Mental stress: A novel cardiovascular risk factor

Table 1 Some recent studies on the cardiac effects of acute stress

Ref.	Setting	Main results
Mostofsky et al[18], 2014	Systematic review of 9 studies	Despite the heterogeneity, all studies found a higher rate of CV events (heart attacks, strokes, and disturbances in cardiac rhythm) in the 2 hours following outbursts of anger
Walker et al[19], 2016	Healthy participants were monitored during no noise, LF (31.5-125 Hz) or HF (500-2000 Hz) noise exposure scenarios lasting 40 minutes. ECGs were processed for measures of HRV	After adjusting for noise frequency, during LF noise exposure, HF, LF, and SDNN were reduced of 32% (-57, -6.2), 34% (-52, -15), and 16% (-26, -6.1); during HF noise exposure, a 21% (-39, -2.3) reduction in LF was found
Modena et al[24], 2017	Global access of patients who arrived at the ED of the three main hospitals in 2012, when two earthquakes hit the province of Modena and Reggio Emilia, compared with that one detected in the same departments and in the same interval of time in 2010	No statistically significant differences in number of cases in relation to gender. The gender analysis showed a prevalence of ACS (P = 0.03) in men, whereas women presented more strokes and TIAs (P = 0.05), atrial fibrillation (P = 0.05), DVT/PE (P = 0.05), and TTS (P = 0.05)
Chatignoux et al[29], 2018	Annual hospital discharge with a primary diagnosis of ACS, heart failure, or stroke from the French Hospital Discharge Database was used to differentiate “unusual” variations in daily hospitalization numbers in the 15 days following the terrorist attacks in Paris and Nice in 2015 and 2016 from the expected rate	The daily number of hospitalizations for heart failure and stroke was higher in the 15 days following each attack. However, multivariate analysis showed no significant variation. Watching events on television was not sufficiently potent trigger for CVD, although it may have led to an increase in hospitalizations for stress or anxiety
Babaie et al[26], 2021	Systematic review of full text articles which considered CVD at the time of flood, storm, and earthquake	Prevalence of CVD increases after disasters. Mental stress after disasters is one of the most significant challenges
Franzen et al[34], 2022	Multi-centre prospective trial at three German sites during the UEFA Soccer Cup 2012 and 2021 comprising healthy participants and patients hospitalized with CVD during matches of the German national team (GP) and no GP	Central BP and HR increased significantly during GP as well as no GP matches and remained elevated beyond the end of the matches. Likewise, arterial stiffness parameters and vascular resistance were higher during the matches and remained elevated after the matches
Olsson et al[50], 2021	Nationwide, retrospective postal survey with case-control design. All individuals suffering an AMI during the Christmas holidays in Sweden completed a questionnaire of about 27 potential AMI-triggers	Patients with AMI on Christmas experienced more stress (37% vs 21%, P = 0.002), compared to the control group
Chang Liu et al[53], 2021	Individuals who experienced SCA, divided into an unexplained SCA or explained SCA subgroup, completed the Recent Life Changes Questionnaire, Student Stress Scale, or Social Readjustment Rating Scale for Non-Adults recalling events during the preceding year; all measure stress in LCUs	No significant difference in LCU score between the control group and the SCA group (248181 LCU vs 252227 LCU; P > 0.05). The explained SCA subgroup had significantly lower mean LCU scores than the unexplained SCA subgroup (163183 LCU vs 308237 LCU; P = 0.030)
Rosman et al[32], 2021	Retrospective case-crossover study during 2016 United States presidential election linking cardiac device data, electronic health records, and historic voter registration records from patients with ICD	Significant increase in the incidence of composite outcomes for any arrhythmia (IRR = 1.77, 95%CI: 1.42-2.21), supraventricular arrhythmia (IRR = 1.82, 95%CI: 1.36-2.43), and ventricular arrhythmia (IRR = 1.6 95%CI: 1.22-2.10) during the election period. There was an increase in AF, SVT, non-sustained VT, and daily AF burden (P < 0.001)
Batelaan et al[55], 2021	Systematic review of various types of observational studies examining the association between anxiety or mental stress and SCA	For anxiety, the overall picture suggests that it predisposes for SCA in physically healthy populations (unadjusted OR = 2.44; 95%CI: 1.06-5.59). However, in populations at risk for SCA, associations were heterogeneous but not significant
Weber et al[36], 2022	Systematic review of 107 publications assessing acute physiological stress responses primarily through salivary cortisol and cardiovascular outcomes	Direct, non-moderated positive associations between acute stress exposure and concurrent cortisol levels (44%), SBP (44%), DBP (53%) and HR (53%)

CV: Cardiovascular; LF: Low frequency; HF: High frequency; ECGs: Electrocardiograms; HRV: Heart rate variability; SDNN: Standard deviation of N-N intervals; ED: Emergency department; ACS: Acute coronary syndrome; TIA: Transient ischemic attack; DVT/PE: Deep venous thrombosis and pulmonary embolism; TTS: Takotsubo syndrome; CVD: Cardiovascular disease; GP: German participation; BP: Blood pressure; HR: Heart rate; AMI: Acute myocardial infarction; SCA: Sudden cardiac arrest; LCU: Life change units; ICD: Implantable cardiac defibrillator; IRR: Incidence risk ratio; CI: Confidence interval; AF: Atrial fibrillation; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; OR: Odds ratio; SBP: Systolic blood pressure; DBP: Diastolic blood pressure.