title: Myocardial ischemia and angiotensin-converting enzyme inhibition: comparison of ischemia during mental and physical stress.
abstract: OBJECTIVE
  Mental stress provokes myocardial ischemia in many patients with stable coronary artery disease (CAD). Mental stress-induced myocardial ischemia (MSIMI) portends a worse prognosis, independent of standard cardiac risk factors or outcome of traditional physical stress testing. Angiotensin II plays a significant role in the physiological response to stress, but its role in MSIMI remains unknown. Our aim was to evaluate whether the use of angiotensin-converting enzyme inhibitors (ACEIs) is associated with a differential effect on the incidence of MSIMI compared with ischemia during physical stress.
  
  
  METHODS
  Retrospective analysis of 218 patients with stable CAD, including 110 on ACEI, was performed. 99m-Tc-sestamibi myocardial perfusion imaging was used to define ischemia during mental stress, induced by a standardized public speaking task, and during physical stress, induced by either exercise or adenosine.
  
  
  RESULTS
  Overall, 40 patients (18%) developed MSIMI and 80 patients (37%) developed ischemia during physical stress. MSIMI occurred less frequently in patients receiving ACEIs (13%) compared with those not on ACEIs (24%; p = .030, adjusted odds ratio = 0.42, 95% confidence interval = 0.19-0.91). In contrast, the frequency of myocardial ischemia during physical stress testing was similar in both groups (39% versus 35% in those on and not on ACEIs, respectively); adjusted odds ratio = 0.91, 95% confidence interval = 0.48-1.73).
  
  
  CONCLUSIONS
  In this retrospective study, patients using ACEI therapy displayed less than half the risk of developing ischemia during mental stress but not physical stress. This possible beneficial effect of ACEIs on MSIMI may be contributing to their salutary effects in CAD.
authors.affiliation: Emory Clinical Cardiovascular Research Institute, 1462 Clifton Road N.E. Suite 507, Atlanta GA 30322. rramad2@emory.edu.
authors.forename: Ronnie
authors.initials: R
authors.lastname: Ramadan
authors.forename: Arshed A
authors.initials: AA
authors.lastname: Quyyumi
authors.forename: A Maziar
authors.initials: AM
authors.lastname: Zafari
authors.forename: Jose N
authors.initials: JN
authors.lastname: Binongo
authors.forename: David S
authors.initials: DS
authors.lastname: Sheps
mesh_terms: D000241:Adenosine; D000368:Aged; D000804:Angiotensin II / Q000502:physiology; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000494:pharmacology / Q000627:therapeutic use*; D003324:Coronary Artery Disease / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D005080:Exercise Test / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D055414:Myocardial Perfusion Imaging / Q000379:methods; D012189:Retrospective Studies; D013315:Stress, Psychological / Q000453:epidemiology* / Q000503:physiopathology; D014665:Vasodilator Agents
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D014665:Vasodilator Agents; D000804:Angiotensin II; D000241:Adenosine
keywords: angiotensin-converting enzyme inhibitors; coronary artery disease; mental stress; myocardial perfusion imaging; stress ischemia; stress test