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The Mental Stress Ischemia Prognosis Study: Objectives, Study Design, and Prevalence of Inducible Ischemia

Hammadah, Muhammad MD; Al Mheid, Ibhar MD; Wilmot, Kobina MD; Ramadan, Ronnie MD; Shah, Amit J. MD; Sun, Yan PhD; Pearce, Brad PhD; Garcia, Ernest V. PhD; Kutner, Michael PhD; Bremner, J. Douglas MD; Esteves, Fabio MD; Raggi, Paolo MD; Sheps, David S. MD; Vaccarino, Viola MD, PhD; Quyyumi, Arshed A. MD

doi: 10.1097/PSY.0000000000000442
Original Articles

Objective Mental stress–induced myocardial ischemia (MSIMI) is a common phenomenon in patients with coronary artery disease (CAD), but contemporary studies of its prognostic significance and its underlying pathophysiology are limited.

Methods We prospectively enrolled patients with confirmed CAD in the Mental Stress Ischemia Prognosis Study (MIPS) between 2011 and 2014. All patients underwent mental stress testing using a standardized public speaking task, and ischemia was detected by 99mTc-sestamibi myocardial perfusion imaging. Patients also underwent conventional stress testing for myocardial ischemia (CSIMI) using exercise or pharmacological stress testing. Furthermore, digital microvascular flow, endothelial function, arterial stiffness, and blood sample collections were performed before, during, and after mental stress. Two-year adverse clinical outcomes are being assessed.

Results Six-hundred ninety-five patients completed baseline enrollment in the MIPS. Their mean (standard deviation) age was 62.9 (9.1) years, 72% were men, 30% were African American, and 32% had a history myocardial infarction. The prevalence of MSIMI and CSIMI is 16.1% and 34.7%, respectively. A total of 151 patients (22.9%) had only CSIMI, 28 (4.2%) had only MSIMI, and 78 (11.8%) had both MSIMI and CSIMI. Patients with ischemia had a lower ejection fraction and higher prevalence of previous coronary artery bypass grafting compared with those without inducible ischemia (p < .050). The prevalence of obstructive CAD was not statistically different between patients with and without MSIMI (p = .426); in contrast, it was higher in patients with CSIMI (p < .001).

Conclusions The MIPS data will provide useful information to assess the prognostic significance and underlying mechanisms of MSIMI.

From the Division of Cardiology (Hammadah, Al Mheid, Wilmot, Ramadan, Shah, Vaccarino, Quyyumi), Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology (Shah, Sun, Pearce, Raggi, Vaccarino), Rollins School of Public Health, Emory University, Atlanta, Georgia; Atlanta VA Medical Center (Shah, Bremner), Decatur, Georgia; Department of Radiology (Garcia, Esteves, Raggi), Emory University School of Medicine, Atlanta, Georgia; Department of Biostatistics and Bioinformatics (Kutner), Rollins School of Public Health, Emory University, Atlanta, Georgia; Department of Psychiatry and Behavioral Sciences (Bremner), Emory University School of Medicine; Mazankowski Alberta Heart Institute (Raggi), University of Alberta, Edmonton, Alberta, Canada; and Division of Cardiovascular Medicine (Sheps), Department of Medicine, University of Florida Health Science Center, Jacksonville, Florida.

Address correspondence and reprint requests to Arshed A. Quyyumi, MD, PhD, Emory University, Department of Cardiology, Emory University School of Medicine, 1462 Clifton Rd NE, Suite 507, Atlanta GA 30322. E-mail:

Received for publication April 6, 2016; revision received November 20, 2016.

Copyright © 2017 by American Psychosomatic Society
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