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Original Investigation
September 11, 2019

Association of Transient Endothelial Dysfunction Induced by Mental Stress With Major Adverse Cardiovascular Events in Men and Women With Coronary Artery Disease

Author Affiliations
  • 1Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
  • 2Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
  • 3Atlanta VA Medical Center, Decatur, Georgia
  • 4Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
  • 5Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville
  • 6Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
  • 7Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
JAMA Cardiol. 2019;4(10):988-996. doi:10.1001/jamacardio.2019.3252
Key Points

Question  Is mental stress–induced endothelial dysfunction associated with major adverse cardiovascular events?

Findings  This cohort study of patients with stable coronary artery disease found a graded positive association between transient endothelial dysfunction with mental stress and major adverse cardiovascular events.

Meaning  Impairment in endothelium-dependent relaxation induced by mental stress confers an increased hazard for adverse events and could be an important risk biomarker for patients with stable coronary artery disease.

Abstract

Importance  Acute mental stress can result in transient endothelial dysfunction, but the prognostic relevance of this phenomenon is unknown.

Objective  To determine the association between mental stress–induced impairment in endothelium-dependent relaxation as assessed by brachial artery flow-mediated vasodilation and adverse cardiovascular outcomes among individuals with stable coronary artery disease.

Design, Setting, and Participants  This cohort study was conducted at a university-affiliated hospital network between June 2011 and August 2014. A cohort of individuals with stable coronary artery disease were included. Data analysis took place from November 2018 to May 2019.

Exposures  Study participants were subjected to a laboratory mental stress task (public speaking).

Main Outcomes and Measures  Flow-mediated vasodilation was measured before and 30 minutes after a public-speaking mental stress task. We examined the association of the rest (prestress), poststress, and δ flow-mediated vasodilation (poststress minus prestress levels) with an adjudicated composite end point of adverse events, including cardiovascular death, myocardial infarction, unstable angina leading to revascularization, and heart failure hospitalization, after adjusting for sociodemographic factors, medical history, and depression.

Results  A total of 569 patients were included (mean [SD] age, 62.6 [9.3] years; 420 men [73.8%]). Flow-mediated vasodilation decreased from a mean (SD) of 4.8% (3.7%) before mental stress to 3.9% (3.6%) after mental stress (a 23% reduction; P < .001), and 360 participants (63.3%) developed transient endothelial dysfunction (a decrease in flow-mediated vasodilation). During a median (interquartile range) follow-up period of 3.0 (2.9-3.1) years, 74 patients experienced a major adverse cardiovascular event. The presence of transient endothelial dysfunction with mental stress was associated with a 78% increase (subdistribution hazard ratio [sHR], 1.78 [95% CI, 1.15-2.76]) in the incidence of major adverse cardiovascular event. Both the δ flow-mediated vasodilation (sHR, 1.15 [95% CI, 1.03-1.27] for each 1% decline) and poststress flow-mediated vasodilation (sHR, 1.14 [95% CI, 1.04-1.24] for each 1% decline) were associated with major adverse cardiovascular event. Risk discrimination statistics demonstrated a significant model improvement after addition of either poststress flow-mediated vasodilation (change in the area under the curve, 0.05 [95% CI, 0.01-0.09]) or prestress plus δ flow-mediated vasodilation (change in the area under the curve, 0.04 [95% CI, 0.00-0.08]) compared with conventional risk factors.

Conclusions and Relevance  In this study, transient endothelial dysfunction with mental stress was associated with adverse cardiovascular outcomes in patients with coronary artery disease. Endothelial responses to stress represent a possible mechanism through which psychological stress may affect outcomes in patients with coronary artery disease.

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