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Can stress trigger a second heart attack? Yes, new research suggests

Patients who developed ischemia with mental stress had more than two times the risk of having a repeat heart attack or dying from heart disease compared with those who did not develop ischemia during mental stress.

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Photo by Kelly Sikkema from Unsplash.com

We all have stress in our lives–whether it’s due to financial woes, work pressures, relationship issues, illness or even natural disasters or health crises like the emerging coronavirus. For some people who survive a heart attack, it seems mental stress–as opposed to physical stress–may be a stronger predictor of a repeat heart attack or dying from heart disease, according to research.

Traditional stress tests, in which someone exercises on a treadmill or takes a medicine that makes the heart beat faster and harder as if the person was actually exercising, have long been used to check blood flow to the heart and gauge the risk of heart problems. Researchers at Emory University sought to investigate whether myocardial ischemia–when blood flow to the heart is reduced such that the heart muscle doesn’t get enough oxygen–induced by mental stress was associated with poor outcomes among heart attack survivors and how this type of stress testing compares with conventional stress brought on by exercise.

Among more than 300 young and middle-aged individuals enrolled in the study, those who endured myocardial ischemia with mental stress had a two-fold higher likelihood of having another heart attack or dying from heart disease compared with those who did not have cardiac ischemia induced by mental stress.

“In our study, myocardial ischemia provoked by mental stress was a better risk indicator than what we were able to see with conventional stress testing,” said Viola Vaccarino, MD, PhD, Wilton Looney Professor of Cardiovascular Research in the department of epidemiology at Emory University Rollins School of Public Health in Atlanta, and the study’s principal investigator, adding that this is the only study of its kind in this relatively young adult population of heart attack survivors. “These data point to the important effect that psychological stress can have on the heart and on the prognosis of patients with heart disease. It gives us tangible proof of how psychological stress, which is not specifically addressed in current clinical guidelines, can actually affect outcomes.”

She added that taking into account patients’ psychological stress may help clinicians better evaluate the risk of recurrent heart attacks or death seen in some patients surviving a heart attack. These results also underscore the need for strategies to identify the best stress management interventions for these patients.

The investigators studied 306 adults aged 61 years or younger (50 years on average and ranging from 22-61 years), who had been in the hospital for a heart attack in the previous eight months. Participants were recruited in the Atlanta metro area and represented a diverse group of patients; half were women and 65% were African American. All participants underwent two types of “stress” testing to examine blood flow to the heart: mental stress testing (provoked by giving one speech with emotional content in front of an intimidating, seemingly disinterested audience followed by myocardial perfusion imaging), and conventional stress testing (pharmacologic or exercise). Patients were followed for a median of three years for the primary endpoint, which included a combination of either the occurrence of a repeat heart attack or cardiovascular death. These were adjudicated through an independent medical record review and examination of death records. Ischemia was defined as a new or worsening disruption in adequate blood flow to the heart and was assessed using cardiac nuclear imaging scans.

Overall, mental stress induced myocardial ischemia occurred in 16% of patients and conventional ischemia in 35%, suggesting that traditional ischemia due to exercise or drug-induced stress is more common. Over a three-year follow-up, 10% of patients (28 individuals) had another heart attack and two died of heart-related problems. The incidence of heart attack or cardiovascular-related death was more than doubled in patients with mental stress induced ischemia compared with those without mental stress ischemia, occurring in 10 (20%) and 20 (8%) patients, respectively. The relationship between acute mental stress and heart attack or death remained even after adjusting for clinical risk factors and symptoms of depression. In contrast, conventional stress ischemia was not significantly related to the primary endpoint.

“Patients who developed ischemia with mental stress had more than two times the risk of having a repeat heart attack or dying from heart disease compared with those who did not develop ischemia during mental stress,” Vaccarino said. “What this means is that the propensity to have a reduction in blood flow to the heart during acute psychological stress poses substantial future risk to these patients.”

Such reduction in blood flow, when it occurs in real life, could trigger a heart attack or serious heart rhythm problems, she said. Another interesting finding, according to Vaccarino, is that ischemia with mental stress and with conventional stress were not strongly related to each other, suggesting that they occur through different pathways.

“This points to the fact that stress provoked by emotions has a distinct mechanism of risk for heart disease and its complications compared with physical stress,” she said.

Vaccarino and her team plan to expand this research using a larger sample size and a longer follow-up time to determine if there are specific subgroups of patients that are especially at risk of adverse outcomes when they develop ischemia from mental stress. Because of the relatively small sample size, the investigators were not able to determine if such risk differs by sex or race, for example, or whether past exposures to social stressors or trauma play a role. Furthermore, the investigators plan to examine whether myocardial ischemia induced by mental stress in the lab reflects enhanced physiological responses to stress in real life.

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Fitness

6 Exercise safety tips

Now, as social restrictions ease, you may find yourself stepping up your workouts, whether you’re training for an event or working to improve your game in a recreational league.

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In the wake of the COVID-19 pandemic, many Americans are more aware of their health and wellness. Now, as social restrictions ease, you may find yourself stepping up your workouts, whether you’re training for an event or working to improve your game in a recreational league.

Sprains, strains and injuries can happen to even the most seasoned athletes. When you’re testing your limits, even a minor injury can alter your performance. Consider products and supports like these from the CURAD Performance Series product line, available at Walmart and Amazon, to help you get back in the game quickly and safely.

Find more resources to support your fitness journey at CURAD.com.

Keep Dirt and Germs Away

The more active you are, the harder it can be to find a bandage that stays with you all day or all game long.

Spray Away Sore Spots

Controlling mild pain can help keep you at the top of your game, and a topical analgesic works fast to heal common pain brought on by fitness and exercise, such as pain in knees, feet, shoulders and backs.

Put Pain in the Past

When recovery becomes the name of the game and pain relief is needed after daily workouts or bodily injuries. Cold packs work to heal bruises, reduce swelling and relieve headaches and general pain points while microwavable heat packs provide satisfying heat therapy to address sore and stiff joints, muscle cramps and tension.

Reduce Impact of Knee Strain

Weak, injured or arthritic knees can come from many sources, including tendonitis and a wide range of conditions that result in strain or overuse. An adjustable band can provide support for on-field sports and during workouts or everyday activities.

Manage Pain and Relieve Pressure

If you participate in endurance and strength exercises or certain sports, you may ask a lot of your joints. Kinesiology tape can be configured a multitude of ways to help reduce pain and improve blood circulation, as well as relieve tension and pressure.

Control Back Strain

When your back is strained, your body and performance can suffer. A mild or moderate sprain can benefit from strong support and compression.

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Fitness

Exercise can provide relief for dry, itchy eyes

A significant increase in tear secretion and tear film stability after participating in aerobic exercise can be another remedy for relieving dry, itchy eyes.

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Photo by Quinten de Graaf from Unsplash.com

A team led by researchers from the University of Waterloo discovered that a significant increase in tear secretion and tear film stability after participating in aerobic exercise can be another remedy for relieving dry, itchy eyes. 

Every time we blink, our eyes are covered in tear film—an essential protective coating necessary for maintaining healthy ocular function. Healthy tear film comprises three layers–oil, water, and mucin–that work together to hydrate the ocular surface and protect against infection-causing irritants like dust or dirt.

When any part of the tear film becomes unstable, the ocular surface can develop dry spots, causing eye symptoms like itchiness or stinging and burning sensations.

“With so much of our activity tied to screen usage, dry eye symptoms are becoming increasingly common,” said Heinz Otchere, a PhD candidate in vision science at Waterloo. “Instead of having to use eye drops or other alternative treatments, our study aimed to determine if remaining physically active can be an effective preventative measure against dryness.”

Fifty-two participants were divided into two groups—athlete and non-athlete—to participate in an exercise session. Participants in the athlete group exercised at least five times per week, while non-athlete participants exercised no more than once per week. Researchers, which included experts from the University of Cape Coast in Ghana, performed visual examinations before and five minutes after each exercise session, where tear secretion and tear break-up time were assessed.

While participants in the athlete group showed the largest increase, Otchere says all participants experienced a meaningful boost in tear quantity and tear film stability after the exercise session. 

“It can be challenging for people to regularly exercise when the demand is there to work increasingly longer hours in front of screens,” Otchere said. “However, our findings show physical activity can be really important for not just our overall well-being, but for our ocular health too.”

The study, Differential effect of maximal incremental treadmill exercise on tear secretion and tear film stability in athletes and non-athletes, was co-authored by Otchere, the University of Cape Coast’s Samuel Abokyi, Sekyere Nyamaah, and Michael Ntodie, and Ghana’s Our Lady of Grace Hospital’s Yaw Osei Akoto. It was recently published in the Experimental Eye Research journal.

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Fitness

Late-life exercise shows rejuvenating effects on cellular level

Late-life exercise mitigates skeletal muscle epigenetic aging.

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Photo by Caley Vanular from Unsplash.com

For people who hate exercising, here comes some more bad news: it may also keep you younger. Not just looking younger, but actually younger, on an epigenetic level. By now, the benefits of exercise have been well established, including increased strength of bones and muscles, improved mobility and endurance, and lower risk of heart disease, diabetes and high blood pressure.

But younger?

A study recently published in Aging Cell, “Late-life exercise mitigates skeletal muscle epigenetic aging,” suggests this could be the case. The paper was written by a team of seven researchers across three institutions, including Kevin Murach, an assistant professor in the Department of Health, Human Performance and Recreation at the U of A. Murach’s grant from the National Institute of Health funded the study, and he was one of three co-first authors.

Bootcamp for Mice

While the paper is dense with data, reflecting the use of several analytic tools, the experiment that generated the data was relatively straightforward. Lab mice nearing the end of their natural lifespan, at 22 months, were allowed access to a weighted exercise wheel. Generally, mice require no coercion to run and will do so voluntarily. Older mice will run anywhere from six to eight kilometers a day, mostly in spurts, while younger mice may run up to 10-12 kilometers. The weighted wheel ensured they built muscle. While there isn’t a direct analogue to most human exercise routines, Murach likened it to “a soldier carrying a heavy backpack many miles.”

When the mice were studied after two months of progressive weighted wheel running, it was determined that they were the epigenetic age of mice eight weeks younger than sedentary mice of the same age — 24 months. Murach noted that while the specific strain of mice and their housing conditions can impact lifespans, “historically, they start dropping off after 24 months at a significant rate.” Needless to say, when your lifespan is measured in months, an extra eight weeks — roughly 10 percent of that lifespan — is a noteworthy gain.

Methylation, My Dear Watson

The science behind this, while complicated, hinges largely on a biological process known as DNA methylation. A recent New York Times article discussing Murach’s work on muscle memory described methylation “as a process in which clusters of atoms, called methyl groups, attach themselves to the outside of genes like minuscule barnacles, making the genes more or less likely to turn on and produce particular proteins.”

As the body ages, there tends to be increased DNA methylation, or even hypermethylation, at promoter sites on genes in muscle. “DNA methylation changes in a lifespan tend to happen in a somewhat systematic fashion,” Murach explained, “to the point you can look at someone’s DNA from a given tissue sample and with a fair degree of accuracy predict their chronological age.” Due to this, researchers can use one of a number of “methylation clocks” to determine the age of a DNA sample.

DNA Methylation, Aging and Exercise

While the paper strengthens the case for exercise, there is still much that needs to be learned. Though the connection between methylation and aging is clear, the connection between methylation and muscle function is less clear. Murach is not yet prepared to say that the reversal of methylation with exercise is causative for improved muscle health. “That’s not what the study was set up to do,” he explained. However, he intends to pursue future studies to determine if “changes in methylation result in altered muscle function.”

“If so, what are the consequences of this?” he continued. “Do changes on these very specific methylation sites have an actual phenotype that emerges from that? Is it what’s causing aging or is it just associated with it? Is it just something that happens in concert with a variety of other things that are happening during the aging process? So that’s what we don’t know.”

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