Mental Stress-Induced Myocardial Ischemia and Cardiovascular Events

Do stress and depression increase your risk of heart attack? Recently, I read with interest correspondence on this topic in JAMA by Dr. Yu-Hsuan Lin from Taiwan and Drs. Viola Vaccarino, J. Douglas Bremner, and Arshed A. Quyyumi from Emory University.

Let’s back up a bit. Back in November 2021, the Emory authors published a paper, a pooled analysis of 2 prospective cohort studies that included 918 participants, on mental-stress induced myocardial ischemia.

Fast forward to last week. Dr. Lin’s letter argued that major depression is also an important psychological risk factor for coronary heart disease. He also stated that the Emory paper was unable to identify new-onset depression prior to cardiovascular events.

Potential mediators of mental-stress-induced myocardial ischemia or depression leading to heart disease include inflammation, dysregulation of autonomic function, and paradoxical vascoconstriction due to endothelial dysfunction.

In reply, the Emory authors agreed with Dr Lin that depression is a potentially important correlate of mental stress-induced myocardial ischemia. They attempted to rule out depression as a confounding factor, but it is possible that study participants who tested positive for ischemia with mental stress went on to develop more depression during follow-up, and that this new-onset depression was involved as a mechanism in their increased risk. However, this mechanism remains speculative.

The bottom line is we are learning more and more about the relationship between the mind and the body. It’s certainly a good idea to avoid depression if you can, because depression causes so much suffering on its own. But the issue of a relationship between mental health and heart disease deserves more study.

I’m interested in this for my patients. But I’m also want to know more about it because my father, Albert Lederer, died suddenly on October 4, 2020, presumably from a cardiac event. I wonder if it was due to conventional risk factors such as hypertension, hyperlipidemia, and vulnerable plaque rupture, or if some of the factors described by Drs. Lin et al might have played a role. COVID has been very difficult for the majority of us and we need to regain our mental health, irrespective of its role in the pathogenesis of cardiovascular disease.

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