title: High Concordance Between Mental Stress-Induced and Adenosine-Induced Myocardial Ischemia Assessed Using SPECT in Heart Failure Patients: Hemodynamic and Biomarker Correlates.
abstract: Mental stress can trigger myocardial ischemia, but the prevalence of mental stress-induced ischemia in congestive heart failure (CHF) patients is unknown. We characterized mental stress-induced and adenosine-induced changes in myocardial perfusion and neurohormonal activation in CHF patients with reduced left-ventricular function using SPECT to precisely quantify segment-level myocardial perfusion.
  
  
  METHODS
  Thirty-four coronary artery disease patients (mean age±SD, 62±10 y) with CHF longer than 3 mo and ejection fraction less than 40% underwent both adenosine and mental stress myocardial perfusion SPECT on consecutive days. Mental stress consisted of anger recall (anger-provoking speech) followed by subtraction of serial sevens. The presence and extent of myocardial ischemia was quantified using the conventional 17-segment model.
  
  
  RESULTS
  Sixty-eight percent of patients had 1 ischemic segment or more during mental stress and 81% during adenosine. On segment-by-segment analysis, perfusion with mental stress and adenosine were highly correlated. No significant differences were found between any 2 time points for B-type natriuretic peptide, tumor necrosis factor-α, IL-1b, troponin, vascular endothelin growth factor, IL-17a, matrix metallopeptidase-9, or C-reactive protein. However, endothelin-1 and IL-6 increased, and IL-10 decreased, between the stressor and 30 min after stress. Left-ventricular end diastolic dimension was 179±65 mL at rest and increased to 217±71 after mental stress and 229±86 after adenosine (P<0.01 for both). Resting end systolic volume was 129±60 mL at rest and increased to 158±66 after mental stress (P<0.05) and 171±87 after adenosine (P<0.07), with no significant differences between adenosine and mental stress. Ejection fraction was 30±12 at baseline, 29±11 with mental stress, and 28±10 with adenosine (P=not significant).
  
  
  CONCLUSIONS
  There was high concordance between ischemic perfusion defects induced by adenosine and mental stress, suggesting that mental stress is equivalent to pharmacologic stress in eliciting clinically significant myocardial perfusion defects in CHF patients. Cardiac dilatation suggests clinically important changes with both conditions. Psychosocial stressors during daily life may contribute to the ischemic burden of CHF patients with coronary artery disease.
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, Maryland;
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Wawrzyniak
authors.affiliation: Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland;
authors.forename: Vasken
authors.initials: V
authors.lastname: Dilsizian
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, Maryland;
authors.forename: David S
authors.initials: DS
authors.lastname: Krantz
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland;
authors.forename: Kristie M
authors.initials: KM
authors.lastname: Harris
authors.affiliation: Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland;
authors.forename: Mark F
authors.initials: MF
authors.lastname: Smith
authors.affiliation: Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland;
authors.forename: Anthony
authors.initials: A
authors.lastname: Shankovich
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, Maryland;
authors.forename: Kerry S
authors.initials: KS
authors.lastname: Whittaker
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, Maryland;
authors.forename: Gabriel A
authors.initials: GA
authors.lastname: Rodriguez
authors.affiliation: Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and.
authors.forename: John
authors.initials: J
authors.lastname: Gottdiener
authors.affiliation: Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and.
authors.forename: Shuying
authors.initials: S
authors.lastname: Li
authors.affiliation: Tilburg University, Tilburg, The Netherlands.
authors.forename: Willem
authors.initials: W
authors.lastname: Kop
authors.affiliation: Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and sgottlie@medicine.umaryland.edu.
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Gottlieb
mesh_terms: D000241:Adenosine; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000378:metabolism; D002317:Cardiovascular Agents; D003326:Coronary Circulation; D005080:Exercise Test; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000139:chemically induced / Q000000981:diagnostic imaging* / Q000503:physiopathology; D013315:Stress, Psychological / Q000503:physiopathology*; D015899:Tomography, Emission-Computed, Single-Photon; D016277:Ventricular Function, Left
chemical_list: D015415:Biomarkers; D002317:Cardiovascular Agents; D000241:Adenosine
keywords: adenosine; heart failure; ischemia; mental stress; myocardial perfusion; single-photon emission computed tomography