Vancheri Federico, Longo Giovanni, Vancheri Edoardo, Henein Michael Y
Department of Internal Medicine, S. Elia Hospital, 93100 Caltanissetta, Italy.
Cardiovascular and Interventional Department, S. Elia Hospital, 93100 Caltanissetta, Italy.
J Clin Med. 2022 Jun 10;11(12):3353. doi: 10.3390/jcm11123353.
Epidemiological studies have shown that a substantial proportion of acute coronary events occur in individuals who lack the traditional high-risk cardiovascular (CV) profile. Mental stress is an emerging risk and prognostic factor for coronary artery disease and stroke, independently of conventional risk factors. It is associated with an increased rate of CV events. Acute mental stress may develop as a result of anger, fear, or job strain, as well as consequence of earthquakes or hurricanes. Chronic stress may develop as a result of long-term or repetitive stress exposure, such as job-related stress, low socioeconomic status, financial problems, depression, and type A and type D personality. While the response to acute mental stress may result in acute coronary events, the relationship of chronic stress with increased risk of coronary artery disease (CAD) is mainly due to acceleration of atherosclerosis. Emotionally stressful stimuli are processed by a network of cortical and subcortical brain regions, including the prefrontal cortex, insula, amygdala, hypothalamus, and hippocampus. This system is involved in the interpretation of relevance of environmental stimuli, according to individual's memory, past experience, and current context. The brain transduces the cognitive process of emotional stimuli into hemodynamic, neuroendocrine, and immune changes, called fight or flight response, through the autonomic nervous system and the hypothalamic-pituitary-adrenal axis. These changes may induce transient myocardial ischemia, defined as mental stress-induced myocardial ischemia (MSIMI) in patients with and without significant coronary obstruction. The clinical consequences may be angina, myocardial infarction, arrhythmias, and left ventricular dysfunction. Although MSIMI is associated with a substantial increase in CV mortality, it is usually underestimated because it arises without pain in most cases. MSIMI occurs at lower levels of cardiac work than exercise-induced ischemia, suggesting that the impairment of myocardial blood flow is mainly due to paradoxical coronary vasoconstriction and microvascular dysfunction.
流行病学研究表明，相当一部分急性冠脉事件发生在缺乏传统心血管高风险特征的个体中。精神压力是冠状动脉疾病和中风新出现的风险及预后因素，独立于传统风险因素。它与心血管事件发生率增加有关。急性精神压力可能由愤怒、恐惧、工作压力导致，也可能是地震或飓风等灾害的后果。慢性压力可能因长期或反复暴露于压力之下而产生，如工作相关压力、社会经济地位低下、财务问题、抑郁以及A型和D型人格。虽然对急性精神压力的反应可能导致急性冠脉事件，但慢性压力与冠状动脉疾病（CAD）风险增加的关系主要是由于动脉粥样硬化加速。情绪应激刺激由包括前额叶皮层、脑岛、杏仁核、下丘脑和海马体在内的皮层和皮层下脑区网络进行处理。该系统根据个体的记忆、过往经历和当前情境参与对环境刺激相关性的解读。大脑通过自主神经系统和下丘脑 - 垂体 - 肾上腺轴将情绪刺激的认知过程转化为血液动力学、神经内分泌和免疫变化，即所谓的战斗或逃跑反应。这些变化可能诱发短暂性心肌缺血，在有或没有明显冠状动脉阻塞的患者中称为精神压力诱发的心肌缺血（MSIMI）。临床后果可能是心绞痛、心肌梗死、心律失常和左心室功能障碍。虽然MSIMI与心血管死亡率大幅增加相关，但它通常被低估，因为在大多数情况下它无疼痛发作。MSIMI发生时的心脏工作水平低于运动诱发的缺血，这表明心肌血流受损主要是由于矛盾性冠状动脉血管收缩和微血管功能障碍。
