Mental Stress and Myocardial Ischemia: Young Women at Risk

Name: Work Video:
Duration: 3 min 30 s
Anita Wokhlu; Carl J. Pepine
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1454, 1578], 'increasingly': [174], 'focused': [175, 1353], 'on': [176, 398, 554, 814, 1239, 1354, 1490, 2278, 2388, 2468, 2509, 2616, 2707, 3300], 'psychosocial': [177, 246, 309, 465, 1303, 1407, 2658], 'or': [178, 439, 445, 466, 898, 1051, 1302, 1385, 1397, 1446, 1474, 1613, 2169, 2200], 'stressors': [180], 'as': [181, 454, 717, 787, 842, 1027, 1410, 1468], 'potential': [182, 1455], 'nontraditional': [183], 'CAD': [184, 211, 339, 413, 497, 551, 987, 1041, 1090, 1189, 1358], 'risk': [185, 203, 515, 1015, 1423, 1430, 1661, 2666], 'conditions.': [186], 'In': [187, 215, 390, 412, 540, 840, 1038, 1093, 1127, 1201, 1223, 2603], 'Psychophysiological': [189, 1812, 1914, 2840], 'Investigations': [190, 1813, 1915, 2006, 2841], 'Ischemia': [193, 235, 724, 1544, 1816, 1863, 1918, 2009, 2441, 2673, 3206, 3272], 'Study,': [194], 'we': [195, 242, 1148], 'found': [196, 243], 'stress–induced': [199, 426, 1079], 'ischemia': [200, 428, 474, 759, 767, 885, 1799, 1946, 1995, 1997, 2086, 2132, 2161, 2245, 2334, 2429, 2547], 'predicted': [201, 293], 'increased': [202, 363, 1014], 'all‐cause': [205, 1801], 'mortality': [206, 294, 1664, 1802, 1853, 2594], 'in': [207, 301, 337, 380, 408, 452, 475, 481, 495, 524, 548, 567, 587, 590, 609, 629, 635, 680, 730, 774, 816, 823, 847, 861, 874, 881, 909, 949, 972, 979, 1040, 1055, 1068, 1082, 1091, 1116, 1168, 1206, 1217, 1256, 1270, 1286, 1294, 1310, 1326, 1348, 1408, 1426, 1458, 1603, 1696, 1700, 1741, 1803, 1904, 1951, 2082, 2087, 2133, 2162, 2203, 2246, 2319, 2330, 2369, 2386, 2424, 2548, 2595, 2762, 2792, 2842, 2886, 2891, 2964, 3039, 3207, 3265, 3331], 'patients': [208, 476, 488, 704, 789, 1042, 1702, 1747, 1804, 1952, 2088, 2134, 2204, 2247, 2331, 2473, 2763], 'exercise‐induced': [213, 1491], 'ischemia.4': [214], 'cohort': [217, 1513], 'symptoms': [221, 993, 1176, 2127, 2590], 'signs': [223, 995], 'ischemic': [225, 303, 318, 997, 1363, 2194, 2598], 'heart': [226, 304, 319, 364, 998, 1209, 2091, 2137, 2250, 2335, 3354], '(mean': [228], 'age': [229, 619], '58': [230], 'from': [232, 928, 1315, 1511, 1524, 1531, 1810, 2338, 2431], "Women's": [234, 1543, 1862, 2672, 3096], 'Syndrome': [236, 1545, 1864, 2442, 2674], 'Evaluation,': [237], 'mostly': [238], 'without': [239, 2167], 'CAD,': [241, 965], 'associations': [244], 'between': [245, 618], 'factors': [247, 310, 1412, 1662, 2667], 'premature': [249, 1164, 1172], 'mortality.5': [250], 'Over': [251], '9.3': [252], 'years,': [253], 'Spielberger': [255], 'Trait': [256], 'Anxiety': [257], 'Index': [258], 'Beck': [260], 'Depression': [261], 'Inventory': [262], 'scores': [263], '(hazard': [264], 'ratio': [265, 272, 287], '1.09,': [266], '95%': [267], 'CI': [268, 274, 289], '1.02–1.15,': [269], 'hazard': [271, 286], '0.86,': [273], '0.78–0.93,': [275], 'respectively)': [276], 'very': [278, 803], 'good': [279], 'self‐rated': [280, 284], '(versus': [282, 1102], 'health,': [285, 391], '0.33,': [288], '0.12–0.96)': [290], 'each': [291], 'independently': [292, 765], 'risk.': [295], 'These': [296, 689, 952], 'results': [297, 927, 1809, 2430, 2712], 'extend': [298], 'prior': [299], 'knowledge': [300, 813], 'female': [302], '/CAD': [306], 'populations.': [307], 'Clearly,': [308], 'link': [311], 'among': [315, 988, 1854, 1992], 'disease,': [320], 'how': [322], 'stress': [324, 342, 350, 360, 393, 533, 715, 727, 762, 795, 1107, 1196, 1259, 1267, 1281, 1288, 1293, 1335, 1367, 1396, 1475, 1510, 1525, 1903, 2159, 2202, 2329, 2467, 2615, 2790], 'uniquely': [325], 'modulates': [326], 'course': [328], 'remains': [332], 'unclear.Physiology': [333], 'Mental': [335, 349, 1797, 2158, 2544, 3042, 3143, 3204, 3275], 'CADIn': [338], 'patients,': [340, 414, 498, 828, 1070], 'well‐described': [345], 'provocateur': [346], 'ischemia.': [348, 938, 1329, 2041, 2171], 'increases': [351, 373], 'oxygen': [353], 'demand.': [354], 'The': [355, 559, 1400, 2610, 3149, 3297], 'physiologic': [356], 'response': [357, 371, 388, 1034, 1364, 2326, 2791], 'encompasses': [361], 'an': [362, 460, 616, 3312], 'rate': [365], 'often': [367], 'peripheral': [369, 1896], 'vasoconstrictor': [370], 'left': [374, 432], 'ventricular': [375, 433], '(LV)': [376], 'afterload.': [377], 'This': [378, 1019, 1247], 'contrast': [381], 'physical': [383, 794], 'exertion': [384, 746], 'where': [385], 'vasodilatory': [387], 'predominates.': [389], 'may': [394, 458, 600, 695, 879, 933, 940, 1020, 1149, 1197, 1274, 1324, 1379, 1405], 'variable': [396], 'effects': [397, 1238, 2464], 'cardiac': [399, 1949, 2470, 2514], 'output': [400], 'occasionally': [403], 'associated': [404, 502, 508, 1012, 1332, 1338, 1484], 'decline': [407], 'LV': [409, 900, 925, 945], 'ejection': [410, 434], 'fraction.6': [411], 'subset': [416], '(20%': [417], '70%)': [419], 'demonstrate': [420, 790, 1360], 'pronounced': [422], 'response,': [423], 'termed': [424], '(MSIMI),': [429], 'defined': [430, 915], 'by': [431, 833, 956, 1006, 1112, 1705, 2758, 3274, 3308], 'fraction': [435], 'reduction': [436], '≥5%,': [437], 'new': [438, 446, 2778], 'worsening': [440], 'regional': [441], 'wall': [442], 'motion': [443], 'abnormalities,': [444], 'perfusion': [448, 583, 838, 889, 1108, 2761], 'defects.7There': [449], 'interest': [451, 978], 'MSIMI': [453, 499, 506, 547, 562, 575, 612, 628, 633, 791, 800, 815, 822, 845, 866, 875, 895, 916, 932, 1026, 1083, 1144, 1285, 1403, 1445, 1453, 1486], 'metric': [456], 'reveal': [459], "individual's": [461], 'cardiovascular': [462, 519, 920, 1074, 1398, 1419, 2323, 2592, 2664], 'vulnerability': [463, 699], 'stressors.': [468], 'Ambulatory': [469], 'electrocardiographic': [470, 492], 'analysis': [471, 581, 754, 835], 'reveals': [472], 'asymptomatic': [473], 'MSIMI.': [478, 738, 1200], 'Exercise': [479], 'testing,': [480], 'contrast,': [482, 841, 1039], 'does': [483], 'not': [484, 1261, 1416, 1607, 3343], 'appear': [485], 'differentiate': [487], 'who': [489, 1359], 'experience': [490], 'ambulatory': [491], 'abnormalities.8': [493], 'Additionally,': [494], 'significantly': [501], 'angina': [504, 2551], 'frequency.9': [505], 'more': [511, 602, 643, 732, 735, 859, 1141], 'doubling': [513], 'major': [517], 'events,': [520], 'mortality.4,': [522], '7MSIMI': [523], 'WomenWhy': [525], 'should': [527, 654], 'propensity': [530, 1401], 'ischemia,': [534], 'unclear.': [539], 'this': [541, 1001, 1462, 1604], 'issue,': [542], 'Vaccarino': [543, 1939, 2034, 2048, 3022, 3137, 3161, 3260], 'et': [544, 819], 'al10': [545], 'investigate': [546], 'focus': [553], '(≤50': [557], 'years).': [558], 'prevalence': [560, 984], 'was': [563, 585, 642, 678, 858], 'only': [564, 1417], 'about': [565, 824], '1': [566], '6,': [568], 'which': [569, 595, 1071, 1470, 1521, 3325], 'less': [571], 'previous': [573], 'reports.': [574], 'frequency': [576], 'measured': [577], 'using': [578, 796, 853], 'quantitative': [579, 751], 'automated': [580], 'defects': [584, 1109], 'greater': [586], 'By': [592, 2727], 'visual': [593, 753, 834], 'analysis,': [594], 'facilitates': [596], 'artifact': [597], 'recognition': [598], 'be': [601, 655, 941, 1022, 1150, 1373, 1380, 1391, 1406], 'representative': [603], 'clinical': [605, 2239], 'practice,': [606], 'sex‐related': [607], 'differences': [608, 744, 832, 873, 1704, 1740, 2081, 2318], 'extent': [610, 1519], 'were': [613, 747], 'still': [614], 'present.Identifying': [615], 'interaction': [617], 'sex,': [621], 'authors': [623], 'characterized': [624, 1005], 'higher': [625, 1188], 'levels': [626], 'young': [631, 639, 667, 1355, 1371, 1501, 1701, 1746], 'women.': [632, 650, 817, 1092, 1155, 1909], 'occurred': [634, 846], 'one': [636, 825], 'third': [637, 826], 'frequent': [644, 860], 'older': [649], 'Although': [651], 'data': [653, 1514, 1670, 2659], 'approached': [656], 'cautiously': [657], 'because': [658], 'small': [661], 'size': [662], 'subgroup': [665, 683, 1183], 'women,': [668, 1096], 'reassuring': [671], 'note': [673, 907], 'similar': [676], 'tendency': [677], 'observed': [679], 'larger': [682, 1512], 'aged': [684], '51': [685], '60': [687], 'years.': [688], 'findings': [690, 808], 'suggest': [691, 784], 'unique': [698, 870], 'stress.In': [702], 'MSIMI,': [706, 741, 913], 'tempting': [709], 'simply': [711], 'dismiss': [712], 'evaluation': [716, 2600], 'submaximal': [719], 'version': [720], 'conventional': [722, 726], 'stress.': [723, 1037], 'testing': [728], 'was,': [729], 'fact,': [731], 'common': [733], 'extensive': [736], 'However,': [739, 923, 1450], 'unlike': [740], 'sex‐based': [743, 831], 'inconsistent': [748], 'when': [749, 924], 'comparing': [750], 'results.': [755], 'Despite': [756], 'general': [757], 'concordance,': [758], 'can': [763], 'occur': [764], 'exercise,': [769], 'been': [772, 976, 1011, 1161, 1414], 'reported': [773, 821], '11%': [775], '29%': [777], 'cohorts.11,': [779], '12,': [780], '13,': [781], '14': [782], 'Others': [783], 'twice': [786], 'many': [788, 1097], 'echocardiographic': [797, 855, 899], 'criteria.14': [798], 'Therefore,': [799], 'different': [804], 'exertional': [806], 'ischemia.These': [807], 'add': [809], 'limited': [812], 'York': [818, 2181, 2259], 'al': [820], 'no': [830, 1438, 1579], 'nuclear': [837], 'studies.15': [839], 'noted': [843], 'above,': [844], 'over': [848], 'half': [849], 'evaluated': [852, 2426], 'mainly': [854], 'criteria': [856], 'men.16Techniques': [864], 'AssessmentIn': [867], 'addition': [868, 1202], 'study': [871, 1754], 'populations,': [872, 1460, 2794], 'across': [876], 'studies': [878, 890, 1061], 'relate,': [880], 'part,': [882], 'assessment': [886], 'modality.': [887], 'Nuclear': [888], 'yield': [891], 'rates': [893], 'radionuclide': [897], 'function': [901, 946, 1273, 2756], 'studies.': [902], 'It': [903], 'relevant': [905], 'prognostic': [910], 'assessments': [911], 'functionally': [914], 'correlates': [917], 'outcomes.4,': [921], '7': [922], 'dysfunction': [926, 1009, 1081, 2512], 'stress,': [929, 1322], 'term': [931], 'overstate': [934], 'role': [936], 'There': [939], 'mechanisms': [942, 2621], 'suppress': [944], 'beyond': [947], 'limitations': [948], 'flow.': [951], 'include': [953], 'those': [954, 1609], 'precipitated': [955], 'dynamic': [957], 'loading,': [958], 'neurohormones,': [959], 'metabolic': [960], 'effects,': [961], 'inflammatory': [963], 'factors.Nonobstructive': [964], 'Response,': [968], 'Microcirculatory': [970], 'Dysfunction': [971], 'WomenRecently,': [973], 'there': [974, 1047, 1436], 'considerable': [977], 'high': [981], 'increasing': [983], 'nonobstructive': [986, 1089, 2375], '(and': [990], 'men)': [991], 'disease.17': [999], 'Within': [1000], 'population,': [1002], 'phenotype': [1004], 'microvascular': [1008, 1029, 1307, 1448, 2417, 2511, 2755], 'outcomes.18': [1018], 'also': [1021, 1062, 1336, 1404, 1422], 'substrate': [1024], 'dilatation': [1030, 1137, 1159], 'normal': [1033, 1905, 2553], 'studied': [1043], 'during': [1044, 1998, 2002], 'tasks,': [1046], 'paradoxical': [1049], 'constriction': [1050], 'failure': [1052], 'dilate': [1054], 'microcirculation.19': [1057], 'Positron': [1058], 'emission': [1059], 'tomography': [1060], 'document': [1063], 'reduced': [1064], 'flow': [1066], 'reserve': [1067], 'portends': [1072], 'worsened': [1073], 'outcomes.20The': [1075], 'model': [1076], 'microcirculatory': [1080], 'fits': [1084], 'current': [1085], 'understanding': [1086], 'symptomatic': [1088], 'affected': [1095], 'whom': [1099], 'CAD),': [1106], 'provoked': [1111], 'pharmacologic': [1113], 'vasodilators,': [1114], 'even': [1115], 'absence': [1118, 1386], 'flow‐limiting': [1120], 'epicardial': [1121], 'disease.': [1122, 1956, 2092, 2138, 2208, 2251, 2476], 'Nonexertional': [1123], 'complaints': [1124], 'common.': [1126], 'so‐called': [1130], '"normal': [1131], 'arteries,"': [1133], 'abnormal': [1134], 'brachial': [1135, 1157], 'flow–mediated': [1136, 1158], '4': [1139], 'times': [1140], 'if': [1143], 'detected.21': [1146], 'Clinically,': [1147], 'able': [1151], 'identify': [1153, 1181], 'Inadequate': [1156], 'linked': [1162], 'onset': [1165, 1173], '"hot': [1166], 'flashes"': [1167], 'middle‐aged': [1169, 1906], 'women;': [1170], 'vasomotor': [1175], 'menopause': [1178], 'seems': [1179], 'younger‐middle‐aged': [1185], 'mortality.22Neurohormonal': [1190], 'hormonal': [1192, 1254], 'responses': [1193, 1900, 2195], 'further': [1198, 1464, 1498], 'elaborate': [1199], 'surges': [1205], 'epinephrine,': [1207], 'its': [1211], 'own': [1212], 'endocrine': [1213], 'functions': [1214], 'effecting': [1215], 'changes': [1216, 1483], 'microcirculation': [1219, 2471], 'endothelial': [1221, 1272, 2618], 'signaling.': [1222], 'addition,': [1224], 'hypothalamic–pituitary–adrenocortical': [1226], 'axis': [1227], 'activated.': [1229], 'Release': [1230], 'cortisol': [1232], 'corticotropin‐releasing': [1234], 'hormone': [1235], 'systemic': [1237], 'inflammation,': [1240], 'microcirculation,': [1241], 'blood': [1242], 'pressure,': [1243], 'platelet': [1245, 1472, 2320], 'function.': [1246], 'complex': [1248], 'combination': [1249], 'events': [1251, 1420, 1950], 'ensures': [1252], 'milieu': [1255], 'situations': [1257], 'temporally': [1262], 'confined': [1263], 'actual': [1266], 'event.': [1268], 'Impairments': [1269], 'linger': [1275], '90': [1276], 'minutes': [1277], 'event.23The': [1282], 'observation': [1283], 'laboratory': [1289], 'underestimates': [1291], 'daily': [1295, 1999], 'life.': [1296], 'Repeated': [1297], 'exposures': [1298], 'stressor': [1304], 'could': [1305, 1390], 'potentiate': [1306], 'dysfunction,': [1308], 'resulting': [1309], 'loss': [1312], 'vasoprotection': [1314], 'endothelium.': [1317], 'Situations': [1318], 'chronic': [1320, 1327], 'therefore,': [1323], 'result': [1325], 'subclinical': [1328], 'Depressed': [1330], 'states': [1331], 'excess': [1340], 'serotonin,': [1341], 'constrictor': [1343], 'microvasculature.Containing': [1346], 'WomenVaccarino': [1350], 'colleagues': [1352], 'heightened': [1362], 'stimulus.': [1368], 'Why': [1369], 'might': [1370], 'prone': [1374], 'MSIMI?': [1376], 'Sex‐specific': [1377], 'hormones': [1378], 'operative,': [1381], 'estrogen,': [1383], 'progesterone,': [1384], 'testosterone,': [1388], 'differentially': [1392], 'modulating': [1393], 'perception': [1394], 'vulnerability.': [1399], 'origin,': [1409], 'predictive': [1415, 2782], 'factor': [1424, 1431], 'development': [1425], 'women.5,': [1427], '24Beyond': [1428], 'traditional': [1429], 'modification': [1432], 'antianginal': [1434], 'therapy,': [1435], 'therapeutic': [1439], 'silver': [1440], 'bullet': [1441], 'treat': [1443], 'either': [1444], 'dysfunction.': [1449], 'identification': [1451], 'management': [1456, 1476], 'implications': [1457], 'high‐risk': [1459], 'requires': [1463], 'study.': [1465, 1817, 2011, 2444], 'Treatments': [1466], 'such': [1467], 'escitalopram,': [1469], 'impacts': [1471], 'aggregability,': [1473], 'techniques': [1477], 'emerged': [1479], 'target': [1481], 'pathophysiological': [1482], 'negligible': [1488], 'impact': [1489, 2611], 'ischemia.25': [1492], 'Some': [1493], 'next': [1494], 'steps': [1495], 'validate': [1499], 'woman': [1502], 'constitute': [1503], 'population': [1505], 'highly': [1506], 'vulnerable': [1507], 'sets': [1515], 'assess': [1517], 'they': [1522], 'benefit': [1523], 'mitigation': [1526], 'strategies.DisclosuresDr': [1527], 'reports': [1529], 'funding': [1530], 'National': [1533, 2433, 2834], 'Institutes': [1534], 'Health': [1536, 2795, 3089], '(NIH)/National': [1537], 'Heart,': [1538, 2434, 2835], 'Lung': [1539, 2435], 'Blood': [1541, 2437, 2838], 'Institute–sponsored': [1542], 'Evaluation': [1546, 2675], '(WISE),': [1547], 'U01': [1548], 'HLO64829,': [1549], 'WISE': [1551, 2439], 'Coronary': [1552, 2416, 3028], 'Vascular': [1553, 3280], 'Dysfunction,': [1554], 'HL090957;': [1555], 'Patient‐Centered': [1557], 'Outcomes': [1558], 'Research': [1559, 1564], 'Institute': [1560, 2438, 2839], '(PCORI)': [1561], 'OneFlorida': [1562], 'Clinical': [1563], 'Consortium;': [1565], 'NIH/National': [1568], 'Center': [1569], 'Advancing': [1571], 'Translational': [1572], 'Sciences': [1573], 'award': [1574], 'TR001427.': [1575], 'Dr': [1576], 'conflicts': [1580], 'disclose.Footnotes*Correspondence': [1582], 'to:': [1583], 'MD,': [1587], '1600': [1588], 'SW': [1589], 'Archer': [1590], 'Rd,': [1591], 'PO': [1592], 'Box': [1593], '100288,': [1594], '32608.': [1597], 'E‐mail:': [1598], 'carl.[email': [1599], 'protected]ufl.eduThe': [1600], 'opinions': [1601], 'expressed': [1602], 'article': [1605, 3315], 'necessarily': [1608], 'editors': [1612], 'Association.References1': [1618], 'van': [1619, 1622], 'Loo': [1620], 'HM,': [1621, 1736], 'den': [1623], 'Heuvel': [1624], 'ER,': [1625], 'Schoevers': [1626], 'RA,': [1627], 'Anselmino': [1628], 'M,': [1629, 1684, 1938, 2067, 2069, 2115, 2180, 2232, 2262, 2270, 2293, 2359, 2486, 2492, 2687, 2729, 2807, 2909, 2942, 2986, 2998, 3066, 3108, 3166, 3191, 3193, 3223, 3242], 'Carney': [1630, 1771], 'RM,': [1631, 1772], 'Denollet': [1632], 'J,': [1633, 1926, 2027, 2029, 2063, 2119, 2230, 2494, 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