Stress, Psychological – ABC CARDIOL

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Original Article

Impact of a Stress Reduction, Meditation, and Mindfulness Program in Patients with Chronic Heart Failure: A Randomized Controlled Trial

Vaisnava Nogueira Cavalcante et al. Evandro Tinoco Mesquita Ana Carla Dantas Cavalcanti Jacqueline Sampaio dos Santos Miranda … Paola Pugian Jardim Glaucio Martins da Silva Bandeira Lais Marcelle Rufino Guimarães Isabella Christina Diniz de Lemos Venâncio Nathalia Manoela Condeixa Correa Angela Maria Rodrigues Dantas João Carlos Tress Ana Catarina Romano Fabiana Bergamin Muccillo Marina Einstoss Barbosa Siqueira Glaucia Cristina Andrade Vieira

Abstract

Background

Heart Failure is a significant public health problem leading to a high burden of physical and psychological symptoms despite optimized therapy.

Objective

To evaluate primarily the impact of a Stress Reduction, Meditation, and Mindfulness Program on stress reduction of patients with Heart Failure.

Methods

A randomized and controlled clinical trial assessed the effect of a stress reduction program compared to conventional multidisciplinary care in two specialized centers in Brazil. The data collection period took place between April and October 2019. Thirty-eight patients were included and allocated to the intervention or control groups. The intervention took place over 8 weeks. The protocol assessed the scales of perceived stress, depression, quality of life, anxiety, mindfulness, quality of sleep, a 6-minute walk test, and biomarkers analyzed by a blinded team, considering a p-value <0.05 statistically significant.

Results

The intervention resulted in a significant reduction in perceived stress from 22.8 ± 4.3 to 14.3 ± 3.8 points in the perceived stress scale-14 items in the intervention group vs. 23.9 ± 4.3 to 25.8 ± 5.4 in the control group (p-value<0.001). A significant improvement in quality of life (p-value=0.013), mindfulness (p-value=0.041), quality of sleep (p-value<0.001), and the 6-minute walk test (p-value=0.004) was also observed in the group under intervention in comparison with the control.

Conclusion

The Stress Reduction, Meditation, and Mindfulness Program effectively reduced perceived stress and improved clinical outcomes in patients with chronic Heart Failure.

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Original Article

Stress in Women with Acute Myocardial Infarction: A Closer Look

Karine Schmidt et al. Aline da Silva Lima Kelly Rocha Schmitt Maria Antonieta Moraes Marcia Moura Schmidt

Abstract

Background:

Women seem to be more susceptible to psychosocial stress than men, and stress is associated with worse outcomes after acute myocardial infarction (AMI).

Objectives:

To investigate whether the female gender is an independent predictor of risk for stress and to compare stress levels between women and men after AMI.

Methods:

Cross-sectional study of a case series. Patients aged 18 to 65 years who were treated for AMI at the study facility between January 2017 and June 2018 were eligible. The presence of stress was assessed using Lipp’s Stress Symptoms Inventory for Adults (ISSL), which categorizes stress into four phases (alertness, resistance, near-exhaustion, and exhaustion), through a list of physical and psychological symptoms. Data were analyzed using SPSS Version 24.0. The significance level was set at p<0.05.

Results:

Of the 330 respondents, 89% of women and 70% of men experienced stress. The female gender was associated with nearly threefold higher odds of experiencing stress (EXP (B)2.79, p = 0.02). Regarding the phases of stress, women were more often in the near-exhaustion and exhaustion phases, while men were more often in the resistance phase.

Conclusions:

This study showed that women are most often in the third and fourth phases of stress, i.e., in situations of long-standing psychosocial stress. These findings can assist in the development of gender-specific strategies for health promotion and disease prevention, aiming to minimize the effects of stress in this population.

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Original Article

Takotsubo Multicenter Registry (REMUTA) – Clinical Aspects, In-Hospital Outcomes, and Long-Term Mortality

Gustavo Luiz Gouvêa de Almeida Junior et al. João Mansur Filho Denilson Campos de Albuquerque Sergio Salles Xavier … Álvaro Pontes Elias Pimentel Gouvêa Alexandre Bahia Barreiras Martins Nágela S. V. Nunes Lilian Vieira Carestiato João Luiz Fernandes Petriz Armando Márcio Gonçalves Santos Bruno Santana Bandeira Bárbara Elaine de Jesus Abufaiad Luciana da Camara Pacheco Maurício Sales de Oliveira Paulo Eduardo Campana Ribeiro Filho Pedro Paulo Nogueres Sampaio Gustavo Salgado Duque Luiz Felipe Camillis André Casarsa Marques Francisco Carlos Lourenço Jr José Ricardo Palazzo Cláudio Ramos da Costa Bibiana Almeida da Silva Cleverson Neves Zukowski Romulo Ribeiro Garcia Fernanda de Carvalho Zonis Suzana Andressa Morais de Paula Carolina Gravano Ferraz Ferrari Bruno Soares da Silva Rangel Roberto Muniz Ferreira Bárbara Ferreira da Silva Mendes Isabela Ribeiro Carvalho de Castro Leonardo Giglio Gonçalves de Souza Luiz Henrique dos Santos Araújo Alexandre Giani

Abstract

Background

Takotsubo syndrome (TTS) is an acquired form of cardiomyopathy. National Brazilian data on this condition are scarce. The Takotsubo Multicenter Registry (REMUTA) is the first to include multicenter data on this condition in Brazil.

Objective

To describe the clinical characteristics, prognosis, in-hospital treatment, in-hospital mortality, and mortality during 1 year of follow-up.

Methods

This is an observational, retrospective registry study including patients admitted to the hospital with diagnosis of TTS and patients admitted for other reasons who developed this condition. Evaluated outcomes included triggering factor, analysis of exams, use of medications, complications, in-hospital mortality, and mortality during 1 year of follow-up. A significance level of 5% was adopted.

Results

The registry included 169 patients from 12 centers in the state of Rio de Janeiro, Brazil. Mean age was 70.9 ± 14.1 years, and 90.5% of patients were female; 63% of cases were primary TTS, and 37% were secondary. Troponin I was positive in 92.5% of patients, and median BNP was 395 (176.5; 1725). ST-segment elevation was present in 28% of patients. Median left ventricular ejection fraction was 40 (35; 48)%. We observed invasive mechanical ventilation in 25.7% of cases and shock in 17.4%. Mechanical circulatory support was used in 7.7%. In-hospital mortality was 10.6%, and mortality at 1 year of follow-up was 16.5%. Secondary TTS and cardiogenic shock were independent predictors of mortality.

Conclusion

The results of the REMUTA show that TTS is not a benign pathology, as was once thought, especially regarding the secondary TTS group, which has a high rate of complications and mortality. (Arq Bras Cardiol. 2020; 115(2):207-216)

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Clinicoradiological Correlation

Case 1/2020 – Very Accentuated Isthmic Coarctation of the Aorta in a Young Individual with Arterial Hypertension Relieved by Interventional Catheterization

Edmar Atik et al. Raul Santiago Arrieta Renata Cassar

Clinical data

Arterial hypertension had been detected 6 months before, after study-related stress in a 16-year-old individual. At the time, diagnostic images (echocardiography and angiotomography) confirmed the presence of accentuated isthmic coarctation of the aorta, with many collaterals that filled the descending aorta. Blood pressure was 170/80 mmHg, which decreased to 130 to 150/80 mmHg with propranolol-80 mg/day. He had been previously submitted to surgery for atrial septal defect closure at 4 years of age. He reported fatigue at exertion since a few months before.

Physical examination: Good overall status, eupneic, acyanotic, wide pulses in the upper limbs and absent in the lower limbs. Weight: 45.5 Kg, Height: 163 cm, right upper limb BP and left upper limb BP = 155/80 mmHg, HR: 55 bpm. Aorta easily palpated at the suprasternal notch.

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Brief Communication

Takotsubo Syndrome in the Context of Transmural Acute Myocardial Infarction: Prevalence and How to Differentiate?

João Paulo Soares Costa et al. Luiz Eduardo Fonteles Ritt Rafael Modesto Fernandes Felipe Alvarenga Duarte Campos … Queila Borges Eduardo Sahade Darzé

Introduction

Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction culminating in acute cardiac dysfunction. It is frequently preceded by emotional or physical stress.^,

The most common symptoms at presentation are chest pain and dyspnea. Because the presentation of TTS is similar to that of acute coronary syndrome (ACS), the differential diagnosis is difficult, especially from ST-elevation myocardial infarction (STEMI). Absence of coronary artery disease in the affected area must be confirmed to establish the diagnosis of TTS. To facilitate the diagnosis of TTS, the European Society of Cardiology has recently developed the InterTAK diagnostic score, a promising tool that estimates the probability of a TTS event.^,

[…]

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Original Article

Bioprosthesis versus Mechanical Valve Heart Prosthesis: Assessment of Quality of Life

José Carlos Molero Junior et al. Rodrigo Daminello Raimundo, Joice Anaize Tonon do Amaral Luiz Carlos de Abreu João Roberto Breda

Abstract

Background:

The aim of this study was to evaluate the QoL of patients undergoing heart valve replacement using the SF-36 questionnaire, compare it between patients with mechanical prosthesis and patients with bioprosthesis, and correlate the results with sociodemographic variables.

Objective:

To assess the QoL of patients undergoing heart valve replacement and compare it between patients with bioprosthetic valves and patients with mechanical prosthetic valves.

Methods:

We included 36 consecutive patients (16 men) with a mean age of 51 years and six months, who underwent mitral or aortic valve replacement from September 2007 to December 2011. The study was conducted between March and May 2012 and involved the application of the SF-36 survey and a sociodemographic questionnaire. Statistical tests were performed, and data are expressed as absolute frequency and percentile, and median and interquartile range (P25 and P75) (Mann-Whitney test), considering a significance of 95%.

Results:

The average time of surgery was 32.5 months (8-61 months). Participants were asked about the practice of physical activity, and 41.7% were physically active. For the SF-36 domains, the highest scores were observed for the social domain whereas the lowest scores were found for mental health, with a mean of 89.25 and 54.44, respectively. In the statistical analysis, we found statistically higher values in emotional functional for patients with mechanical valve prosthesis (p = 0.0084).

Conclusion:

The QoL of the patients undergoing heart valve replacement improves considerably after the surgery, except for the mental health domain, probably due to the low practice of physical activity. The type of prosthesis seems not to influence the QoL or the patients in the late postoperative period.

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Editorial

Anxiety, Depression, Stress and the Heart: When Measurement Matters

Cristiano Tschiedel Belem da Silva et al. Rafaela Doebber Escobar

The interplay between cardiovascular symptoms and stress has been a matter of concern for centuries. The first known scientific description of panic disorder, for example, which would nowadays be considered a mixture of panic disorder itself, post-traumatic-stress disorder, cardiac arrhythmia and congestive heart failure, took place in a cohort of three hundred patients of a military hospital in Philadelphia (USA). The name of the new diagnostic entity that followed (“irritable heart syndrome” or simply “Da Costa Syndrome,” named after the author of the original description) is rather an indicator of the historical overlap between cardiovascular diseases (CVD) and psychosocial conditions than properly an example of scientific rigor in describing the discovery of a new medical syndrome.

About sixteen years after the description of the irritable heart syndrome, Augustus Waller, a British physiologist, published the first human electrocardiogram (EKG) applying a capillary electrometer and placing electrodes in the chest and back of an individual. More than half a century after Waller’s publication, the 12-Lead EKG – as we know it now – was standardized by the American Heart Association. Since then, EKG is the most important test for the interpretation of cardiac rhythm and for the detection of myocardial ischemia. In sharp contrast with diagnostic developments in Cardiology and despite a whole new era in neuroimaging, no single physiological marker has emerged to help detecting anxiety disorders or depression in Psychiatry. Nonetheless, the degree to which mental disorders are realized within the brain or in the rest of the body is still unclear.

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Editorial

Prenatal Stress: Molecular Mechanisms and Cardiovascular Disease

Marcelo Diarcadia Mariano Cezar et al. Mariana Janini Gomes Ricardo Luiz Damatto

Concern of the researchers in finding the causes of cardiovascular disorders is evident. Recently, scientists are focusing in intrauterine environment investigations in order to seek early causes of these diseases. Studies indicates that prenatal stress increases risk of cardiovascular diseases in adulthood.^, Among the risks, susceptibility to adult hypertension is a concern, and the sympathetic nervous system is one of the targets of interest, specifically the activity of beta-adrenergic receptors, which has subtype β1 cardiac predominance.^, These receptors modulates cardiac changes and may lead to ventricular dysfunction as well as severe conditions of heart failure, which increases mortality risk as showed in hypertensive rats studies.^,

Another factor associated with the occurrence of heart failure is monoamine oxidase A (MAO-A). This enzyme has its activity increased in hypertension and is responsible for the degradation of catecholamine, which increases the reactive oxygen species generation leading to cardiotoxicity. Therefore, it is extremely important target the causes to prevent or attenuate the of alterations resulting from cardiovascular diseases.

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Original Article

Anxiety, Depression, and General Psychological Distress in Patients with Coronary Slow Flow

Mehmet Baran Karataş et al. Ebru Şahan Kazım Serhan Özcan Yiğit Çanga … Barış Güngör Tolga Onuk Göktürk İpek Yasin Çakıllı Emre Arugaslan Osman Bolca

Abstract

Background:

The relationship between psychiatric illness and heart disease has been frequently discussed in the literature. The aim of the present study was to investigate the relationship between anxiety, depression and overall psychological distress, and coronary slow flow (CSF).

Methods:

In total, 44 patients with CSF and a control group of 50 patients with normal coronary arteries (NCA) were prospectively recruited. Clinical data, admission laboratory parameters, and echocardiographic and angiographic characteristics were recorded. Symptom Checklist 90 Revised (SCL-90-R), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) scales were administered to each patient.

Results:

The groups were comparable with respect to age, sex, and atherosclerotic risk factors. In the CSF group, BAI score, BDI score, and general symptom index were significantly higher than controls (13 [18.7] vs. 7.5 [7], p = 0.01; 11 [14.7] vs. 6.5 [7], p = 0.01; 1.76 [0.81] vs. 1.1[0.24], p = 0.01; respectively). Patients with CSF in more than one vessel had the highest test scores. In univariate correlation analysis, mean thrombolysis in myocardial infarction (TIMI) frame counts were positively correlated with BAI (r = 0.56, p = 0.01), BDI (r = 0.47, p = 0.01), and general symptom index (r = 0.65, p = 0.01). The psychiatric tests were not correlated with risk factors for atherosclerosis.

Conclusion:

Our study revealed higher rates of depression, anxiety, and overall psychological distress in patients with CSF. This conclusion warrants further studies.

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Artigo Original

Short and Long-Term Outcome of Stress-Induced Cardiomyopathy: What Can We Expect?

Vânia Filipa Andrade Ribeiro et al. Mariana Vasconcelos Filipa Melão Ester Ferreira … Gracieta Malangatana Maria Júlia Maciel

Background:

Stress-induced/Takotsubo cardiomyopathy (TC) is an increasingly recognized diagnostic entity.

Objective:

This study was aimed to assess the prevalence and clinical predictors of short and long-term outcome of patients (pts) diagnosed with TC.

Methods:

We included all consecutive pts admitted in our department, from November 2006 to August 2011, who met the Mayo Clinic criteria for TC diagnosis.

Results:

We evaluated 37 pts (35 women) with a mean age of 63 ±13 years. TC was precipitated by a stressful emotional event in the majority (57%) and chest pain was the most common symptom (89%). Twelve pts (32%) had ST-segment elevation and 15 pts (41%) had T-wave inversion on the electrocardiogram at admission. Severe left ventricular (LV) dysfunction was found in 16 pts (43%) and the mean troponin I level was 2.6±1.8 ng/mL. The in-hospital complication rate was 30%, with cardiogenic shock being the most common situation. Physical stress, severe LV systolic dysfunction and peak brain natriuretic peptide (BNP) were predictors of acute complications. On the other hand, we found no association between peak troponin I and electrocardiographic presentation. Thirty-five pts were followed for a mean time of 482 ± 512 days, without clinic recurrence.

Conclusion:

In our cohort of pts, TC was associated with a high in-hospital complications rate. Physical stress, LV dysfunction and peak BNP could predict acute adverse outcomes.

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Artigo Original

Psychological characteristics of patients undergoing percutaneous coronary interventions

Márcia M. Schmidt et al. Alexandre S. Quadros Anibal P. Abelin Edson L. Minozzo … Shana H. Wottrich Henrique Z. Kunert Evelyn S. Vigueras Patrícia P. Ruschel Rogério Sarmento-Leite Carlos A. M. Gottschall

BACKGROUND: There is few data evaluating the prevalence and influence of adverse psychological characteristics on the prognosis of individuals submitted to percutaneous coronary interventions. No study has addressed this issue in Brazil. OBJECTIVE: To investigate the prevalence of depression, anxiety, psychological stress, and Type D personality and its association with cardiovascular events in patients undergoing percutaneous coronary interventions. METHODS: Psychological characteristics were evaluated by scales: Beck Depression Inventory, Beck Anxiety Inventory, Lipp Inventory for Stress Symptoms for Adults and Type D Personality Scale. The end-point of this study was the occurrence of major cardiovascular events in one-year follow-up. RESULTS: During March and May 2006, 137 patients were included. Type D personality was identified in 34% of the cases, 29% presented anxiety, 25% presented depression and 70% of the patients presented stress. In relation to the frequency of psychological characteristics according to the occurrence of major adverse cardiovascular events, there was no statistical difference between both groups of patients regarding depression (29% vs. 26% p = 0.8), anxiety (33% vs. 23% p = 0.3), stress (76% vs. 65% p = 0.3), and Type D personality (33% vs. 32% p = 0.9). However, the negative affectivity score was significantly higher in the group of patients presenting events (13.9 vs. 9.8 p = 0.01). CONCLUSION: In patients submitted to percutaneous coronary interventions, the prevalence of adverse psychological characteristics was high. One-year major cardiovascular adverse events were associated with baseline negative affectivity, but not with the other psychological characteristics studied

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Artigo Original

Vitamin C restores blood pressure and vasodilator response during mental stress in obese children

Pricilla Regina Oliveira Fernandes Fernandes et al. Fabio Alexandre dos Santos Lira Vanessa Vieira Lopes Borba Maria José Carvalho Costa … Ivani Credidio Trombeta Maria do Socorro Brasileiro Santos Amilton da Cruz Santos

BACKGROUND: Peripheral vasodilation response plays an important role in the pathophysiology of obesity and heart disease. OBJECTIVE: To evaluate the chronic effect of vitamin C (VitC) supplementation on blood pressure and on vasodilation response to mental stress. METHODS: In a double-blind, randomized and prospective study we evaluated obese children with 8 to 12 years in 2 similar groups: 1) supplemented with 500 mg VitC (n = 11) and 2) placebo (n = 10) for 45 days. Eight age-matched lean control children were also studied. We evaluated: mean blood pressure (MBP), heart rate (HR) and forearm blood flow by venous occlusion plethismography. Forearm vascular conductance (FVC) was calculated by: (forearm blood flow/PAM) X100. RESULTS: On pre-intervention evaluations obese children showed higher MBP and lower FVC compared to lean control children. After intervention VitC diminished MBP at rest (81 ± 2 vs 75 ± 1 mmHg, p = 0.01), whereas placebo did not promote changes in MBP (p = 0.58). In addition, VitC promoted FVC increase at rest (3.40 ± 0.5 vs 5.09 ± 0.6 un, p = 0.04) and during the mental stress (3.92 ± 0.5 vs 6.68 ± 0.9 un, p = 0.03). Moreover, after VitC supplementation FVC levels were similar to the lean control children at rest (5.09 ± 0.6 vs 5.82 ± 0.4 un, p > 0.05) and during mental stress (6.68 ± 0.9 vs 7.35 ± 0.5 un, p > 0.05). CONCLUSION: VitC supplementation reduced the MBP and restored peripheral vasodilatation response during mental stress in obese children.

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Artigo Original

Cardiovascular response to Stroop test: comparison between the computerized and verbal tests

Daniel Fernandes Barbosa et al. Francisco José A. Prada Maria Fátima Glanner Otávio de Toledo Nóbrega Cláudio Córdova

BACKGROUND: The Stroop test requires the individual to respond to specific elements of a stimulus, whereas inhibiting more automated processes. OBJECTIVE: To compare the cardiovascular reactivity induced by the computerized version of the Stroop word-color test TESTINPACS® with the traditional version based on the reading of printed words. METHODS: The sample of convenience consisted of 20 women (22.4 ± 4.1 years). Analyses of variance with repeated measures were used to compare the main effects between the tests (computerized vs verbal), as well as between phases of the test (baseline, Stroop 1, Stroop 3) on the physiological variables (arterial pressure, respiratory sinus arrhythmia, heart failure and respiratory rate). The t tests for paired samples were used to compare the pressure means between Stroop 3 and baseline. Additionally, the magnitude of the effects (d’) was estimated in order to assess the impact of the changes in the physiological measurements between Stroop 3 and the baseline. RESULTS: The two versions of the assessment tool caused significant increase in heart rate (p<0.01) and systolic arterial pressure (p<0.05) when the measurements obtained at the Stroop 3 were compared to that of baseline. However, no significant differences were observed regarding the different versions of the test on the other investigated variables. The d' statistics confirmed the high magnitude of the effects (-1.04 to +1.49) between the measurements from the Stroop 3 and the baseline ones. CONCLUSION: It is concluded that the current computerized version (TESTINPACS TM) of the Stroop test constitutes a useful instrument to induce cardiovascular reactivity in women.

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Case Report

Takotsubo cardiomyopathy causing transitory ventricular dysfunction

Angele A. Alves et al. Ingrid Kowatsch Jeane Mike Tsutsui José C. Nicolau … Marta F. Lima Wilson Mathias Junior

This is the report of a 74-year-old female patient with a history of systemic hypertension and peripheral vascular disease who presented acute coronary syndrome symptoms. Coronary angiography showed coronary arteries with no significant obstructions. Ventriculography and echocardiography showed akinesia in mid and apical segments; and hyperkinesia of left ventricle basal segments. Two weeks after the onset of symptoms, a new echocardiogram demonstrated normal global and regional systolic function. The uncommon, reversible pattern for systolic dysfunction and segmental compromising that gives left ventricle a takostubo-like shape is known today as stress cardiomyopathy.

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Case Report

Broken-heart syndrome (Takotsubo syndrome)

Alessandra Edna Teófilo Lemos et al. Antonio Luiz Junior Araújo Michely Teófilo Lemos Lucia de Souza Belém … Francisco Juarez C. Vasconcelos Filho Raimundo Barbosa Barros

Stress-induced cardiomyopathy, also know as reversible left ventricular apical ballooning, ” Broken-Heart” syndrome, and in Japan, Takotsubo, is characterized by the presence of a transient left ventricular dyskinetic movement of the anterior wall of with hypercontraction of the ventricular basilar segments precipitated by emotional stress. The clinical course of Takotsubo cardiomyopathy is similar to that of an acute myocardial infarct with typical chest pain and electrocardiographic changes, and during the acute phase, coronary angiography is used to distinguish between the two conditions.

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