Relationship among mental stress-induced ischemia and ischemia during daily life and during exercise: The psychophysiologic investigations of myocardial ischemia (PIMI) study

OBJECTIVES The purposes of this database study were to determine: 1) the relationship between mental stress-induced ischemia and ischemia during daily life and d uring exercise; 2) whether patients who exhibited daily life ischemia exper ienced greater hemodynamic and catecholamine responses to mental or physica l stress than patients who did not exhibit daily life ischemia, and 3) whet her patients who experienced daily life ischemia could be identified on :th e basis of laboratory-induced ischemia using mental or exercise stress test ing. BACKGROUND The relationships between mental stress-induced ischemia in the laboratory and ischemia during daily life and during exercise are unclear. METHODS One hundred ninety-six stable patients with documented coronary disease and a positive exercise test underwent mental stress testing and bicycle exerc ise testing. Radionuclide ventriculography and electrocardiographic (ECC) w ere performed during the mental stress and bicycle tests. Patients underwen t 48 h of ambulatory ECC monitoring Hemodynamic and catecholamine responses were obtained during mental stress and bicycle tests. RESULTS Ischemia (reversible left ventricular dysfunction or ST segment depression greater than or equal to 1 mm) developed in 106 of 183 patients (58%) durin g the mental stress test. There were no significant differences in clinical characteristics of patients with, compared with those without, mental stre ss-induced ischemia. Patients with mental stress ischemia more often had da ily Life ischemia than patients without mental stress ischemia, but their e xercise tests were similar. Patients with daily life ischemia had higher ej ection fraction and cardiac output, and lower systemic vascular resistance during mental stress than patients without daily life ischemia. Blood press ure and catecholamine levels at rest and during the mental stress tests wer e not different in patients with, compared with those without, daily life i schemia. Patients with daily life ischemia had a higher ejection fraction a t rest and at peak bicycle exercise compared with patients without daily li fe ischemia, but were were no other differences in peak hemodynamic or cate cholamine responses to exercise. The presence of ST segment depression duri ng routine daily activities was best predicted by ST segment depression dur ing mental or bicycle exercise stress, although ST segment depression was r are during mental stress. CONCLUSIONS Patients with daily life ischemia exhibit a heightened generalized response to mental stress. ST segment depression in response to mental or exercise stress is more predictive of ST segment depression during routine daily act ivities than other laboratory-based ischemic maskers. Therapeutic managemen t strategies might therefore focus on patients with these physiologic respo nses to stress and on whether lessening such responses reduces ischemia. (C ) 1999 by the American College of Cardiology.