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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 1
| Issue : 3 | Page : 93-96 |
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The link between brain and heart in mental stress-induced myocardial ischemia
Huan Ma1, Guihao Liu2, Lan Guo1, Qingshan Geng2
1 Department of Cardic Rehabilitation, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, China
2 Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, China
| Date of Web Publication | 17-Jul-2018 |
Correspondence Address:
Dr. Qingshan Geng
Guangdong General Hospital, Guangdong Academy of Medical Sciences, 102 Zhongshan Road, Guangzhou, Guangdong
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_11_17
This article reviewed the epidemiology of coronary heart diseases combined with psychological diseases and noted the ubiquitous presence of coronary diseases combined with psychological diseases. This article also highlights the possible mechanisms underlying the induction of myocardial ischemia by mental stress and proposed that cardiac microvascular diseases may be a key connecting myocardial ischemia induced by mental stress. The clinical manifestations of nonobstructive coronary artery diseases and mental stress-induced myocardial ischemia are found to be similar, and the pathogenic mechanisms exhibit certain consistencies; however, studies on the association between these two diseases have not been reported. This article emphasizes a direction for future studies. Keywords: Brain, heart, mental stress-induced myocardial ischemia
How to cite this article:
Ma H, Liu G, Guo L, Geng Q. The link between brain and heart in mental stress-induced myocardial ischemia. Heart Mind 2017;1:93-6 |
| The Burden of Cardiovascular Disease | |  |
In the 1997 report titled “Meet the challenges of the 21st century,” the World Health Organization proposed the concept of a “health-care crisis,” which meant that the economic growth rate of a country could not bear the speed of the increase of medical expenses.[1] In recent years, the annual growth rate of medical expenses for acute myocardial infarction was 25% in China,[2] which greatly exceeded the growth rate of the gross domestic product. This statistic suggests that China is facing a health-care crisis. A fundamental way to solve this problem is to establish a suitable “prevention-standard treatment-rehabilitation,” a “social-biological-psychological model,”[3] and a “prevention-treatment-control” care system for a patient's entire life and to pay attention to the overall physical and mental health of patients.[4]
| Physiological, Sociological, and Psychological Aspects of Coronary Heart Disease | | |
Coronary heart disease is not only a vascular disease but also it is a social disease. People living in large cities are more likely to have coronary heart diseases.[5],[6] In addition, coronary heart disease is also a psychological disease. Affected patients are usually afflicted with different combinations of psychological problems.[7],[8] Psychological disorders can cause a series of pathophysiological changes in the body, which can aggravate the prognosis of cardiovascular diseases.[9] In the past 40 years, more than 60 studies and a large amount of meta-analyses all confirmed that depression is closely associated with the morbidity and mortality of cardiovascular diseases.[10],[11] Antidepression therapy targeting patients with coronary heart disease combined with depression could improve the long-term prognosis of the disease.[12],[13]
When an individual is under different types of emotional status/mental stress, the heart will react differently. The responses of different people to mental stress are also different. When challenged with the same stimuli, some people will be angry, and some people will not mind; thus, the consequences are different for such individuals. When an individual who has an irritable heart condition is under a high mental stress condition year-round, the adrenaline level in the body is persistently elevated, and myocardial cells experience sustained damage until cardiomyopathy and malignant sudden death occur, which is known as mental stress-induced myocardial injury.[8] A large number of epidemiological surveys have shown that at the late stage of mental disorders, most patients also have symptoms of heart injury.[8],[14] The sympathetic storm also has physical and mental mechanisms. The stock market effect in the US and the demolition effect in China are good examples of this phenomenon. Therefore, mental stress-induced myocardial injury is visible in different aspects of real life.
The heart is a pump-powered organ and possesses endocrine functions.[15] After stimulation, the heart can secrete active substances, such as components of the renin–angiotensin system, vascular peptides, and brain natriuretic peptide. These substances regulate the circulatory system (including the heart) and the metabolic balance of the body through the neuroendocrine system.[16] Under different circumstances, an individual will generate different emotions due to different thought processes, and emotions will cause changes in neuroendocrine metabolism. These changes will manifest in the heart. The mechanism underlying heart changes induced by mental stress is called the “stress-brain-emotion-heart” pattern.
| Potential Molecular Mechanisms Underlying the Stress-Induced Coronary Heart Disease | | |
Because mental stress functions in the heart mainly through the neuroendocrine system in the human body, hormones secreted by endocrine cells function in touch with the receptors on specific cells through the blood circulation. After binding with receptors, hormones can then exert their functions. It was previously shown that these receptors are mainly distributed on microvessels.[17] Therefore, cardiac microvascular diseases may be a key connecting myocardial ischemia induced by mental stress.
Microvessels are secondary blood vessels with inner diameters smaller than 300 μm that are distributed in the myocardium. They are responsible for the regulation of blood flow in myocardial perfusion. Microvessels are not visible to the naked eye and can be assessed using intravascular ultrasound and fractional flow reserve. The understanding of coronary heart disease is a process under continuous development. With the in-depth development of coronary artery interventional technology over the past 20 years, some observations were not consistent with the existing theory – only the visible coronary artery stenosis leads to chest pain while some chest pain patients had negative coronary angiography but slow blood flow. Myocardial biopsies on these patients revealed that the major reason for slow blood flow was myocardial ischemia resulting from microvascular dysfunction.[17],[18] The Grade 5 and above visible large blood vessels in these patients did not have atherosclerotic plaques; however, the microvessels exhibited the first signs of change. Therefore, negative coronary angiography did not mean the absence of coronary heart disease. The understanding of coronary heart disease, therefore, shifted from the traditional obstructive change of the primary blood vessels of the heart to the combination with functional changes in secondary blood vessels (microvessels). Functional changes in coronary arteries usually occur earlier than structural changes,[19] and microvessels play a key role in the functional changes of coronary arteries.[20] The inclusion of myocardial ischemia caused by microvascular diseases in the guidelines indicates that cardiovascular physicians' understanding of the heart has already changed from structural changes to functional changes. The 2013 European Society of Cardiology guidelines noted that stable coronary heart diseases not only include atherosclerotic stenosis but also must consider chest symptoms induced by exercise or stress resulting from microvascular dysfunction and coronary artery spasm. The guidelines noted that even when obstructive coronary heart disease is confirmed, it should also be determined whether the coronary arteries are experiencing microvascular dysfunction or coronary artery spasm.
Nonobstructive coronary heart disease also involves myocardial ischemia; however, its ischemic features are different from those of obstructive coronary heart disease. Nonobstructive disease mainly consists of downstream microvascular changes. Microvascular dysfunction results in a slowing of the blood flow in coronary arteries and reductions in the intraluminal pressure. A particular feature of ischemia of nonobstructive coronary heart disease is punctate ischemia.
Stress-induced heart injury might be behind the slow blood flow in coronary arteries, a phenomenon that is also called left ventricular ballooning syndrome or stress-induced heart disease. Strong emotional attacks in patients will induce sympathetic storms in the body. The effect of a large amount of adrenaline on myocardial cells causes myocardial injury and expansion, thus causing cardiac changes. In unpleasant emotional conditions, emotional issues induce changes in the internal neuroendocrine system, which eventually present as symptoms of heart disease. This extensive disease induces functional changes in the entire body, which represents the association between heart and psychology.
There are a large number of known and unknown psychological problem-induced myocardial injuries. Studies have shown that approximately half of stable coronary heart disease patients had mental stress-induced myocardial injury.[21] People with positive screening results have increased risks for the development of coronary artery events in the future, and their mortality concomitantly increases. Antidepressant treatments could keep approximately 40% of these patients negative;[22] however, the exact molecular mechanisms of their function are yet to be determined.
| Experimental Assessment of Stress-Induced Coronary Heart Disease | | |
Currently, the assessment of mental stress mainly uses a psychology test scale. However, scale assessment is relatively simple and has bias; in contrast, clinical problems are complex and often cannot be solved only with a scale. Therefore, there are unified international methods for the assessment of mental stress-induced myocardial injury.[23] For example, psychological stress tests (i.e., mental arithmetic testing, memories of public speaking, and mirror drawing tests) can be used to actively stimulate patients. After being stimulated by these types of psychological stresses, some individuals will present with transient ischemic signs in their myocardia.[24] Transient ischemia can be assessed using electrocardiograms, color ultrasonic cardiograms, and radionuclide myocardial scans. These methods are used for the quantitation of mental stress-induced myocardial ischemia.
| Stress-Induced Coronary Heart Disease in Traditional Chinese Medicine | | |
Coronary heart disease belongs to the scope of “angina pectoris,” “thoracic obstruction,” and “palpitation” in traditional Chinese medicine, and the location of the disease is at the heart. Traditional Chinese medicine considered that the physiological functions of the heart have two aspects: “heart controls mental activities” and “heart controls blood circulation.” Therefore, coronary heart disease patients have not only pathological changes of circulation of qi and blood but also abnormal behaviors in their spiritual consciousness, such as anxiety, emotional depression, insomnia and dreaminess, irritability, and forgetfulness and dementia. Therefore, coronary heart disease is called the “two-heart disease” and severely affects the quality of life and disease prognosis of patients.
“Heart controls mental activities” refers to the fact that the heart possesses the functions of controlling the physiological activities of systemic organs, limbs, and orifices of sensory organs and the psychological activities of human mental will, cognition, and thinking. Huangdi Neijing, Su Wen, Ling Lan secret code all mentioned that “the heart is the monarch from whom the spirits are derived.” The Principles and Prohibitions for the Medical Profession mentioned that the “heart is the grand master of the organs, which governs the soul and spirit as well as conscious activities.” These statements indicate that the treatment of coronary heart disease should pay attention to the treatment of the “two hearts” simultaneously. The “two-heart” diseases should be treated through the overall adjustment and differentiation of symptoms.
| Conclusion | | |
We suggest a model where mental stress affects the brain like a stressor. The brain then instructs the individual to produce a specific emotion. Emotion induces the release of neuroendocrine. The hormones then exhibit their function through specific receptors in the cardiac microcirculation, thus causing electrophysiological changes in the heart and the occurrence of myocardial ischemia. This process is known as mental stress-induced myocardial ischemia. Currently, there are few studies on the mechanisms underlying the induction of myocardial ischemia by mental stress. The microcirculation may be a key connecting myocardial ischemia induced by mental stress; however, further studies are needed to dis (approve) this hypothesis. In addition, patients with nonobstructive coronary artery diseases have myocardial ischemia, feature signs of myocardial ischemia similar to those of mental stress-induced myocardial ischemia. The causal association between these two conditions still requires further clinical confirmation.
Financial support and sponsorship
The study was supported by the grant (20172072) from Guangdong Provicial Bureau of Traditional Chinese Medicine and the grant (81602848) from The National Natural Science Fund, People's Republic of China.
Conflicts of interest
There are no conflicts of interest.
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