title: Variability of myocardial ischemic responses to mental versus exercise or adenosine stress in patients with coronary artery disease.
abstract: BACKGROUND
  Mental stress precipitates myocardial ischemia in a significant percentage of coronary artery disease (CAD) patients. Exercise or adenosine stresses produce different physiologic responses and cause myocardial ischemia via different mechanisms. Little is known about the comparative severity and location of myocardial ischemia provoked by these different stressors. In this study we sought to compare the within-individual ischemic responses to mental versus exercise or adenosine stress in a cohort of CAD patients.
  
  
  RESULTS
  All patients underwent mental stress and either exercise or adenosine testing within a 1-week period. Mental stress was induced via a public speaking task. Rest-stress myocardial perfusion imaging was used with all testing protocols. Participants were 187 patients (65 women [35%]) with a documented history of CAD and a mean age of 64 +/- 9 years. Mental stress-induced myocardial ischemia (MSIMI) was less prevalent and frequently of less magnitude than exercise- or adenosine-induced ischemia. Ischemia induced by exercise or adenosine testing did not accurately predict the development or the location of MSIMI. The overall concordance between these stressors for provoking ischemia was weak (percent agreement, 71%; kappa [+/- SE], 0.26 +/- 0.07). In a minority of patients (11%) mental stress provoked ischemia in the absence of exercise- or adenosine-induced ischemia. Moreover, in patients who had myocardial ischemia during both stressors, there were significant within-individual differences in the coronary artery distribution of the ischemic regions. MSIMI was more likely to occur in a single-vessel distribution (86%) compared with exercise- or adenosine-induced ischemia (54%). The stressors had moderate agreement if the ischemic region was in the right coronary artery territory (percent agreement, 76%; kappa, 0.52 +/- 0.19) or the left anterior descending coronary artery (percent agreement, 76%; kappa, 0.51 +/- 0.19) and significantly lower agreement in the left circumflex territory (percent agreement, 62%; kappa, 0.22 +/- 0.18).
  
  
  CONCLUSIONS
  Our findings indicate that mental and exercise or adenosine stresses provoke different myocardial ischemic responses. These observations suggest that exercise or adenosine testing may not adequately assess the likelihood of occurrence or severity of MSIMI and that different mechanisms are operative in each condition.
authors.affiliation: Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL, USA. mustafa.hassan@medicine.ufl.edu
authors.forename: Mustafa
authors.initials: M
authors.lastname: Hassan
authors.forename: Kaki M
authors.initials: KM
authors.lastname: York
authors.forename: Qin
authors.initials: Q
authors.lastname: Li
authors.forename: Dorian G
authors.initials: DG
authors.lastname: Lucey
authors.forename: Roger B
authors.initials: RB
authors.lastname: Fillingim
authors.forename: David S
authors.initials: DS
authors.lastname: Sheps
mesh_terms: D000241:Adenosine; D000368:Aged; D015984:Causality; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000523:psychology; D005080:Exercise Test / Q000706:statistics & numerical data*; D005260:Female; D005431:Florida / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000523:psychology; D011877:Radionuclide Imaging; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013315:Stress, Psychological / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000523:psychology; D014665:Vasodilator Agents
chemical_list: D014665:Vasodilator Agents; D000241:Adenosine