The patient is a 64-year-old male with a history of hypertension, hyperlipidemia and coronary artery disease status post coronary artery bypass grafting two years prior with preserved left ventricular ejection fraction. He denies chest pain or shortness of breath. He has unlimited exercise tolerance. As he is about to complete his office visit, he mentions that over the prior six months, because of a poor economy, he has had to work longer hours, which has resulted in increased job stress. He is unmarried and lives alone. He denies depression.
His current medications currently include aspirin, metoprolol, lisinopril and atorvastatin.
His resting electrocardiogram is normal. An echocardiogram shows abnormal septal motion consistent with post-operative state, but otherwise a normal ejection fraction of 60-65% and no significant valvular abnormalities. Lipid panel includes total cholesterol 138 ml/dL, LDL-C 68mg/L, non-HDL-C 88 mg/dL, HDL-C 50 mg/dL, and triglycerides of 100 mg/dL. Blood pressure is 118/78, heart rate is 65 beats per minute. He is in no acute distress and his exam is unremarkable.
After further discussion of stressors, what is your next step in the management of this patient?
The correct answer is: 2. Prescribe a stress management and regular aerobic exercise program and encourage increased social support.
This case describes a patient with stable coronary disease presenting without symptoms of angina but with increased mental stress at increased risk for mental stress induced myocardial ischemia (MSIMI). Unmarried men, individuals living alone and women may be at higher risk for MSIMI (see the accompanying article of the month from Jiang, et al.). He is on optimal medical therapy with aspirin, beta-blocker, ace-inhibitor and statin for stable coronary disease.
With regard to answer 1, given an absence of typical symptoms of angina, and since MSIMI rarely manifests with physical symptoms, an exercise stress echocardiogram is not indicated at this time.
With regard to answer 2, two studies from Blumenthal, et al., tested the role of stress management training or supervised aerobic exercise training compared to usual routine medical care. In one randomized prospective clinical study, the investigators found smaller reductions in left ventricular ejection fraction and wall motion abnormalities during mental stress testing and reduced emotional distress.1 In the other non-randomized prospective study, there was a significantly lower risk of adverse cardiac events at two years (p=0.01) and five years (p=0.04) of follow-up in the stress management group with lower, but non-significant events in the exercise group.2 Group interaction and social support were also strongly encouraged in these trials.
With regard to answer 3, for mental stress induced myocardial ischemia (MSIMI) the REMIT (The Responses of Mental Stress Induced Myocardial Ischemia to Escitalopram Treatment) study is the first clinical trial to test use of SSRI for MSIMI.3 The rationale for use of SSRI therapy includes: 1) treatment of depression 2) modulation of negative emotions that are associated with ischemic activity 3) use of SSRI to reduce platelet activity in response to enhanced platelet activity from SSRI. While SSRI treatment represents an intriguing approach to MSIMI, there is not yet enough evidence to recommend this strategy.
With regard to answer 4, given the presence of patient’s life stressors that place this patient at increased risk for cardiovascular events, further discussion and modulation of his life stressors is necessary.
Blumenthal JA, Sherwood A, Babyak MA et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial. JAMA 2005;293:1626-34.
Blumenthal JA, Babyak M, Wei J et al. Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men. Am J Cardiol 2002;89:164-8.
Jiang W, Velazquez EJ, Samad Z et al. Responses of mental stress-induced myocardial ischemia to escitalopram treatment: background, design, and method for the Responses of Mental Stress Induced Myocardial Ischemia to Escitalopram Treatment trial. Am Heart J 2012;163:20-6.