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Sex-Specific Association Between Coronary Artery Disease Severity and Myocardial Ischemia Induced by Mental Stress

Almuwaqqat, Zakaria, MD, MPH; Sullivan, Samaah, PhD, MPH; Hammadah, Muhammad, MD; Lima, Bruno B., MD, PhD; Shah, Amit J., MD, MSCR; Abdelhadi, Naser, MD; Fang, Shuyang, MD, MPH; Wilmot, Kobina, MD; Al Mheid, Ibhar, MD; Bremner, J. Douglas, MD; Garcia, Ernest, PhD; Nye, Jonathon A., PhD; Elon, Lisa, MS, MPH; Li, Lian, MPH; O'Neal, Wesley T., MD, MPH; Raggi, Paolo, MD; Quyyumi, Arshed A., MD; Vaccarino, Viola, MD, PhD

doi: 10.1097/PSY.0000000000000636

Objective It is unclear whether mental stress–induced myocardial ischemia (MSIMI) is related to obstructive coronary artery disease (CAD). We examined this question and contrasted results with ischemia induced by conventional stress testing (CSIMI). Because women are more susceptible to ischemia without coronary obstruction than men, we examined sex differences.

Methods We studied 276 patients 61 years and younger with recent myocardial infarction. CAD severity was quantified using the log-transformed Gensini Score (lnGS) and the Sullivan Stenosis Score. Patients underwent myocardial perfusion imaging with mental stress (public speaking) and conventional (exercise or pharmacological) stress testing. MSIMI and CSIMI were defined as a new or worsening perfusion defect.

Results The prevalence of MSIMI was 15% in men and 20% in women. The median GS for patients with MSIMI was 65.0 in men and 28.5 in women. In logistic regression models adjusted for demographic and cardiovascular risk factors, CAD severity was associated with CSIMI in the full sample (odds ratio [OR] = 1.49, 95% [CI], 1.14–1.95, per 1-unit increase in lnGS), with no significant difference by sex. Although CAD severity was not associated with MSIMI in the entire sample, results differed by sex. CAD severity was associated with MSIMI among men (OR = 1.95, 95% CI, 1.13–3.36, per 1-unit increase in lnGS), but not among women (OR = 1.02, 95% CI, 0.74–1.42, p = .042 for interaction). Analysis using Sullivan Stenosis Score yielded similar results.

Conclusions Findings suggest that CAD severity is related to MSIMI in men but not women. MSIMI in women may therefore be driven by alternative mechanisms such as coronary microvascular disease.

From the Department of Epidemiology (Almuwaqqat, Sullivan, Lima, Shah, Fang, Li, O'Neal, Vaccarino), Rollins School of Public Health, Emory University, Atlanta, Georgia; Division of Hospital Medicine (Almuwaqqat), Division of Cardiology, Department of Medicine, (Almuwaqqat, Hammadah, Lima, Shah, Abdelhadi, Wilmot, Al Mheid, O'Neal, Quyyumi, Vaccarino), and Department of Psychiatry and Behavioral Sciences (Bremner), Emory University School of Medicine, Atlanta, Georgia; Atlanta VA Medical Center (Shah, Bremner), Decatur, Georgia; Department of Radiology and Imaging Sciences (Garcia, Nye), Emory University School of Medicine, Atlanta, Georgia; Department of Biostatistics and Bioinformatics (Elon), Rollins School of Public Health, Emory University, Atlanta, Georgia; and Mazankowski Alberta Heart Institute (Raggi), University of Alberta, Edmonton, Canada.

Address correspondence to Viola Vaccarino, MD, PhD, Department of Epidemiology, Emory University, Rollins School of Public Health, 1518 Clifton Rd NE, Rm 3011, Atlanta, GA 30322. E-mail:

Supplemental Content

Received for publication December 26, 2017; revision received July 16, 2018.

Copyright © 2019 by American Psychosomatic Society
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