mental stress and heart rhythm disorders: understanding the … · 2015-05-29 · mental stress and...
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Mental Stress and Heart Rhythm Disorders:
Understanding the Mind-Body Connection
Rachel Lampert, MDYale University School of MedicineAugust 19, 2012
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Disclosures:
Dr. Lampert has received research funding for unrelated studies fromBoston Scientific/GuidantMedtronic, IncSt Jude Medical
Participated in clinical trials funded bySt Jude MedicalMedtronic
Received modest honoria fromBoston Scientific/GuidantMedtronic, Inc
There is no conflict of interest with the subject of today’s talk
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“Direct events often precipitated the disease; the infarct began in one case on climbing a high staircase, in anotherduring an unpleasant conversation, and in a third, duringemotional distress associated with a heated card game”
A quote form the early description of MI published by Obraztsov and Strazhesko in 1910
Coronary occlusion takes place irrespective of thephysical activity performed or the type of rest taken
A quote from a study of the role of effort in precipitating MI publishedby Master in 1960
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From Leor, et al, New England Journal, 1996
Northridge Earthquake: Atherosclerotic Deaths
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Northridge Earthquake: Atherosclerosis-relatedsudden death
From Leor, et al, New England Journal, 1996
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Population Stressors and Cardiovascular Morbidity and Mortality
Athens Earthquake, 1981Lancet 1983
Cardiovascular death
Hanshin-Awaji Earthquake, J Thromb Haemostasis 1995
Cardiovascular and sudden death
Iraqui Missile War (Israel)JAMA 1995Lancet 1991 Acute MI, sudden death
Cardiovascular death
Croatia (Zagreb air raids)Lancet 1992
Acute MI, cardiovascular death
World Cup Soccer—England loses to Argentina
BMJ 2002
Acute MI
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Circadian Variation of Sudden Cardiac Death and Non-Fatal Infarction
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From Lampert, Rosenfeld, Batsford, Lee, McPherson, Circulation 1996
Circadian Variation of Ventricular Tachycardia
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From Lampert, Rosenfeld, Batsford, Lee, McPherson, Circulation 1996
Circadian Variation of Ventricular Tachycardia in aSingle Patient
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Weekly distribution of ICD shocksfrom Peters, Circ 1996
Sun Mon Tues Weds Thurs Fri Sat0
200
400
600
800
1000
1200
ICDShocks683 patientsworking
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Emotional and Physical Precipitants of Ventricular Arrhythmias
From Lampert, Joska, Burg, Batsford, McPherson, Jain , Circulation 2002
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Anger Level: Pre-shock versus control periods
From Lampert, Joska, Burg, Batsford, McPherson, Jain , Circulation 2002
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Electrophysiological Characteristics of Anger-Triggered Arrhythmias
Polymorphic PVC-Initiated
Pause-dependent
0102030405060708090
100Anger-triggered
Non-Anger-triggered
perc
ent
Stopper, Jain, Burg, Joska, McPherson, Batsford, Lampert; Heart Rhythm, 4:268-273
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Non-anger-triggered arrhythmia, sudden onset
Anger-triggered, PVC-initiated
Stopper, Jain, Burg, Joska, McPherson, Batsford, Lampert; Heart Rhythm, 4:268-273
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Anger-triggered, polymorphic, pause-associated arrhythmia
Stopper, Jain, Burg, Joska, McPherson, Batsford, Lampert; Heart Rhythm, 4:268-273
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Appropriate ICD Therapies following 9/11/01
From Steinberg, et al, JACC 2004
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From Toivonen, et al, JACC, 1997
Electrocardiographic repolarization during stress from awakening on alarm call
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Adaptation of the QT Interval to HR: Arousal vs Rest
arousal
rest
From Toivonen, et al, JACC, 1997
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Repolarization changes with mental stress
From Lampert, Shusterman Burg, Lee, Earley, Goldberg, McPherson, Batsford, Soufer, J Cardiovasc Electrophysiology, 2005
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Increase in TWA with stress based on catecholamine response to stress
From Lampert, Shusterman Burg, Lee, Earley, Goldberg, McPherson, Batsford, Soufer, J Cardiovasc Electrophysiology, 2005
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Predictive value of anger-induced TWA
From Lampert, Shusterman, Burg, McPherson, Batsford, Goldberg, Soufer, JACC, 3/09
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Anger-induced TWA and arrhythmia recurrence (cont)
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Effects of Stress on Arrhythmia Inductionin Dogs
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Patient Preparation:IV insertionVEST positionedECG, R-2 pads
MentalArithmetic
VentricularArrhythmia
AngerRecall
VentricularArrhythmia
BP, HR, ECGcatecholamines
Programmedstimulation
30’
VentricularArrhythmia
7-15’
Programmedstimulation
3’Time
Programmedstimulation
7-15’ 3’
Baseline
Changes in Induced Arrhythmias During Mental Stress: Protocol
From Lampert, Jain, Burg, Batsford, McPherson, Circulation 2000
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Change in Tachycardia Inducibility With Mental Stress
“long-short” + 2 PES
BASELINE MENTAL STRESS
CL 500 + 1 PES
CL 400 + 1 PES
CL 500 + 2 PES
CL 400 + 2 PES
CL 500 + 3 PES
CL 400 + 3 PES
“long-short”+ 1 PES
Non-inducible
Beginning of Protocol
End of Protocol
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Alteration of VT CL by anger
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Change in Termination of Induced Arrhythmias With Mental Stress
Self-terminating
ATP success
ATP failure (shock within zone)
ATP acceleration(into next zone)
BASELINE MENTAL STRESS
From Lampert, Jain, Burg, Batsford, McPherson, Circulation 2000
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Alteration of VT termination by anger
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EmotionalStress
PolymorphicVentricularTachycardia
SuddenDeath
IncreasedCatecholamines
HeterogeneityOf Repolarization
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Stress is bad….Does this mean I better not go to the in-laws forthe holidays?
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Changes in Ventricular Tachycardia with Mental Stress: Pigs
form Kirby, Am J Physiol 1991
baseline stress300
320
340
360
380
400
420
440
0
10
20
30
40
50
60
70
control
beta-blocked
Increased Ease of InductionWith stress
Tachycardia Rate (bpm)
perc
ent
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Effects of atenolol andmetoprolol on stress-inducedchanges in heart-ratevariability
From Tuininga, et al, Circulation 1995
baseline (open bars)200 mg metoprolol CR (shaded bars) 100 mg atenolol (filled bars)
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Psychological Intervention after ICD Implantation
Depression Anxiety Psychosocial distress
From Kohn, PACE 2000
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Psychological Intervention and Shocks
From Chevalier, Am Heart J, 2006
CBT
Usual Care
3 months 12 months0
1
2
3
4
5
6Shocks received
3 months 12 months0123456789
Anxiety
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RISTA: Reducing ICD shock-treated arrhythmias
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“Reducing Vulnerability to ICD Shock Treated Ventricular Arrhythmias”
Randomized clinical trial of the effects of a stress reduction intervention (SRT) on the prevalence of shock-treated ventricular arrhythmia among new patients with ICD.
1) SRT will be associated with reduced relative risk of ventriculararrhythmias requiring shock for termination;
2) SRT will be associated with a decrease in arrhythmogenic electrophysiological changes (T-wave alternans) seen in response to acute stress in the laboratory;
3) SRT will be associated with better QOL after ICD implantation.
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“Complementary” Therapies: Reiki
• Reiki – light touch therapy and spiritual healing practice
• Promotes relaxation• Reduces anxiety, perceived
stress, pain severity (Wardell et al, 2001)
• Preliminary studies show autonomic effects (Mackay, 2004)
• Increased use in hospital setting– YNHH Reiki Volunteer
Program• Limited rigorous clinical
research examining physiologic changes
Slide courtesy Rachel Freidman
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Effects of Reiki on autonomic activity early after acute coronary syndrome
Rest n= 23 [Passive Control]Minimal Distraction Environ
Supine, TV off, lights off,no visitors, door closed, DND sign)
Music n = 23 [Active Control]MDE
Music via HeadphonesSlow tempo classical or new age
Reiki n = 23 [Intervention]MDE
Reiki TreatmentStandardized 7 Positions
RANDOMIZATION
Eligible Patients Admitted to CCU/5-2/5-3Inclusion Criteria: ACS within 72 hrs
Exclusion Criteria: A-fib, paced rhythm,symp/psych drugs, unable to give consent
Slide courtesy Rachel Freidman
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Freidman, Burg, Miles, Lee, Lampert, J Am Coll Cardiol, 2010:56:995-6
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Yoga For Internal Cardioverter Defibrillator Patients
by Stefanie C.F. Toise, MPH, PhD candidate
Preliminary Results:(as compared to usual care)
• Lowers shock anxiety
• Improves patient acceptance of device
• Lowers depression
and may reduce shock episode duration
and/or frequency (currently under study)
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Effect of Yoga on Arrhythmia Burden, Anxiety, Depression and Quality of Life in Paroxysmal Atrial
Fibrillation: The ‘YOGA My Heart’ StudyDhanunjaya Lakkireddy, MD, Donita Atkins, RN, Jayasree Pillarisetti, MD, Kay Ryschon, MS, Sudharani
Bommana, M.Phil., Jeanne Drisko, MD, Subba Reddy Vanga, MBBS, MS, Buddhadeb Dawn, MD
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Patients shocked at baseline
From Lampert, Jain, Burg, Batsford, McPherson, Circulation 2000