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.





Start 2021 in a Good Night Sleep

Picture source: (Kuehn 2019)

Should you make new year’s resolutions? Many may think the new year’s resolutions are meaningless. Especially after a year of frustration and uncertainty, New year’s resolutions seem less encouraging. A few small and attainable goals could help to provide a sense of purpose and improve our well-being. The most popular goals for new year’s resolutions include exercise more, eat healthier, and get rid of bad habits.

[1]Sleep deprivation is one of the common bad habits in modern society. According to a study in the Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Report, 1 in 3 Americans don’t get enough sleep on a regular basis. To promote optimal health and well-being, the American Academy of Sleep Medicine and the Sleep Research Society recommend at least 7 hours of sleep each night for adults aged 18-60 years old. The adverse effects of sleep deprivation (less than seven hours per day) include obesity(Beccuti and Pannain 2011), diabetes(Shan et al. 2015), high blood pressure(Gangwisch et al. 2006), cardiovascular disease(Nagai, Hoshide, and Kario 2010; Kuehn 2019), stroke, and mental distress(Baglioni et al. 2016). It’s undeniable that having sufficient sleep is essential to our optimal health and well-being. Here are some helpful tips to start your 2021 with a good night’s sleep.

Bedroom: light, noise, and temperature

Research shows artificial light at night can disrupt circadian rhythms and cause adverse effects on sleep(Aulsebrook et al. 2018). A dim bedroom environment can help the body to recognize the time to rest. Electronic devices emit blue lights, many studies show that blocking blue light is beneficial for patients to suffer from insomnia(Janků et al. 2020). Restricting electronic devices before sleep or using blue-light blocking approaches are helpful to maintain a good quality sleep.

Noise can also affect sleep(Basner and McGuire 2018). Try to reduce noise in the bedroom environment could fall asleep faster and minimize disruption during sleep. Both environmental and body temperature impact sleep duration and sleep quality(Troynikov, Watson, and Nawaz 2018). Increased bedroom and body temperature decrease sleep quality. Finding a comfortable temperature for yourself will improve sleep quality. For most people, the desirable bedroom temperature is around 70 ˚F (20 ˚C). Taking a good bath or shower before bed will prepare the body to adjust to a favorable temperature for sleep.

De-stress: mentally and physically

Most of us have experienced some form of insomnia when we have something in our minds. Integrative approaches to insomnia such as mind-body therapies (mindfulness mediation, yoga, tai chi) have been shown beneficial to de-stress the body as well the mind(Zhou, Gardiner, and Bertisch 2017). Exercise is beneficial for the overall well-being, can improve the quality of sleep(Kelley and Kelley 2017). Various approaches can help relax the body and mind, finding your favorite ones requires a little bit of exploration.

Routine: timing and time

We are creatures of habits. Especially when it comes to sleep. Disruption of the circadian clock adversely affects sleep, which causes cardiovascular diseases(Chellappa et al. 2019). Cultivating a wake-up and night-time routine will have profound impacts on the overall performance. When to go to bed is different for everyone. Anecdotally, it’s best to go to bed earlier and wake up early each day. This may not work for everyone’s schedule. Keeping the recommended amount of sleep is more important than strictly enforcing yourself against your circadian clock.

Food and drink

Investigation of the impact of food choice and consumption on sleep is an emerging field. Early clinical studies investigated the effects of certain macronutrients such as carbohydrate, protein or fat on daytime alertness and nighttime sleep. Some popular sleep–promoting foods, such as milk, fatty fish, cherries, and kiwifruit have been reported(St-Onge, Mikic, and Pietrolungo 2016). Avoid late caffeine consumption(Clark and Landolt 2017) and alcohol(Thakkar, Sharma, and Sahota 2015) are common practices to improve sleep quality.

All of the above are potential strategies for sleep improvement. Making small adjustments in your sleep hygiene routine could have a promising outcome. The key is to start small and stick to it until it incorporates into your day-to-day life.


Aulsebrook, Anne E., Therésa M. Jones, Raoul A. Mulder, and John A. Lesku. 2018. “Impacts of Artificial Light at Night on Sleep: A Review and Prospectus.” Journal of Experimental Zoology Part A: Ecological and Integrative Physiology. https://doi.org/10.1002/jez.2189.

Baglioni, Chiara, Svetoslava Nanovska, Wolfram Regen, Kai Spiegelhalder, Bernd Feige, Christoph Nissen, Charles F. Reynolds, and Dieter Riemann. 2016. “Sleep and Mental Disorders: A Meta-Analysis of Polysomnographic Research.” Psychological Bulletin. https://doi.org/10.1037/bul0000053.

Basner, Mathias, and Sarah McGuire. 2018. “WHO Environmental Noise Guidelines for the European Region: A Systematic Review on Environmental Noise and Effects on Sleep.” International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph15030519.

Beccuti, Guglielmo, and Silvana Pannain. 2011. “Sleep and Obesity.” Current Opinion in Clinical Nutrition and Metabolic Care. https://doi.org/10.1097/MCO.0b013e3283479109.

Chellappa, Sarah L., Nina Vujovic, Jonathan S. Williams, and Frank A.J.L. Scheer. 2019. “Impact of Circadian Disruption on Cardiovascular Function and Disease.” Trends in Endocrinology and Metabolism. https://doi.org/10.1016/j.tem.2019.07.008.

Clark, Ian, and Hans Peter Landolt. 2017. “Coffee, Caffeine, and Sleep: A Systematic Review of Epidemiological Studies and Randomized Controlled Trials.” Sleep Medicine Reviews. https://doi.org/10.1016/j.smrv.2016.01.006.

Gangwisch, James E., Steven B. Heymsfield, Bernadette Boden-Albala, Ruud M. Buijs, Felix Kreier, Thomas G. Pickering, Andrew G. Rundle, Gary K. Zammit, and Dolores Malaspina. 2006. “Short Sleep Duration as a Risk Factor for Hypertension: Analyses of the First National Health and Nutrition Examination Survey.” Hypertension. https://doi.org/10.1161/01.HYP.0000217362.34748.e0.

Janků, Karolina, Michal Šmotek, Eva Fárková, and Jana Kopřivová. 2020. “Block the Light and Sleep Well: Evening Blue Light Filtration as a Part of Cognitive Behavioral Therapy for Insomnia.” Chronobiology International. https://doi.org/10.1080/07420528.2019.1692859.

Kelley, George A., and Kristi Sharpe Kelley. 2017. “Exercise and Sleep: A Systematic Review of Previous Meta-Analyses.” Journal of Evidence-Based Medicine. https://doi.org/10.1111/jebm.12236.

Kuehn, Bridget M. 2019. “Sleep Duration Linked to Cardiovascular Disease.” Circulation 139 (21): 2483–84. https://doi.org/10.1161/CIRCULATIONAHA.119.041278.

Nagai, Michiaki, Satoshi Hoshide, and Kazuomi Kario. 2010. “Sleep Duration as a Risk Factor for Cardiovascular Disease- a Review of the Recent Literature.” Current Cardiology Reviews. https://doi.org/10.2174/157340310790231635.

Shan, Zhilei, Hongfei Ma, Manling Xie, Peipei Yan, Yanjun Guo, Wei Bao, Ying Rong, Chandra L. Jackson, Frank B. Hu, and Liegang Liu. 2015. “Sleep Duration and Risk of Type 2 Diabetes: A Meta-Analysis of Prospective Studies.” Diabetes Care. https://doi.org/10.2337/dc14-2073.

St-Onge, Marie Pierre, Anja Mikic, and Cara E. Pietrolungo. 2016. “Effects of Diet on Sleep Quality.” Advances in Nutrition. https://doi.org/10.3945/an.116.012336.

Thakkar, Mahesh M., Rishi Sharma, and Pradeep Sahota. 2015. “Alcohol Disrupts Sleep Homeostasis.” Alcohol. https://doi.org/10.1016/j.alcohol.2014.07.019.

Troynikov, Olga, Christopher G. Watson, and Nazia Nawaz. 2018. “Sleep Environments and Sleep Physiology: A Review.” Journal of Thermal Biology. https://doi.org/10.1016/j.jtherbio.2018.09.012.

Zhou, Eric S., Paula Gardiner, and Suzanne M. Bertisch. 2017. “Integrative Medicine for Insomnia.” Medical Clinics of North America. https://doi.org/10.1016/j.mcna.2017.04.005.

[1] Picture source: (Kuehn 2019)


“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”


March Madness – Dealing with the Stressing of Training

March is synonymous with college basketball, winning brackets (or losing in my case), and general merriment. For those of us in medicine, it may have a different meaning – stresses of matching, winter blues, and a general feeling of being burnt out. For me, March was one of the hardest months to get through in training, despite it being my birthday month.

Living in Massachusetts means long winters and I notice the general spirit of trainees tends to drop during this time. The novelty of winter has grown old, as the holidays have passed and we all seem to anxiously await the spring. The grueling winter days make it challenging to be outdoors, inhibiting us from enjoying our hobbies, and in short, tired of being cold. My friends who have trained or are working in cold climates (i.e Minnesota, Michigan, Wisconsin, Vermont to mention a few) have echoed the same sentiment. My personal interactions with interns and residents are often highlighted by fatigue, decreased empathy towards patients, and a desperate need for “the year to be over.” So, what are the tools we can use to help get through our own March Madness?

Here are a few tips and tricks that have helped me improve my wellbeing.

  • Stress to Strength: Growing up, I played soccer, basketball, tennis, tried picking up running (but limited by jumpers’ knee), and occasionally surfing. Clearly, none of these are great activities if it’s cold outside which caused me to feel claustrophobic in the winters. I instead work out in the hospital gym much more to try to stay active and have a positive outlet for when I am stressed. I often get asked, “what’s a good strategy for me to make it to the gym with our crazy schedule?” I’ve realized not everyone wants to go to the gym before work (which is my routine) but having small, achievable goals is the way to go. For example, try going one day before work, one day after work, and once during the weekend. You don’t need to go every single day to be healthy or stress-free. Having a few days per week in dedicated time slots will help create structure and not make going to work out feel like a chore.
  • Mindfulness: Mindfulness is becoming more popular in the west and for valid reasons. It is the ability to pay attention to the present moment with curiosity, openness, and acceptance. We can exacerbate stress if we ruminate about the past, worry about the future, or even engage in self-criticism; and I have been guilty of all 3. I discovered a great app called “Headspace” that helped me with guided mediation and mindfulness. The app has evolved to help fit nearly everyone’s needs and I have recommended it to several friends/colleagues.
  • Making my list, checking it twice: Trainees have so many tasks they need to complete: pre-rounding, rounding, Epic tasks, notes, discharge summaries, more Epic tasks, case reports, quality improvement projects, and if they have time – grocery shopping. I always keep a list of tasks I need to complete – partly because it helps me stay organized, but also my obsessive-compulsive personality LOVES to cross tasks off the list. If you get overwhelmed with the countless tasks you have to do, start keeping a list. This will help create structure, organization, and improve productivity.


  • Reach Out: We all need to have friends, family, and colleagues to turn to when we are feeling burnt out. Fortunately, many training programs have resources available from their GME office, which are often underutilized. My clinic preceptor (and friend) Dr. Brigid Carlson has invited me out for coffee, dinner with her family, and always welcomes me to speak to her if I am feeling overwhelmed. Knowing I have someone to turn to has helped me not “bottle things up.”

Although March Madness is traditionally stressful with college basketball, it should not be the same for the workplace. With spring on the horizon, many of us feel the stresses of training but there are resources to help us to continue to be successful.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”




“Run, Forrest, Run!” – Effects of Cardiovascular Exercising on Mental Health



If life gave me a box of chocolates, I am pretty sure I would eat them all. As a basic science researcher, I am all too familiar with burn-outs and stress, and more recently to the effects of stress-induced anxiety. So, I started running. I ran when my worries got too overwhelming, I ran when I had a bad day in the lab. Next thing I knew, I was running for pleasure. And this is something I did not see coming, especially because I hated running before!

Long before medications were available or even prescribed for mental or emotional disorders, exercising remained the only prescription for tacking problems of mental health by doctors.1 The AHA recommends 150 minutes of moderate-high intensity aerobic exercising a week for adults. Researchers have found this to improve balance of neurotransmitters and show effects as early as the first thirty minutes.

Here are some evidence-based effects of exercising on mental health –

  1. Stress and anxiety – Chronic stress can shrivel parts of the brain. Exercises have found to reverse this effect and even induce growth of neurons and improve synaptic plasticity in the brain.1,2
  2. Depression – Regular aerobic exercising can improve blood circulation to the brain and it is known to positively influence hypothalamus-pituitary-adrenal axis of the brain. All of this bounce back the balance of neurotransmitters, elevate mood, attenuate stress and fight back fear.3
  3. Addiction – While dealing with addiction, exercising has been shown to give a sense of control. Individuals with a tendency to be obsessive, need to fill a void quickly and exercising has shown to be effective in this regard.
  4. Hormonal fluctuations in women – Hormones estrogen and progesterone play an important role for neurotransmitter in the brain, by providing receptors for them to bind. In some women, this complex pathway can behave in a way that increases aggressive behavior which is found to be dramatically reduced by exercise. Exercising is certainly known to increase levels of tryptophan, the precursor to the happy chemical serotonin. This helps in dealing with the constant fluctuations of hormones during a cycle.1
  5. Attention deficits – Aerobic exercising has been successful with disorders of distractions, improving focus, concentration and memory of a task.

As with any given task, starting it – is always a challenge. If you are someone like me who is a novice at running, or the thought of running itself induces fear and anxiety – then start with small steps. Take a walk, slowly increase that to brisk walking and when you feel comfortable start jogging. It doesn’t necessarily even need to be running – jumping rope, biking, throwing ball – any activity that spikes your heart rate are good.

So, will you run away from your problems?



  1. John Ratey, Spark: The Revolutionary New Science of Exercise and the Brain, ISBN:0316028355
  2. Carek PJ, Laibstain SE, Carek SM, Exercise for the treatment of depression and anxiety. Int J Psychiatry Med. 2011;41(1):15-28.
  3. Toups M, Carmody T, Greer T, Rethorst C, Grannemann B, and Trivedi MH. Exercise is an effective treatment for positive valence symptoms in major depression. J Affect Disord 2017; 209: pp. 188-194





Managing High Blood Pressure by Managing Stress

manage stressWe are faced with a number of changes in our lives. The old saying, “life happens” generally means take the changes as they come and keep it moving. The human body is not equipped to distinguish between distress and eustress. Amazing life changes happens such as getting acknowledged for an accomplishment, passing the preliminary exams for a PhD program, getting the job of your dreams, or even getting the funding you have worked so hard to apply for consideration. Contrarily, changes that can be viewed as less than optimal such as being passed over for a promotion, losing the sole source of your family’s income, death of dreams, and rejection are all sources of stress. Good or bad, these events affect hypertensive rates potentially leading to a more serious chronic illness such as heart attacks, strokes, or even metabolic disease.

Often people, especially scientist and clinicians think their stress is just a way of life and there is nothing that can be done about that constant state. Scientist are always on the hunt for research funding and publishing; while clinicians holds the consequences of a person’s life in each of their decisions. These are significant burdens for a person to hold. It is imperative to manage stress as a means of preventing and treating high blood pressure. It is definitely easier said than done, but attempting these steps to control stress could lead to a better life:

  • Sleep quality and quantity can make a huge difference in managing mental alertness and energy but sleep allows the body time to relax and heal. Quality sleep can aid in the reduction of blood pressure leading to vascular repair.
  • Reiki principles that include meditation enhances muscle and mental relaxation. This include activities such as guided imagery, deep breathing, and massage therapy to act as stress-relievers.
  • Strengthen your social network. Connect with others by taking a class, joining an organization, or participating in a support group.
  • Try to resolve negative situations quickly so they do not fester. It is best to let go of adverse events and interactions; whether it is something that is in or out of your control
  • Don’t be afraid to ask for help from a counselor. Although there is a negative stigma surrounding seeing a therapist they are the best resource for dealing with stressful situations because your spouse, friends, and neighbors generally have as much going on as you and their opinions can be clouded by their own experiences.

I recently started working with a mentor to help with stress and how to interact with individuals to manage stress. As the young adults say, “I like to keep it 100” but often being brutally honest is not received well by the masses. I also made the determination that whether working or interacting on a personal level, I will not extend myself beyond my comfort zone nor will I compromise my values or ethics to fit into anyone’s idea of what I should be doing. Staying true to oneself is among the first steps to happiness and managing blood pressure. I have found that when I over extend myself, my stress level increases and my performance decrease in some areas (namely self care). My life, your life, is not worth negativity. Being that stress is inevitable, I choose the eustress. It is my opinion that this type of stress leads to self happiness and the contribution of the happiness of others.

Thank you for reading this blog. If you would like to share some of your methods for dealing with stress or how you keep your life stress limited, let me know comment or tweet @AnberithaT so we can share ideas.