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Noninvasive Detection of Risk for Emotion Provoked Myocardial Ischemia

From the Section of Cardiovascular Medicine (M.M.B., B.G., A.V., C.E., J.L., R.L., R.S.), Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System (M.M.B., A.V., D.C., C.E., R.L., R.S.), West Haven Campus, West Haven, Connecticut; and Behavioral Cardiovascular Health Center (M.M.B.), Columbia University School of Medicine, New York City, New York.

Address correspondence and reprint requests to: Matthew M. Burg, PhD, Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar Street, 3 FMP, PO Box 208017, New Haven, CT 06520-8017. E-mail: mb2358{at}columbia.edu

Objectives: To test an easily administered, noninvasive technology to identify vulnerability to mental stress ischemia.

Background: Myocardial ischemia provoked by emotional stress (MSI) in patients with stable coronary artery disease (CAD) predicts major adverse cardiac events. A clinically useful tool to risk stratify patients on this factor is not available.

Methods: Patients with documented CAD (n = 68) underwent single photon emission CT myocardial perfusion imaging concurrent with pulse wave amplitude assessment by peripheral arterial tonometry (PAT) during a mental stress protocol of sequential rest and anger stress periods. Heart rate and blood pressure were assessed, and blood was drawn for catecholamine assay, during rest and stress. MSI was defined by the presence of a new perfusion defect during anger stress (n = 26) and the ratio of stress to rest PAT response was calculated.

Results: Patients with MSI had a significantly lower PAT ratio than those without MSI (0.76 ± 0.04 versus 0.91 ± 0.05, p = .03). An ROC curve for optimum sensitivity/specificity of PAT ratio as an index of MSI produced a sensitivity of 0.62 and a specificity of 0.63. Among patients taking angiotensin converting enzyme (ACE) inhibitors, the sensitivity and specificity of the test increased to 0.86 and 0.73, respectively; 90% of patients without MSI were correctly identified.

Conclusions: PAT in concert with ACE inhibition may provide a useful approach to assess risk for MSI. Future studies should help determine how best to utilize this approach for risk assessment in the clinical setting.

Key Words: mental stress • myocardial ischemia • PAT

Abbreviations: CAD = coronary artery disease; MSI = mental stress induced ischemia; SPECT = single photon emission computed tomography; PAT = peripheral arterial tonometry; PWA = pulse wave amplitude; ACE = angiotensin converting enzyme; ACS = acute coronary syndrome; IV = intravenous; MPI = myocardial perfusion imaging; SBP/DBP = systolic/diastolic blood pressure; HR = heart rate; RPP = rate pressure product; LVEF = left ventricular ejection fraction; ROC = receiver operating characteristics curve.