Anxiety and hemodynamic reactivity during cardiac stress testing: The role of gender and age in myocardial ischemia

Maria T Bekendam, Paula M C Mommersteeg, Willem J Kop, Jos W Widdershoven, Ilse A C Vermeltfoort, Maria T Bekendam, Paula M C Mommersteeg, Willem J Kop, Jos W Widdershoven, Ilse A C Vermeltfoort

Abstract

Background: The prevalence of myocardial ischemia is associated with anxiety. State and trait anxiety are more common in younger women compared to men, and high anxiety levels could affect hemodynamic reactivity during cardiac stress testing. The aim is to examine whether anxiety plays a role in gender differences in patients ≤ 65 and > 65 years in hemodynamic reactivity and ischemia during cardiac stress testing.

Methods and results: Included were 291 patients (66.8 ± 8.7 years, 45% women) with suspect ischemia undergoing myocardial perfusion single-photon emission computed tomography (MPI-SPECT). Primary outcomes were semi-quantitative summed difference score (SDS) and summed stress score (SSS), as continuous indicators of myocardial ischemia. Analyses were stratified by age. Trait anxiety was measured using a validated questionnaire (GAD-7) and state anxiety using facial expression analyses software. Overall, trait and state anxiety were not associated with the prevalence of ischemia (N = 107, 36%). A significant interaction was found between gender and trait anxiety in women ≤ 65 years for SDS (F(1,4) = 5.73, P = .019) and SSS (F(1,10) = 6.50, P = .012). This was not found for state anxiety.

Conclusion: SDS and SSS were significantly higher in women younger than 65 years with high trait anxiety. This interaction was not found in men and women over 65 years.

Keywords: Age; Cardiac stress testing; Myocardial ischemia; Sex differences; Trait anxiety.

© 2020. The Author(s).

Figures

Figure 1
Figure 1
Summed Difference Score (SDS, square root transformed) stratified for trait anxiety (high/low), gender and age groups. The presence of ischemia is presented in the bar graphs as % per subgroup
Figure 2
Figure 2
Summed Stress Score (SSS, square root transformed) stratified for trait anxiety (high/low), gender and age groups. The presence of ischemia presented in the bar graphs as % per subgroup

References

    1. O’Brien C, Valsdottir L, Wasfy JH, Strom JB, Secemsky EA, Wang Y, et al. Comparison of 30-day readmission rates after hospitalization for acute myocardial infarction in men versus women. Am J Cardiol. 2017;120:1070–1076.
    1. Levit RD, Reynolds HR, Hochman JS. Cardiovascular disease in young women: A population at risk. Cardiol Rev. 2011;19:60–65.
    1. Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): Case-control study. Lancet. 2004;364:953–962.
    1. Smaardijk VR, Lodder P, Kop WJ, van Gennep B, Maas A, Mommersteeg PMC. Sex- and gender-stratified risks of psychological factors for incident ischemic heart disease: Systematic review and meta-analysis. J Am Heart Assoc. 2019;8:e010859.
    1. Roest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: A meta-analysis. Psychosom Med. 2010;72:563–569.
    1. Nicholson A, Kuper H, Hemingway H. Depression as an aetiologic and prognostic factor in coronary heart disease: A meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J. 2006;27:2763–2774.
    1. Smaardijk VR, Maas AHEM, Lodder P, Kop WJ, Mommersteeg PMC. Sex and gender-stratified risks of psychological factors for adverse clinical outcomes in patients with ischemic heart disease: A systematic review and meta-analysis. Int J Cardiol. 2019;S0167-5273(19):33509.
    1. Davidson KW, Korin MR. Depression and cardiovascular disease: Selected findings, controversies, and clinical implications from 2009. Cleve Clin J Med. 2010;77(Suppl 3):S20–S26.
    1. Lichtman JH, Bigger JT, Jr, Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lespérance F, et al. Depression and coronary heart disease: Recommendations for screening, referral, and treatment: A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Psychiatric Association. Circulation. 2008;118:1768–1775.
    1. Authors/Task Force M. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR) Eur J Prev Cardiol. 2016;23:NP1–NP96.
    1. Olafiranye O, Jean-Louis G, Zizi F, Nunes J, Vincent M. Anxiety and cardiovascular risk: Review of epidemiological and clinical evidence. Mind Brain. 2011;2:32–37.
    1. Roest AM, Martens EJ, de Jonge P, Denollet J. Anxiety and risk of incident coronary heart disease: A meta-analysis. J Am Coll Cardiol. 2010;56:38–46.
    1. Rutledge T, Reis SE, Olson M, Owens J, Kelsey SF, Pepine CJ, et al. History of anxiety disorders is associated with a decreased likelihood of angiographic coronary artery disease in women with chest pain: The WISE study. J Am Coll Cardiol. 2001;37:780–785.
    1. Rutledge T, Linke SE, Krantz DS, Johnson BD, Bittner V, Eastwood J-A, et al. Comorbid depression and anxiety symptoms as predictors of cardiovascular events: Results from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study. Psychosom Med. 2009;71:958–964.
    1. Bangasser DA, Valentino RJ. Sex differences in stress-related psychiatric disorders: Neurobiological perspectives. Front Neuroendocrinol. 2014;35:303–319.
    1. Altemus M, Sarvaiya N, Neill Epperson C. Sex differences in anxiety and depression clinical perspectives. Front Neuroendocrinol. 2014;35:320–330.
    1. Anand SS, Islam S, Rosengren A, Franzosi MG, Steyn K, Yusufali AH, et al. Risk factors for myocardial infarction in women and men: Insights from the INTERHEART study. Eur Heart J. 2008;29:932–940.
    1. Christoph M, Christoph A, Dannemann S, Poitz D, Pfluecke C, Strasser RH, et al. Mental symptoms in patients with cardiac symptoms and normal coronary arteries. Open Heart. 2014;1:e000093.
    1. Hinz A, Kittel J, Karoff M, Daig I. Anxiety and depression in cardiac patients: Age differences and comparisons with the general population. Psychopathology. 2011;44:289–295.
    1. Vaccarino V, Wilmot K, Al Mheid I, Ramadan R, Pimple P, Shah AJ, et al. Sex differences in mental stress-induced myocardial ischemia in patients with coronary heart disease. J Am Heart Assoc. 2016 doi: 10.1161/JAHA.116.003630.
    1. Gebhard C, Messerli M, Lohmann C, Treyer V, Bengs S, Benz DC, et al. Sex and age differences in the association of heart rate responses to adenosine and myocardial ischemia in patients undergoing myocardial perfusion imaging. J Nucl Cardiol. 2018 doi: 10.1007/s12350-018-1276-x.
    1. Gabet A, Danchin N, Juilliere Y, Olie V. Acute coronary syndrome in women: rising hospitalizations in middle-aged French women, 2004-14. Eur Heart J. 2017;38:1060–1065.
    1. Puymirat E, Simon T, Steg PG, Schiele F, Gueret P, Blanchard D, et al. Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction. JAMA. 2012;308:998–1006.
    1. Izadnegahdar M, Singer J, Lee MK, Gao M, Thompson CR, Kopec J, et al. Do younger women fare worse? Sex differences in acute myocardial infarction hospitalization and early mortality rates over ten years. J Womens Health (Larchmt) 2014;23:10–17.
    1. Paine NJ, Bacon SL, Pelletier R, Arsenault A, Diodati JG, Lavoie KL. Do women with anxiety or depression have higher rates of myocardial ischemia during exercise testing than men? Circ Cardiovasc Qual Outcomes. 2016;9:S53–S61.
    1. Vermeltfoort IA, Raijmakers PG, Odekerken DA, Kuijper AF, Zwijnenburg A, Teule GJ. Association between anxiety disorder and the extent of ischemia observed in cardiac syndrome X. J Nucl Cardiol. 2009;16:405–410.
    1. Rutledge T, Kenkre TS, Bittner V, Krantz DS, Thompson DV, Linke SE, et al. Anxiety associations with cardiac symptoms, angiographic disease severity, and healthcare utilization: The NHLBI-sponsored Women’s Ischemia Syndrome Evaluation. Int J Cardiol. 2013;168:2335–2340.
    1. Verkuil B, Brosschot JF, Thayer JF. Cardiac reactivity to and recovery from acute stress: Temporal associations with implicit anxiety. Int J Psychophysiol. 2014;92:85–91.
    1. Fu P, Gibson CJ, Mendes WB, Schembri M, Huang AJ. Anxiety, depressive symptoms, and cardiac autonomic function in perimenopausal and postmenopausal women with hot flashes: A brief report. Menopause. 2018;25:1470–1475.
    1. Clayton JA, Tannenbaum C. Reporting sex, gender, or both in clinical research? JAMA. 2016;316:1863–1864.
    1. Heller EN, DeMan P, Liu YH, Dione DP, Zubal IG, Wackers FJ, et al. Extracardiac activity complicates quantitative cardiac SPECT imaging using a simultaneous transmission-emission approach. J Nucl Med. 1997;38:1882–1890.
    1. Berman DS, Abidov A, Kang X, Hayes SW, Friedman JD, Sciammarella MG, et al. Prognostic validation of a 17-segment score derived from a 20-segment score for myocardial perfusion SPECT interpretation. J Nucl Cardiol. 2004;11:414–423.
    1. Dorbala S, Ananthasubramaniam K, Armstrong IS, Chareonthaitawee P, DePuey EG, Einstein AJ, et al. Single photon emission computed tomography (SPECT) myocardial perfusion imaging guidelines: Instrumentation, acquisition, processing, and interpretation. J Nucl Cardiol. 2018;25:1784–1846.
    1. Neglia D, Rovai D, Caselli C, Pietila M, Teresinska A, Aguade-Bruix S, et al. Detection of significant coronary artery disease by noninvasive anatomical and functional imaging. Circ Cardiovasc Imaging. 2015 doi: 10.1161/CIRCIMAGING.114.002179.
    1. Slomka PJ, Nishina H, Berman DS, Akincioglu C, Abidov A, Friedman JD, et al. Automated quantification of myocardial perfusion SPECT using simplified normal limits. J Nucl Cardiol. 2005;12:66–77.
    1. Lowe B, Decker O, Muller S, Brahler E, Schellberg D, Herzog W, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008;46:266–274.
    1. Lewinski P. Automated facial coding software outperforms people in recognizing neutral faces as neutral from standardized datasets. Front Psychol. 2015;6:1386.
    1. Soares CD, Panuganti PK, Shrivastava A, Aroor S, Keinath KM, Bromagen MC, et al. Experimental pain assessment in patients with poststroke aphasia. Neurology. 2018;91:e793–e799.
    1. Gandolphe MC, Nandrino JL, Delelis G, Ducro C, Lavallee A, Saloppe X, et al. Positive facial expressions during retrieval of self-defining memories. J Integr Neurosci. 2018;17:367–376.
    1. Skiendziel T, Rösch AG, Schultheiss OC. Assessing the convergent validity between the automated emotion recognition software Noldus FaceReader 7 and Facial Action Coding System Scoring. PLoS ONE. 2019;14:e0223905.
    1. Bishop CM. Neural networks for pattern recognition. Oxford: Oxford University Press; 1995.
    1. Ekman P, Keltner D. Universal facial expressions of emotion. In: Segerstrale U, Molnar P, editors. Nonverbal communication: Where nature meets culture. Mahwah: Lawrence Erlbaum Associates; 1997. pp. 27–46.
    1. Arbit B, Azarbal B, Hayes SW, Gransar H, Germano G, Friedman JD, et al. Prognostic contribution of exercise capacity, heart rate recovery, chronotropic incompetence, and myocardial perfusion single-photon emission computerized tomography in the prediction of cardiac death and all-cause mortality. Am J Cardiol. 2015;116:1678–1684.
    1. Bravo PE, Hage FG, Woodham RM, Heo J, Iskandrian AE. Heart rate response to adenosine in patients with diabetes mellitus and normal myocardial perfusion imaging. Am J Cardiol. 2008;102:1103–1106.
    1. Abidov A, Hachamovitch R, Hayes SW, Ng CK, Cohen I, Friedman JD, et al. Prognostic impact of hemodynamic response to adenosine in patients older than age 55 years undergoing vasodilator stress myocardial perfusion study. Circulation. 2003;107:2894–2899.
    1. Barnett SR, Morin RJ, Kiely DK, Gagnon M, Azhar G, Knight EL, et al. Effects of age and gender on autonomic control of blood pressure dynamics. Hypertension (Dallas, Tex : 1979) 1999;33:1195–1200.
    1. Johnston DL, Hodge DO, Hopfenspirger MR, Gibbons RJ. Clinical determinants of hemodynamic and symptomatic responses in 2,000 patients during adenosine scintigraphy. Mayo Clinic Proc. 1998;73:314–320.
    1. De Bondt P, Van de Wiele C, De Sutter J, De Winter F, De Backer G, Dierckx RA. Age- and gender-specific differences in left ventricular cardiac function and volumes determined by gated SPET. Eur J Nucl Med. 2001;28:620–624.
    1. Peix A, Cabrera LO, Padrón K, Rodríguez L, Fernández J, López G, et al. Association between non-perfusion parameters and presence of ischemia in gated-SPECT myocardial perfusion imaging studies. J Nucl Cardiol. 2018;25:609–615.
    1. Narita K, Murata T, Hamada T, Takahashi T, Kosaka H, Yoshida H, et al. Association between trait anxiety and endothelial function observed in elderly males but not in young males. Int Psychogeriatr. 2007;19:947–954.
    1. Friedman BH, Thayer JF. Autonomic balance revisited: panic anxiety and heart rate variability. J Psychosom Res. 1998;44:133–151.
    1. Longhurst JC. Coronary arteriolar vasoconstriction in myocardial ischaemia: Reflexes, sympathetic nervous system, catecholamines. Eur Heart J. 1990;11(Suppl B):43–52.
    1. Rosenberg EL, Ekman P, Jiang W, Babyak M, Coleman RE, Hanson M, et al. Linkages between facial expressions of anger and transient myocardial ischemia in men with coronary artery disease. Emotion. 2001;1:107–115.
    1. Crea F, Battipaglia I, Andreotti F. Sex differences in mechanisms, presentation and management of ischaemic heart disease. Atherosclerosis. 2015;241:157–168.
    1. Pelletier R, Humphries KH, Shimony A, Bacon SL, Lavoie KL, Rabi D, et al. Sex-related differences in access to care among patients with premature acute coronary syndrome. CMAJ. 2014;186:497–504.
    1. Collins SD. Acute myocardial infarction in women: Is there a sex disparity between door-to-balloon time and clinical outcomes? Cardiovasc Revascularization Med. 2012;13:125–127.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren