Effects of emotional excitement on cardiovascular regulation

Abstract The incidence of adverse cardiovascular events is higher among spectators of exciting sports events, particularly in patients with coronary artery disease (CAD), but the mechanistic link between the events is not known. We assessed the hemodynamic, autonomic function, plasma catecholamines, endothelin-1, interleukin-6, and markers of platelet activation and blood coagulation of enthusiastic male ice hockey spectators with CAD (n=55, 60±9 years) and healthy subjects (n=16, 48±6 years) during Finnish national league ice hockey final play-off matches and on a control day. Blood markers were also measured before and after a maximal exercise test with a bicycle ergometer. Systolic and diastolic blood pressure (BP) were significantly higher one hour before, during, and one hour after the match than on the control day. During the match the highest systolic BP was 180±14 vs. 145±15 and diastolic BP was 103±13 vs. 82±11 mmHg (respectively, p<0.001 for both). Heart rate (HR) was higher throughout the match (p<0.05) and remained elevated two hours after the match (p<0001), and measures of HR variability were decreased during the match (p<0.01). Plasma endothelin-1 (ET-1), interleukin-6 (IL-6) and noradrenaline (NOR) increased during the match (p<0.01 for all), but markers of platelet activation and coagulation remained unchanged. ET-1 did not change during exercise but NOR, adrenaline, IL-6, and markers of platelet activation and blood coagulation increased statistically significantly (p<0.0001 for all). A statistically significantly more marked increase in both endothelin-1 and interleukin-6 was observed in CAD patients compared with healthy subjects during the match (time x group interaction p<0.05 for both). The high-frequency power of R-peak-to-R-peak intervals decreased in CAD patients (p<0.001) but did not change in healthy subjects during the match. Maximal metabolic equivalens (METs) were most strongly correlated with ET-1 response during the match (β =-0.45, partial correlation r=-0.43, p=0.002) when age, body mass index, METs, left ventricular ejection fraction, basal ET-1 and subjective experience of excitement were entered into the model as independent variables in a linear stepwise regression analysis. In conclusion, autonomic reactions and vasoconstriction may partly explain the vulnerability to cardiovascular events caused by this type of leisure-time emotional excitement. Emotional excitement causes concomitant increases in markers reflecting vulnerability to atherosclerotic plaque complications, while physical exercise causes more prominent changes in markers of coagulation. Emotional excitement causes more significant increases of markers of vasoconstriction and acute inflammation and withdrawal of cardiac vagal regulation in patients with CAD than in healthy subjects. Exercise capacity may protect against further cardiovascular events in CAD patients because it is associated with reduced ET-1 release during emotional excitement.Tiivistelmä Jännittävän urheilutapahtuman on havaittu lisäävän sydäntapahtumia erityisesti sepelvaltimotautipotilailla. Syyt eivät ole selvillä. Tutkimuksen kohteena oli jääkiekon mestaruussarjan pudotuspelien seuraamisen vaikutus sekä sepelvaltimotautisten (n=55, 60±9 vuotta) että terveiden (n=16, 48±6 vuotta) jääkiekkofanien verenkiertoon, autonomiseen hermostoon, veren katekolamiinien, endoteliini-1:n (ET-1) ja interleukiini-6:n (IL-6) pitoisuuksiin sekä veren hyytymiseen paikan päällä jäähallissa seurattuna. Muuttujat mitattiin jäähallissa ottelun aikana. Ne mitattiin myös ennen ottelua ja eri päivänä sairaalassa ennen kuntopyörällä tehtyä maksimaalista sydämen kuormitustestiä ja heti sen jälkeen. Sepelvaltimotautipotilaiden ylä- ja alaverenpaineet kohosivat tilastollisesti merkitsevästi tuntia ennen jääkiekkopeliä ja sen aikana, ja ne olivat koholla vielä tunnin ajan pelin jälkeen kontrollipäivään verrattuina. Ottelun aikana yläpaineet olivat 180±14 vs. 145±15 ja alapaineet 103±13 vs. 82±11 mmHg (p<0.001 molemmille painetasoille). Sydämen syke oli korkeampi pelin ajan (p<0.05), ja se pysyi koholla kahden tunnin ajan pelin jälkeen (p<0.001). Lisäksi sykevaihtelu heikentyi pelin aikana (p<0.01) kontrollipäivään verrattuna. Veren ET-1-, IL-6- ja noradrenaliinipitoisuudet (p<0.01) nousivat pelin aikana, mutta veren hyytymistä kuvastavat lukemat säilyivät muuttumattomina. ET-1 ei noussut fyysisessä kuormitustestissä, mutta noradrenaliini- ja adrenaliinipitoisuudet sekä IL-6:n ja veren hyytymistä kuvaavat lukemat kasvoivat tilastollisesti merkitsevästi (p<0.0001). Pelin aikana sepelvaltimotautipotilaiden ET-1 ja IL-6 pitoisuudet kohosivat enemmän kuin terveiden vastaavat arvot (p<0.05). Lisäksi ottelun aikana sydämen sykevaihtelu laski sepelvaltimopotilailla (p<0.001), muttei muuttunut terveillä. Polkupyörätestin maksimaalinen suorituskyky (METs) oli voimakkaasti yhteydessä ET-1 vasteeseen pelin aikana (β =-0.45, r=-0.43, p=0.002), kun ikä, painoindeksi, METs, sydämen supistusvireys, ET-1:n lähtötaso ja koehenkilöiden kokema jännitystaso huomioitiin itsenäisinä muuttujina regressiotyyppisessä tilastolaskennassa. Yhteenvetona todetaan itsenäisesti toimivan hermoston muutosten ja verisuonten supistumisen voivan osittain selittää aiemmin havaitun sydäntapahtumien lisääntymisen tutkimuskohteen tyyppisessä vapaa-ajan tunne-elämyksessä. Jääkiekkopelin jännitys aiheuttaa muutoksia sepelvaltimotautialueiden repeämisherkkyyttä kuvaaviin tekijöihin, kun taas fyysinen rasitus vaikuttaa voimakkaammin veren hyytymistä ilmaiseviin lukemiin. Potilailla jännitys lisäsi enemmän suonten supistuvuutta, akuuttia tulehdusreaktiota ja nosti parasympaattisen hermoston vetäytymistä kuvaavia lukemia terveisiin koehenkilöihin verrattuna. Hyvä suorituskyky voi suojata korkean riskin sepelvaltimotautipotilaita sydäntapahtumilta vähentämällä ET-1:n vapautumista jännityksen aikana

Recovery of rate-pressure product and cardiac mortality in coronary artery disease patients with type 2 diabetes

Abstract Aims: To investigate prognostic significance of post-exercise recovery of rate-pressure product (RPP) in patients with stable coronary artery disease (CAD) and type 2 diabetes (T2D). Methods: Patients with angiographically documented CAD and T2D (n = 697) underwent symptom-limited bicycle exercise test. Exercise capacity (EC), heart rate, blood pressure and RPP responses to peak exercise and recovery (2′ and 5′ after cessation of exercise) were analyzed. Cardiac death was the primary and sudden cardiac death (SCD) secondary endpoint. Results: During a median follow-up of 76 months, 49 cardiac deaths (7.0%) and 28 SCDs (4.0%) were observed. The recovery of RPP at 5′ was the strongest univariate predictor of cardiac death (hazard ratio [HR]: 2.55 per SD decrease, 95%CI: 1.82–3.58, p < 0.001) and SCD (HR: 2.34, 95%CI: 1.51–3.62, p < 0.001). In multivariate analysis, it remained significantly associated to cardiac death and SCD without (HR: 1.66, 95%CI: 1.14–2.41, p < 0.01 and HR: 1.75, 95%CI: 1.08–2.85, p < 0.05, respectively) and with additional adjustment for EC and peak RPP (HR: 1.45, 95%CI: 1.09–1.92, p < 0.05 and HR: 1.52, 95%CI: 1.01–2.27, p < 0.05, respectively). Conclusions: The recovery of RPP after exercise is a potent predictor of cardiac death in patients with CAD and T2D. It provides significant prognostic information beyond EC and peak RPP

Effect of changes in physical activity on risk for cardiac death in patients with coronary artery disease

Abstract Leisure-time physical activity (LTPA) is associated with longevity in patients with coronary artery disease (CAD). However, less is known about prognostic significance of longitudinally assessed LTPA in patients with stable CAD. The present study assessed the relationship between changes in LTPA and cardiac mortality in patients with CAD. Patients with angiographically documented CAD (n = 1,746) underwent clinical examination and echocardiography at the baseline. Lifestyle factors, including LTPA (inactive, irregularly active, active, highly active), were surveyed at baseline and after 2 years’ follow-up. Thereafter, the patients entered the follow-up (median: 4.5 years; first to third quartile: 3.4 to 5.8 years) during which cardiac deaths were registered (n = 68, 3.9%). The patients who remained inactive (n = 114, 18 events, 16%) and became inactive (n = 228, 18 events, 8%) had 7.6- (95% confidence interval [CI] 4.2 to 13.6) and 3.7-fold (95% CI 2.1 to 6.7) univariate risk for cardiac death compared with those who remained at least irregularly active (n = 1,351, 30 events, 2%), respectively. After adjustment for age, gender, body mass index, diabetes, previous myocardial infarction, left ventricular ejection fraction, angina pectoris grading, cardiovascular event during initial 2-year follow-up, smoking and alcohol consumption, the patients who remained inactive and became inactive still had 4.9- (95% CI 2.4 to 9.8, p <0.001) and 2.4-fold (95% CI 1.3 to 4.5, p <0.01) risk for cardiac death, respectively, compared with patients remaining at least irregularly active. In conclusion, LTPA has important prognostic value for cardiac death in patients with stable CAD. Even minor changes in LTPA over 2 years were related to the subsequent risk for cardiac death

Biomarkers as predictors of sudden cardiac death in coronary artery disease patients with preserved left ventricular function (ARTEMIS study)

Abstract Aims: Biomarkers have shown promising results in risk assessment of cardiovascular events. Their role in predicting the risk of sudden cardiac death (SCD) is not well established. We tested the performance of several biomarkers in risk assessment for SCD in patients with coronary artery disease (CAD) and preserved left ventricular function. Methods and results: The study population consisted of 1,946 CAD patients (68% male; mean age 66.9±8.6 yrs; type 2 diabetes (T2D) 43%) enrolled in the ARTEMIS study. The study subjects underwent examinations with echocardiography and measurement of several biomarkers. The primary endpoint of the study was SCD. During the mean follow up of 76±20 months 50 patients experienced SCD. Elevated high sensitive CRP (hs-CRP, p = 0.001), soluble ST2 (sST2, p&lt;0.001), B-type natriuretic peptide (BNP, p&lt;0.001), and highly sensitive TroponinT (hs-TnT, p&lt;0.001) predicted the occurrence of SCD in univariate analysis. Using the optimal cutoff points, elevated sST2 (≥27.45ng/mL; hazard ratio [HR] 2.7; 95%CI 1.4–5.1, p = 0.003) and hs-TnT (≥15 ng/mL; HR 2.9; 95% CI 1.5–5.6, p = 0.002) were the strongest predictors of SCD followed by hs-CRP (HR 2.4; 95% CI 1.3–4.4, p = 0.004) and BNP (HR 1.9; 95% CI 1.0–3.7, p = 0.046) in adjusted analysis. Combination of elevated hs-TnT and sST2 resulted in adjusted HR of 6.4 (95% CI 2.6–15.5, p&lt;0.001). Conclusion: Elevated sST2 and hs-TnT predict the occurrence of SCD among patients with CAD and preserved left ventricular function. The association between sST2, hs-TnT and SCD may be explained by an ongoing myocardial apoptosis followed by fibrosis leading to vulnerability to malignant arrhythmias

Prediabetes and risk for cardiac death among patients with coronary artery disease:the ARTEMIS study

Abstract Objective: To compare cardiac mortality in patients with CAD and prediabetes with that in CAD patients with normal glycemic status and type 2 diabetes. Research design and methods: The Innovation to Reduce Cardiovascular Complications of Diabetes at the Intersection (ARTEMIS) study included patients with CAD after revascularization (79%), optimal medical therapy, or both. Patients had type 2 diabetes (n = 834), impaired glucose tolerance (IGT; n = 314), impaired fasting glucose (IFG; n = 103), or normal glycemic status (n = 697) as defined on the basis of the results of an oral glucose tolerance test. The primary end point was cardiac death. Major adverse cardiac event (MACE: cardiac death, heart failure, or acute coronary syndrome) and all-cause mortality were secondary end points. Results: During a mean ± SD follow-up of 6.3 ± 1.6 years, 101 cardiac deaths, 385 MACEs, and 208 deaths occurred. Patients with IGT tended to have 49% lower adjusted risk for cardiac death (P = 0.069), 32% lower adjusted risk for all-cause mortality (P = 0.076), and 36% lower adjusted risk for MACE (P = 0.011) than patients with type 2 diabetes. The patients with IFG had 82% lower adjusted risk for all-cause mortality (P = 0.015) than the patients with type 2 diabetes, whereas risks for cardiac death and MACE did not differ significantly between the two groups. The adjusted risks for cardiac death, MACE, and all-cause mortality among patients with IGT and IFG did not significantly differ from those risks among patients with normal glycemic status. Conclusions: Cardiac mortality or incidence of MACE in patients with CAD with prediabetes (i.e., IGT or IFG after revascularization, optimal medical therapy, or both) does not differ from those values in patients with normal glycemic status

MANTA versus ProGlide vascular closure devices in transfemoral transcatheter aortic valve implantation

Abstract Background: The MANTA system is a novel vascular closure device (VCD) and its safety and efficacy were compared to the ProGlide VCD in patients undergoing transfemoral transcatheter aortic valve implantation (TAVI). Methods: This is a retrospective study including 222 patients who underwent transfemoral TAVI at three Finnish University Hospitals. The MANTA VCD was used in 107 patients and their outcome was compared with that of 115 patients in whom the arterial access was closed with the ProGlide VCD. Results: VARC-2 VCD failure occurred less frequently in the MANTA cohort (3.7% vs. 7.8%, p = 0.378), but the difference did not reach statistical significance. When adjusted for the introducer outer diameter, the MANTA cohort had similar rates of VARC-2 major vascular complications (9.3% vs. 12.2%, adjusted: p = 0.456), VARC-2 life-threatening/disabling bleeding (9.3% vs. 6.1%, adjusted: p = 0.296) and need of invasive treatment of bleeding (4.7% vs. 7.0%, adjusted: p = 0.416) compared to the ProGlide cohort. Additional VCDs were more frequently needed in the ProGlide cohort (58.3% vs. 1.9%, p < 0.0001). Conclusions: In patients undergoing transfemoral TAVI, the MANTA VCD showed a similar risk of VARC-2 vascular and bleeding complications compared to the ProGlide VCD, but it reduced significantly the need of additional VCDs for completion of hemostasis