Emotional Triggers of Acute Coronary Syndromes: Strength of Evidence, Biological Processes, and Clinical Implications

doi:10.1016/j.pcad.2006.11.002

Progress in Cardiovascular Diseases

Volume 49, Issue 5, March–April 2007, Pages 353-365

https://doi.org/10.1016/j.pcad.2006.11.002 Get rights and content

Emotional triggers of acute coronary syndromes include population-level events such as earthquakes and terrorist attacks, and individual experiences of acute anger, stress and depression. The methodology of studying emotional triggers has developed markedly over recent years, though limitations remain. The biological processes underlying triggering include acute autonomic dysregulation, neuroendocrine activation, hemostatic and inflammatory responses which, when associated with plaque disruption, promote myocardial ischemia, cardiac dysrhythmia and thrombosis formation. Prevention and management strategies for ameliorating emotional triggering remain to be effectively developed.

Section snippets

Pathophysiological Processes Underlying Emotional Triggering

The key pathological events underlying ACS are the disruption of coronary plaque and the subsequent development of a thrombus. Plaque rupture is the commonest type of disruption, accounting for some 70% of fatal acute MI and SCD.¹⁰ Rupture occurs when the fibrous cap of the plaque is mechanically disturbed or degraded by the action of matrix metalloproteinases released by macrophages. In other cases, thrombus is superimposed on a plaque that is intact except for the loss of the endothelial cell

Methods of Studying Emotional Triggers

Emotional triggering of ACS is difficult to study prospectively because this would involve identifying patients at high risk and monitoring their activities and feelings over an indefinite period in the expectation that a cardiac event might occur at some point. Data collection is therefore typically retrospective. Two broad strategies are used. The first is to investigate the impact on ACS admissions or SCD of stressful events that affect large numbers of people, such as natural disasters,

Earthquakes

Rates of cardiac events after earthquakes have been studied in the United States, Japan, Australia, and Europe. Living through an earthquake is a devastating experience, but it is important to distinguish between the effects of stress and responses to sudden physical exertion (eg, running away from buildings), direct injury, or trauma. The impact of earthquakes on ACS onset has not been completely consistent. The most systematic analyses have been those of the Northridge Earthquake that took

Individual Emotional Experiences

Early research involved collating reports from patients soon after their hospital admission. The incidence of emotional triggers varied widely between studies. For example, the Multicenter Investigation of Limitation of Infarct Size study involved 849 patients with acute MI interviewed within 18 hours of symptom onset, of whom 18% reported emotional upset.⁶² The pilot stage of the Triggers and Mechanisms of Myocardial Infarction study included 224 patients with acute MI, 35% of whom reported

Underlying Biological Mechanisms

The processes that theoretically mediate emotional triggering of acute cardiac events have been outlined in Fig 1. Unfortunately, there is little direct evidence as yet documenting the activation of these pathways in ACS. The emotions identified in the triggering literature certainly stimulate relevant biological responses in patients with CAD. For instance, anger recall elicits greater increases in vascular resistance in patients with CAD compared with controls⁸⁴ and vasoconstriction in

Clinical Implications

The clinical implications of identifying emotional stimuli as triggers of ACS are related both to prognosis and prevention. From the prognostic perspective, emotional triggering may imply a special vulnerability to interpersonal events that place certain types of patient at high risk. Such individuals may require special attention. In addition, patients who experience acute depression in the hours immediately preceding ACS symptom onset are more likely to have elevated depression scores after

Conclusions

Studies involving a range of different methodologies provide convergent evidence on the role of emotional stimuli in the acute triggering of ACS. Emotional triggering appears to be more common in people in the lower socioeconomic status. The pathophysiological processes underlying emotional triggering remained to be fully elucidated but include processes that may promote plaque rupture, together with a prothrombotic vascular environment that encourages thrombosis formation, and neuroendocrine

Acknowledgments

This research was supported by the British Heart Foundation.

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We may emphasize, that short periods of strong contraction and expansion of vessels lead to the increase of level of LDL in the blood. Self-dependent restoration of normal level of LDL in blood occurs in the case of restoration of pressure in the limits of numbers, which are specific for particular person, and which don't exceed the physiological standard.
Among patients with long duration of stress, the duration of vasospasm increases. LDL, without having a possibility to crumble, begin to stick together and form the yielding cylindrical plaque. It is characterized by having of not so strong connection with the vascular wall, and maintains only at the expanse of iteration of the vascular wall, it has cylindrical shape, is elastic and yellow. The thickness and length of walls depends on the degree of cross-clamping during the time of formation of yielding cylindrical plaque. In the case of stopping of spasm, yielding cylindrical plaque can resolve slowly.
Among hypotensive and individuals, which have normal pressure, the increase of level of LDL isn't noted. There aren't such investigations, where such link was noted. The increasing of level of LDL among these people (especially under the stress) can say about cases of short-term increase of pressure, which could be unnoticed. These patients require pressure monitoring and, accordingly, the adjustment of the state of stress and anger.

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Emotional Triggers of Acute Coronary Syndromes: Strength of Evidence, Biological Processes, and Clinical Implications

Section snippets

Pathophysiological Processes Underlying Emotional Triggering

Methods of Studying Emotional Triggers

Earthquakes

Individual Emotional Experiences

Underlying Biological Mechanisms

Clinical Implications

Conclusions

Acknowledgments

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Prog Cardiovasc Dis

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Lancet

Lancet

Am Heart J

Am J Med Sci

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Lancet

Int J Cardiol

Am J Cardiol

Am J Med

Int J Cardiol

Biol Psychiatry

J Psychosom Res

J Am Coll Cardiol

Am J Cardiol

J Psychiatr Res

Am Heart J

J Am Coll Cardiol

Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique

Psychosom Med

Triggering of acute cardiovascular disease and potential preventive strategies

Circulation

Risk of myocardial infarction and stroke after acute infection or vaccination

N Engl J Med

Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group

N Engl J Med

Triggering of myocardial infarction by cocaine

Circulation

Triggering myocardial infarction by marijuana

Circulation

Heavy meals as a trigger for a first event of the acute coronary syndrome: a case-crossover study

Isr Med Assoc J

From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: part I

Circulation

Inflammation, atherosclerosis, and coronary artery disease

N Engl J Med

Vulnerable atherosclerotic plaque: a multifocal disease

Circulation

Coronary plaque morphology and frequency of ulceration distant from culprit lesions in patients with unstable and stable presentation

Arterioscler Thromb Vasc Biol

From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: part II

Circulation

Psychosocial factors and coronary heart disease: the role of psychoneuroimmunological processes

Effects of psychological stress and psychiatric disorders on blood coagulation and fibrinolysis: a biobehavioral pathway to coronary artery disease?

Psychosom Med

The effect of atherosclerosis on the vasomotor response of coronary arteries to mental stress

N Engl J Med

Effects of acute mental stress and exercise on T-wave alternans in patients with implantable cardioverter defibrillators and controls

Circulation

Effects of psychologic stress on repolarization and relationship to autonomic and hemodynamic factors

J Cardiovasc Electrophysiol

Systematic review of mental stress-induced myocardial ischaemia

Eur Heart J

Ischemic, hemodynamic, and neurohormonal responses to mental and exercise stress. Experience from the Psychophysiological Investigations of Myocardial Ischemia Study (PIMI)

Circulation