Association Between High-Sensitivity Cardiac Troponin Levels and Myocardial Ischemia During Mental Stress and Conventional Stress.
This study sought to investigate whether patients with mental stress-induced myocardial ischemia will have high resting and post-mental stress high-sensitivity cardiac troponin I (hs-cTnI).



Hs-cTnI is a marker of myocardial necrosis, and its elevated levels are associated with adverse outcomes. Hs-cTnI levels may increase with exercise in patients with coronary artery disease. Mental stress-induced myocardial ischemia is also linked to adverse outcomes.



In this study, 587 patients with stable coronary artery disease underwent technetium Tc 99m sestamibi-single-photon emission tomography myocardial perfusion imaging during mental stress testing using a public speaking task and during conventional (pharmacological/exercise) stress testing as a control condition. Ischemia was defined as new/worsening impairment in myocardial perfusion using a 17-segment model.



The median hs-cTnI resting level was 4.3 (interquartile range [IQR]: 2.9 to 7.3) pg/ml. Overall, 16% and 34.8% of patients developed myocardial ischemia during mental and conventional stress, respectively. Compared with those without ischemia, median resting hs-cTnI levels were higher in patients who developed ischemia either during mental stress (5.9 [IQR: 3.9 to 8.3] pg/ml vs. 4.1 [IQR: 2.7 to 7.0] pg/ml; p < 0.001) or during conventional stress (5.4 [IQR: 3.9 to 9.3] pg/ml vs. 3.9 [IQR: 2.5 to 6.5] pg/ml; p < 0.001). Patients with high hs-cTnI (cutoff of 4.6 pg/ml for men and 3.9 pg/ml for women) had greater odds of developing mental (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 1.5 to 3.9; p < 0.001) and conventional (OR: 2.4; 95% CI: 1.7 to 3.4; p < 0.001) stress-induced ischemia. Although there was a significant increase in 45-min post-treadmill exercise hs-cTnI levels in those who developed ischemia, there was no significant increase after mental or pharmacological stress test.



In patients with coronary artery disease, myocardial ischemia during either mental stress or conventional stress is associated with higher resting levels of hs-cTnI. This suggests that hs-cTnI elevation is an indicator of chronic ischemic burden experienced during everyday life. Whether elevated hs-cTnI levels are an indicator of adverse prognosis beyond inducible ischemia or whether it is amenable to intervention requires further investigation.
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Muhammad
M
Hammadah
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Ibhar
I
Al Mheid
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Kobina
K
Wilmot
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Ronnie
R
Ramadan
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Ayman
A
Alkhoder
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Malik
M
Obideen
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Naser
N
Abdelhadi
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Shuyang
S
Fang
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Ijeoma
I
Ibeanu
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Pratik
P
Pimple
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Heval
H
Mohamed Kelli
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Amit J
AJ
Shah
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Brad
B
Pearce
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Yan
Y
Sun
Department of Radiology, Emory University School of Medicine, Atlanta, Georgia.
Ernest V
EV
Garcia
Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Michael
M
Kutner
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Qi
Q
Long
Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Laura
L
Ward
Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.
J Douglas
JD
Bremner
Department of Radiology, Emory University School of Medicine, Atlanta, Georgia.
Fabio
F
Esteves
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Department of Radiology, Emory University School of Medicine, Atlanta, Georgia; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
Paolo
P
Raggi
Department of Epidemiology, University of Florida, Gainesville, Florida.
David
D
Sheps
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Viola
V
Vaccarino
Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia. Electronic address: aquyyum@emory.edu.
Arshed A
AA
Quyyumi
D000368:Aged; D015415:Biomarkers / Q000097:blood; D015444:Exercise; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000097:blood* / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D055414:Myocardial Perfusion Imaging / Q000379:methods; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D019275:Radiopharmaceuticals / Q000008:administration & dosage; D013060:Speech; D013312:Stress, Physiological; D013315:Stress, Psychological / Q000150:complications* / Q000523:psychology; D017256:Technetium Tc 99m Sestamibi / Q000008:administration & dosage; D015899:Tomography, Emission-Computed, Single-Photon; D019210:Troponin I / Q000097:blood*; D015854:Up-Regulation
D015415:Biomarkers; D019275:Radiopharmaceuticals; D019210:Troponin I; D017256:Technetium Tc 99m Sestamibi
high-sensitivity troponin I; mental stress; myocardial ischemia; physical stress