Mental stress may lead to poor cardiovascular outcomes

The presence of mental-stress-induced myocardial ischemia is associated with an increased risk of cardiovascular death and nonfatal myocardial infarction, as per an interesting study published in JAMA Network by researchers from Emory University.1

Several studies have revealed the correlation between acute mental stress and the onset of myocardial ischemia seen on myocardial perfusion imaging, strengthening the concept of mental stress and coronary heart disease (CHD). These studies parallelly enrolled patients with stable CHD in the Mental Stress Ischemia Prognosis Study (MIPS) and Myocardial Infarction and Mental Stress Study 2(MIMS2). All participants underwent clinical and psychological assessment at baseline, standardized mental stress test, and myocardial perfusion imaging at rest, with mental stress and exercise or pharmacological stress test.

638 and 313 participants were enrolled in MIPS and MIMS2 study, respectively. Mental stress-induced ischemia was seen in 15%(MIPS) and 17%(MIMS2) participants. Over a medial follow up of 5 years, the pooled results of both studies revealed a higher event rate of cardiovascular death or myocardial infarction (6.9 per 100 patient-years) in positive mental stress-induced ischemia compared to those without ischemia (2.6 per 100 patient-years) (HR: 2.5, 95% CI: 1.8-3.5).1 There was an even higher rate in patients with conventional and mental-stress-induced ischemia (8.1 events per 100 patient-years, HR:3.8, 95% CI: 2.6-5.6).  Interestingly, participants with conventional stress ischemia did not have an increased risk of cardiovascular events. The study also revealed statistically significant higher heart failure incidence in patients with mental stress-induced ischemia. 1

The Brain-Heart axis has been an active area of research over the last decade2; the current study further strengthens this correlation. This study differentiates between the ischemia incidence and outcomes based on mental and conventional stress, which has not been reported in prior studies. It is noteworthy that patients with mental stress-induced ischemia have a higher incidence than conventional ischemia. ere have been other studies in the past which have investigated the impact of acute mental stress leading to decline in cardiac function known as Takotsubo cardiomyopathy, or commonly known as broken-heart syndrome.3 Interestingly, a few smaller studies have shown that an ecstatic happiness state can also lead to Takotsubo cardiomyopathy.3 Nevertheless, the acute decline in these scenarios are mostly transient, but, as per the current study effect of mental stress induced ischemia my lead to prolonged adverse outcomes.

Further studies evaluating the screening for mental stress-induced ischemia and potential early interventions can pave the pathway for reducing CHD, thereby strengthening the concept of the Brain-Heart axis.


  1. Vaccarino V, Almuwaqqat Z, Kim JH, et al. Association of Mental Stress–Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease. JAMA. 2021;326(18):1818-1828.
  2. Tahsili-Fahadan P, Geocadin RG. Heart–Brain Axis. Circulation Research. 2017;120(3):559-572.
  3. Lyon AR, Citro R, Schneider B, et al. Pathophysiology of Takotsubo Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol. 2021;77(7):902-921.