title: Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study.
abstract: BACKGROUND
  Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates.
  
  
  RESULTS
  To determine whether mental stress-induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5+/-0.4 years and 5.2+/-0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (P=0.04) and significantly predicted death (rate ratio=3.0; 95% CI, 1.04 to 8.36; P=0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (P=0.9) and did not predict death even after adjusting for resting ejection fraction (P=0.63), which was similar in both groups (mean, 56.4 versus 59.7; P=0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise.
  
  
  CONCLUSIONS
  In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stress-induced ischemia predicts subsequent death.
authors.affiliation: University of Florida College of Medicine, the Malcom Randall Veterans Affairs Medical Center, and the Medical Research Service of the Department of Veterans Affairs, Gainesville, Fla 32610-0277, USA. shepsds@medicine.ufl.edu
authors.forename: David S
authors.initials: DS
authors.lastname: Sheps
authors.forename: Robert P
authors.initials: RP
authors.lastname: McMahon
authors.forename: Lewis
authors.initials: L
authors.lastname: Becker
authors.forename: Robert M
authors.initials: RM
authors.lastname: Carney
authors.forename: Kenneth E
authors.initials: KE
authors.lastname: Freedland
authors.forename: Jerome D
authors.initials: JD
authors.lastname: Cohen
authors.forename: David
authors.initials: D
authors.lastname: Sheffield
authors.forename: A David
authors.initials: AD
authors.lastname: Goldberg
authors.forename: Mark W
authors.initials: MW
authors.lastname: Ketterer
authors.forename: Carl J
authors.initials: CJ
authors.lastname: Pepine
authors.forename: James M
authors.initials: JM
authors.lastname: Raczynski
authors.forename: Kathleen
authors.initials: K
authors.lastname: Light
authors.forename: David S
authors.initials: DS
authors.lastname: Krantz
authors.forename: Peter H
authors.initials: PH
authors.lastname: Stone
authors.forename: Genell L
authors.initials: GL
authors.lastname: Knatterud
authors.forename: Peter G
authors.initials: PG
authors.lastname: Kaufmann
mesh_terms: D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality* / Q000523:psychology*; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D017202:Myocardial Ischemia / Q000209:etiology* / Q000523:psychology; D013315:Stress, Psychological / Q000150:complications