title: Meta-analysis of mental stress-induced myocardial ischemia and subsequent cardiac events in patients with coronary artery disease.
abstract: Mental stress-induced myocardial ischemia (MSIMI) has been associated with adverse prognosis in patients with coronary artery disease (CAD), but whether this is a uniform finding across different studies has not been described. We conducted a systematic review and meta-analysis of prospective studies examining the association between MSIMI and adverse outcome events in patients with stable CAD. We searched PubMed, EMBASE, Web of Science, and PsycINFO databases for English language prospective studies of patients with CAD who underwent standardized mental stress testing to determine presence of MSIMI and were followed up for subsequent cardiac events or total mortality. Our outcomes of interest were CAD recurrence, CAD mortality, or total mortality. A summary effect estimate was derived using a fixed-effects meta-analysis model. Only 5 studies, each with a sample size of <200 patients and fewer than 50 outcome events, met the inclusion criteria. The pooled samples comprised 555 patients with CAD (85% male) and 117 events with a range of follow-up from 35 days to 8.8 years. Pooled analysis showed that MSIMI was associated with a twofold increased risk of a combined end point of cardiac events or total mortality (relative risk 2.24, 95% confidence interval 1.59 to 3.15). No heterogeneity was detected among the studies (Q=0.39, I2=0.0%, p=0.98). In conclusion, although few selected studies have examined the association between MSIMI and adverse events in patients with CAD, all existing investigations point to approximately a doubling of risk. Whether this increased risk is generalizable to the CAD population at large and varies in patient subgroups warrant further investigation.
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Jingkai
authors.initials: J
authors.lastname: Wei
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Cherie
authors.initials: C
authors.lastname: Rooks
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Ronnie
authors.initials: R
authors.lastname: Ramadan
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Atlanta Veterans Affairs Medical Center, Decatur, Georgia.
authors.forename: Amit J
authors.initials: AJ
authors.lastname: Shah
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: J Douglas
authors.initials: JD
authors.lastname: Bremner
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Arshed A
authors.initials: AA
authors.lastname: Quyyumi
authors.affiliation: Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Michael
authors.initials: M
authors.lastname: Kutner
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia. Electronic address: lvaccar@emory.edu.
authors.forename: Viola
authors.initials: V
authors.lastname: Vaccarino
mesh_terms: D003324:Coronary Artery Disease / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D004562:Electrocardiography; D014943:Global Health; D006801:Humans; D015994:Incidence; D017202:Myocardial Ischemia / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D011379:Prognosis; D012307:Risk Factors; D013315:Stress, Psychological / Q000150:complications*; D015996:Survival Rate / Q000639:trends