coronary vasoconstriction was observed when infusing acetylcholine during mental stress testing _ Yeung AC et al, N Eng J Med 1991;325:1551-6Boltwood MD et al, Am J Cardiol 1993;72:1361-5 Coronary circul

35、ation was observed to fail to dilate during mental stress testing _Dakak N et al, Am J Cardiol 1995;76:125-30StressStress in Chinese meansPressure &Strength or powerIf there is no stress, there will be no strength Emotional DistressAnger or HostilityDepressionAnxietyNegativity, like the “half glass

36、empty”HopelessSocial IsolationInterpersonal ConflictJob Stress PerceptionVs.RealityThreat of Emotional Distress Severity and/or intensity of stressDuration of stressSusceptibility of individualNegative cognitionCoping skillsUnderlying medical or psychiatric conditionsBurned outThreat of Emotional Di

37、stress Mental stress induced LV dysfunction is associated with 3-fold increase in risk of cardiac events during a 2-year follow-up; BB use have no effect _Jain et al. Am J Cardiol 1995;76:31Over a 5-year f/u, MSIMI was associated with increased cardiac events during a 5-year follow-up (OR 2.8; 95% C

38、I 1.0-7.7), independent of age, history of prior myocardial infarction, and baseline cardiac function. However, exercise-induced ischemia did not predict for adverse cardiac events (OR, 1.5; 95% CI, 0.6-3.9) in the same sample _Jiang et al. JAMA 1996;275:1651-6New or worsened wall motion abnormalities during the speech test is significantly predicted death (OR 3.0; 95% CI, 1.04 to 8.36) over 5-year _ Sheps et al. Circulation 2002;105:1780 Threat of Emotional Distress Implicated therap