Mental Stress Worsens Cardiovascular Outcomes in Coronary Heart Disease

physician stressed
physician stressed
Researchers compared the link between mental stress- or conventional stress-induced ischemia and adverse CV events in patients with coronary heart disease.

Mental stress-induced ischemia among individuals with stable coronary heart disease (CHD) is associated with a greater risk for myocardial infarction (MI) or cardiovascular (CV) mortality, according to a study published in JAMA.

For the study, researchers used a pooled analysis of 2 prospective cohort studies conducted in Atlanta, Georgia between June 2011 and March 2016. Participants (N=918) had a mean age of 60±10 years; 34% were women; 55% were White; and 40% were Black.

Testing was performed in the morning following a 12-hour fast. Participants performed a public speaking task to induce mental stress, throughout which heart rate and blood pressure were recorded to calculate a rate-pressure outcome. Participants reported their distress ratings using the Subjective Units of Distress Scale. A conventional stress test was also conducted using either exercise or a pharmacological solution, with myocardial perfusion imaging via single-photon emission computed tomography used for evaluation. The primary outcome was either CV mortality or nonfatal MI. A secondary endpoint was heart failure­–related hospitalization.

Among the composite study population, 16% experienced mental stress­–induced ischemia, 31% experienced conventional stress­–induced ischemia, and 10% experienced both. Throughout the 5-year median follow-up, 156 participants (n=90 and n=66 from the 2 studies) met the primary endpoint. The pooled event rates for individuals with and without mental stress­–induced ischemia were 6.9 and 2.6 per 100 person-years, respectively. The pooled, adjusted hazard ratio (aHR) for individuals with vs without the primary endpoint was 2.5 (95% CI, 1.8-3.5). Individuals with mental stress-induced ischemia alone were at significantly higher risk than those without (4.8 vs 2.3 per 100 person-years, respectively; aHR, 2.0; 95% CI, 1.1-3.7); for both stressors, the respective aHR was 3.8 (95% CI, 2.6-5.6). Risk was not significantly higher for individuals with conventional stress ischemia alone (aHR, 1.4; 95% CI, 0.9-2.1; event rate, 3.1 per 100 person-years). However, those with both mental and conventional stress ischemia had a higher risk than those with conventional stress ischemia alone (aHR, 2.7; 95% CI, 1.7-4.3). Heart failure-related hospitalization occurred in 319 individuals (n=166 and n=153 from the 2 studies). The event rates for persons with and without mental stress-induced ischemia were 12.6 and 5.6 per 100 person-years, respectively (adjusted HR, 2.0; 95% CI, 1.5-2.5).

Limitations to this study include a need for further study on the relationship between mental stress and stress in everyday life, the use of just one mental stressor, potentially reduced generalizability, and a lack of evaluation of clinical value or feasibility.

“Among patients with stable [CHD], the presence of mental stress–induced ischemia, compared with no mental stress–induced ischemia, was significantly associated with an increased risk of [CV] death or nonfatal [MI],” the study authors said. “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.”


Vaccarino V, Almuwaqqat Z, Kim JH, et al. Association of mental stress-induced myocardial ischemia with cardiovascular events in patients with coronary heart disease. JAMA. 2021;326(18):1818-1828.