情绪压抑和精神紧张引起的心肌缺血.ppt

WeiJiang,MDAssociateProfessorInternalMedicinePsychiatry25:247-53,A64yoWFpresentstoalocalER,complainingof2-hsubsternalchestpainMilddyspneawithHR72bpm,BP136/72mmHg,RR20/min,T97.9F,andO2saturation96%onRANopastmedicalhistory,postmenopausal,walksdaily,andonbalanceddiet12-leadEKGshowsSTelevationinleadsV3-V6,troponin3.5ng/dLandCPK275m/L,LVEF40%withmoderateventricledysfunction,apicalakinesis,andpreservedbasalfunctionbyEchocardiograpmThepatientreceivednewsthatherdaughterhadbeenseverelyinjuredinacaraccidentseveralhoursbeforeheronsetofchestpain,ATypicalCase:,“Ihavealwaysbeenimpressedbytheprobabilityofanimportantrelationshipbetweenpersonalityattributes,stresscopingstrategiesandheartdiseasewithmyocardialinfarctioninparticular.Ihavewitnessedseveralfriendsdiesuddenlythisway.Theydidnotsmoke,werenotoverweight,andtheircholesterollevelswereunremarkable.ButIknewthemtobeunderconsiderablestrainastheresultofprofessionalandpersonalstressors,andIhavealwaysbelievedthattheirlackofinsight,resilience,andemotionalresourcefulness,alongwiththeircharacteristicpatternofrespondingtostresswithhelplessanger,significantlycontributedtotheirdemise.”_AnanonymousCardiologist,AQuotefromaCardiologist,Ampullacardiomyopathy(Takotusbocardiomyopathy)-reversibleleftventriculardysfunction:withSTsegmentelevation8elderlywomenandonemiddle-agedmanarestudied.Allcoronaryarteriogramsarenormal,though7ofthemhadSTelevationonelectrocardiogram.Coronaryspasmwaspositiveinonly2ofthe7patientswhoreceivedprovocationtestsBiopsyspecimensrevealedfocalmyocyteinjuryNormalcoronaryarteriogramsduringSTelevationandthepresenceofpathologicmyocardiallesionswerenotconsistentwithaconceptofstunnedmyocardium.Thepresenceofmyocardiallesionssuggestedthatfocalanddisseminatedmyocardialdamagehadoccurred.,Kawai,etal.JpnCircJ2000;64:237,AutopsyFindingsfollowinganEarthquake,Formalautopsyfindingsfrom111earthquake-relateddeathsThemedianextricationtimefor99of102victimsburiedortrappedincollapsedbuildingswas2.1(range0.1-7.8)daysDeathswerecausebybluntinjuries,asphyxiaandmyocardialinfarction.Injuriesimpairedtheairway,breathing,circulation,andbrainorspinalfunctionsin10.5,61.9,46.6and57.1%ofthevictims,respectively.,Papadopoulosetal.JSurgery.2019;91:1633-40,KloneretalJAmCollCardiol.2019;32:553-4,IncreasedMIfollowinganEarthquake_U.S.A,IncreasedMIfollowinganEarthquake_Japan,Matsuoetal.IntJHematol2019;67:1239,Tsaietal.Psychosomatics.45(6):477-82,2019Nov-Dec.,IncreasedMIfollowinganEarthquake_Taiwan,Mentalstress-InducedMyocardialIschemicActivity,MyocardialIschemiaoccurswhenthedemandonthemyocardiumisnotmetbythebloodsupplyHighmyocardiumdemandanythingincreasesactivitiesofmyocardium,mostnotably,physicalexerciseorconditioncausingelevationofheartrateLowbloodsupplyconstrictionofcoronaryarteriesanatomicallyorhemodynamicallyMyocardialIschemiaoccurstransientlyinrelationshipofthealterationofthebalancebetweendemandandsupply,MechanismofMyocardialIschemia,DemandHRDoubleProduct,SupplyStenosisVesselConstriction,MentalStress-InducedMyocardialIschemicActivity,Myocardialischemiainducedinthelaboratoryis,ingeneral,basedonthemechanismofincreasingmyocardiumdemand,i.e.highsystolicbloodpressureandrapidheartrate;bymeansofexerciseorpharmacologicalinterventionMyocardialischemiaoccursduringdailylivingnotnecessarilyrelatedtoincreasedphysicalintensity,itoccursduringmentalactivitiesaswellMyocardialIschemiamaybedetectedbyelectrocardiograminthelaboratoryandduringdailyliving,andmyocardiumimaginginlaboratorysettingOccurrenceofmyocardialischemiaisassociatedwithpoorerprognosisinpatientswithcoronaryarterydisease,MentalStress-InducedMyocardialIschemicActivity,BarryJetal.AmJCardiol1988;61:989-93,Totalof372ischemicepisodes,MentalStressTasks,CommonlyUtilizedMentalTasksinLaboratorySetting:MentalArithmeticPublicSpeechMirrorTraceStroopColorWordReadingTypeAPersonalityInterviewStartwithabriefintroduction,followedbya30-secondpreparation.Thetaskslast3-5minutes,MentalStress-InducedMyocardialIschemicActivity,Deanfieldetal.Lancet1984;92:2102-8,Deanfieldetal.Lancet1984;92:2102-8,MentalStress-InducedMyocardialIschemicActivity,AcomparativestudyamongpatientswithpositiveexercisetestingandnormalcontrolswithlowIHDprobability,Rozanskietal.NEJM1988;318:1005,*ThoseabnormalitiesoccurredexclusivelyinassociationwithLVWMA,MentalStress-InducedMyocardialIschemicActivity,ScintographicallyRecordedResponsestoExerciseandMentalArithmetictesting,Giubbinietal.Circulation1991;83:II100,MentalStress-InducedMyocardialIschemicActivity,Blumenthal92:2102-8,Flowmal-distribution,Hypoperfusion,Diastolicdysfunction,Systolicdysfunction,ECGchanges,Angina,PerfusionImaging,Echocardiography,TissueDopplerEcho,CascadeofMyocardialIschemia,MentalStress-InducedMyocardialIschemicActivity,MentalstressinducedmyocardialischemiausuallyasymptomaticMSIMIdoesnothavetooccurinpatientswithoutsignificantstenosisofcoronaryarteriesPatientswithmentalstressinducedischemiahadincreasedriskfordeathorrevascularizationsovera5-yearfollow-up,especiallyforthosewhoserestingLVEF60%Neitherexerciseinducedischemianorischemicactivitiesdetectedduringdailylivingwasassociatedwithincreasedpooroutcomeinthesamegroupofpatients.,JiangWetal.JAMA2019;275:1651-6,MentalStress-InducedMyocardialIschemicActivity,Whathappensemotionallywhenpatientsexhibiteddailyischemiawhichisnotrelatedtophysicalactivityormyocardialischemiaduringmentalstresstesting?,MentalStress-InducedMyocardialIschemicActivity,Gullette,Eetal,JAMA2019;277:1521-1526,PercentageofhourswithIschemiaandLevelofEmotion,MentalStress-InducedMyocardialIschemicActivity,EmotionalResponsestoMentalStressandExerciseTesting,DepressionandMortalityPostMyocardialinfarction(N=222),MentalStress-InducedMyocardialIschemicActivity-apotentialmechanism,Arepatientswithdepressionmorelikelytoexperiencementalstress-inducedischemia?,MentalStress-InducedMyocardialIschemicActivity,PercentageofPatientsDevelopedWMADuringMentalStressTesting,MentalStress-InducedMyocardialIschemicActivity,RelationshipofDepressiveSymptomatologyandMentalStressInducedWMA,MentalStress-InducedMyocardialIschemicActivity,EstimatedRRofDepressionfortheLikelihoodofMSIMI,Kop.PsychosomaticMedicine2019;61:476-487,MentalStress-InducedMyocardialIschemicActivity,Hemo-dynamicresponsestomentalstressandexercise,MentalStress-InducedMyocardialIschemicActivity,RozanskiAetal.NengJmed1988;318:1005-12,MentalStress-InducedMyocardialIschemicActivity,SBPReaction,BlumenthalJAetal.Circulation2019;92:2102-8,MentalStress-InducedMyocardialIschemicActivity,DBPReaction,BlumenthalJAetal.Circulation2019;92:2102-8,MentalStress-InducedMyocardialIschemicActivity,HRReaction,BlumenthalJAetal.Circulation2019;92:2102-8,MentalStress-InducedMyocardialIschemicActivity,Double-product=SBPxHR_anindicatorofmyocardiumdemand,MentalStress-InducedMyocardialIschemicActivity,UniquenessofCoronaryCirculation,Epicardialcoronaryarteriesgiveoffsmalltranmuralpenetratingarteriesintothemyocardiallayers,i.e.arterioleswhichterminatesincapillaryvesselsthatdirectlysupplycardialmyocytes.Non-stenosedepicardialcoronaryarteryplaysaminorroleintheregulationofcoronaryvascularresistanceMostoftheresistancearisesfromcoronaryarterioleswhichopposescoronarybloodflow,Microcirculation,DistributionofCoronaryResistanceinCoronaryBed,Inresponsetovesselwallinjury,alterationsofbloodflow(shearstress),orchemicalstimuli(eg,thrombinorcatecholamines),plateletsmanifestaseriesoflinkedfunctionalresponses(ie,adhesion,secretion,andaggregation)ThesurfaceofactivatedplateletsexpressesprocoagulantphospholipidsandbindingsitesforFVandFVIIIthatconstitutetheplateletcoagulationactivityreferredtoasplateletfactor3HemostaticfunctioniscloselyrelatedtovWF,thatisstoredinendothelialcellsandplatelets.vWFiscrucialforbothplateletadhesiontoinjuredsubendothelialstructuresandplateletaggregation.Inaddition,vWFbindstoandprotectsFVIIIfromproteolysis,HomeostasisPathways,DisturbedHomeostasis,Ahypercoagulablestatepriortoovertthrombosisresultingfromanimbalancebetweenthecoagulationandfibrinolysissystemsisrelatedtocardiovasculardiseaseprogressionandacutecoronarysyndromes,DisturbedHomeostasis,Searchofliteratureoncoagulation,anticoagulation,andfibrinolysismeasuresinconjunctionwithmentalstress,psychosocialstrain,andpsychiatricdisordersinMEDLINEfrom1966conducted,identifying68articles.,DisturbedHomeostasis,Inhealthysubjects,acutementalstresssimultaneouslyactivatescoagulation(ie,fibrinogenorvWF)andfibrinolysis(ie,tissue-typePA)withinaphysiologicalrange.Inpatientswithatherosclerosisandimpairedendothelialanticoagulantfunction,however,procoagulantresponsestoacutestressorsmayoutweighanticoagulantmechanismsandtherebypromoteahypercoagulablestate.Chronicpsychosocialstressors(jobstrainorlowsocioeconomicstatus)arerelatedtoahypercoagulablestatereflectedbyincreasedprocoagulantmolecules(ie,fibrinogenorfactorVII)andbyreducedfibrinolyticcapacity.Thereisalsosomeevidencethatpointstohypercoagulabilityindepression.,MentalStress-InducedMyocardialIschemicActivity,Significantcoronaryvasoconstrictionwasobservedwheninfusingacetylcholineduringmentalstresstesting_YeungACetal,NEngJMed1991;325:1551-6BoltwoodMDetal,AmJCardiol1993;72:1361-5Coronarycirculationwasobservedtofailtodilateduringmentalstresstesting_DakakNetal,AmJCardiol2019;76:125-30,Stress,StressinChinesemeansPressureBBusehavenoeffect_Jainetal.AmJCardiol2019;76:31Overa5-yearf/u,MSIMIwasassociatedwithincreasedcardiaceventsduringa5-yearfollow-up(OR2.8;95%CI1.0-7.7),independentofage,historyofpriormyocardialinfarction,andbaselinecardiacfunction.However,exercise-inducedischemiadidnotpredictforadversecardiacevents(OR,1.5;95%CI,0.6-3.9)inthesamesample_Jiangetal.JAMA2019;275:1651-6Neworworsenedwallmotionabnormalitiesduringthespeechtestissignificantlypredicteddeath(OR3.0;95%CI,1.04to8.36)over5-year_Shepsetal.Circulation2019;105:1780,ThreatofEmotionalDistress,ImplicatedtherapeuticmodalityislimitedBetablocker:maybehelpfulamongoneswi