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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

Study finds moderate-vigorous physical activity is the most efficient at improving fitness

Dedicated exercise (moderate-vigorous physical activity) was the most efficient at improving fitness. Specifically, exercise was three times more efficient than walking alone and more than 14 times more efficient than reducing the time spent sedentary. Additionally, they found that the greater time spent exercising and higher steps/day could partially offset the negative effects of being sedentary in terms of physical fitness.

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In the largest study performed to date to understand the relationship between habitual physical activity and physical fitness, researchers from Boston University School of Medicine (BUSM) have found that higher amount of time spent performing exercise (moderate-vigorous physical activity) and low-moderate level activity (steps) and less time spent sedentary, translated to greater physical fitness.

“By establishing the relationship between different forms of habitual physical activity and detailed fitness measures, we hope that our study will provide important information that can ultimately be used to improve physical fitness and overall health across the life course,” explained corresponding author Matthew Nayor, MD, MPH, assistant professor of medicine at BUSM.

He and his team studied approximately 2,000 participants from the community-based Framingham Heart Study who underwent comprehensive cardiopulmonary exercise tests (CPET) for the “gold standard” measurement of physical fitness. Physical fitness measurements were associated with physical activity data obtained through accelerometers (device that measures frequency and intensity of human movement) that were worn for one week around the time of CPET and approximately eight years earlier.

They found dedicated exercise (moderate-vigorous physical activity) was the most efficient at improving fitness. Specifically, exercise was three times more efficient than walking alone and more than 14 times more efficient than reducing the time spent sedentary. Additionally, they found that the greater time spent exercising and higher steps/day could partially offset the negative effects of being sedentary in terms of physical fitness.

According to the researchers, while the study was focused on the relationship of physical activity and fitness specifically (rather than any health-related outcomes), fitness has a powerful influence on health and is associated with lower risk of cardiovascular disease, diabetes, cancer and premature death. “Therefore, improved understanding of methods to improve fitness would be expected to have broad implications for improved health,” said Nayor, a cardiologist at Boston Medical Center.

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Fitness

Tips to avoid common running injuries

Injuries are very common among runners. Recent research estimates that 82% of runners will become injured during their running career and up to 90% will experience injury while training for a marathon. Some of the most common include a stress fracture, plantar fasciitis, hamstring tendinitis, ankle sprain, runners’ knee, and Achilles’ tendonitis.

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Whether training for a marathon or preparing for your first community race, being knocked off course with pain can be hard to handle mentally and physically.

Injuries are very common among runners. Recent research estimates that 82% of runners will become injured during their running career and up to 90% will experience injury while training for a marathon. Some of the most common include a stress fracture, plantar fasciitis, hamstring tendinitis, ankle sprain, runners’ knee, and Achilles’ tendonitis.

Injury prevention is critical. Here are some safety tips from Dr. Joshua Blomgren, a 15-time Chicago Marathon team physician and sports medicine physician, Midwest Orthopaedics at Rush:

Don’t over-train

Don’t increase weekly mileage or intensity by more than 10 percent each week. Build up slowly and let a good training schedule determine how much you run.

Invest in good shoes

Go to a specialty running shop to be properly fitted for running shoes and/or orthotics. Replace them every 350-500 miles. Incorrect shoes can affect your gait, leading to injuries in your feet, legs, knees, or hips.

Choose the best running surface

Look for running surfaces that absorb shock. Opt for asphalt over concrete. Find grass or dirt trails, especially for higher mileage. Avoid uneven surfaces and seek paths with slow curves.

Stretch!

Training causes tight muscles, leading to strain and changes in your gait. Commit to a stretching program. Just 5 -10 minutes after each workout can make a big difference.

Strengthen muscles

Runners have tight hip flexors because their quads are overtrained. Strengthen your hamstrings and glutes to reduce chance of injury and abductors, adductors, and core to create stability.

Watch out for heel striking

Heel striking occurs when your feet land in front of you and your heel hits the ground first. This is common among new runners but can lead to injuries such as shin splints, stress fractures, and joint pain. Land mid-sole with your foot directly underneath your body.

Prioritize posture

Good form means staying upright and keeping your shoulders back and relaxed. Work core exercises into your training and do posture checks every so often. Hold your head right above your shoulders and hips.

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Fitness

Postmenopausal women can dance their way to better health

After menopause, women are more likely to experience weight gain, overall/central body adiposity increases, and metabolic disturbances, such as increases in triglycerides and bad cholesterol. Together, these changes ultimately increase cardiovascular risk. Around this same time, women often are less physically active, which translates into reductions in lean mass and an increased risk of falls and fractures.

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Women often struggle with managing their weight and other health risk factors, such as high cholesterol, once they transition through menopause. A new study suggests that dancing may effectively lower cholesterol levels, improve fitness and body composition and in the process, improve self-esteem. Study results are published online today in Menopause, the journal of The North American Menopause Society (NAMS).

After menopause, women are more likely to experience weight gain, overall/central body adiposity increases, and metabolic disturbances, such as increases in triglycerides and bad cholesterol. Together, these changes ultimately increase cardiovascular risk. Around this same time, women often are less physically active, which translates into reductions in lean mass and an increased risk of falls and fractures. As a result of all these changes, postmenopausal women often suffer from decreased self-image and self-esteem, which are directly related to overall mental health.

Physical activity has been shown to minimize some of the many health problems associated with menopause. The effect of dancing, specifically, has already been investigated with regard to how it improves body composition and functional fitness. Few studies, however, have investigated the effects of dance on body image, self-esteem, and physical fitness together in postmenopausal women.

This new study was designed to analyze the effects of dance practice on body composition, metabolic profile, functional fitness, and self-image/self-esteem in postmenopausal women. Although the sample size was small, the study suggested some credible benefits of a three-times-weekly dance regimen in improving not only the lipid profile and functional fitness of postmenopausal women but also self-image and self-esteem.

Dance therapy is seen as an attractive option because it is a pleasant activity with low associated costs and low risk of injury for its practitioners. Additional confirmed benefits of regular dancing include improvement in balance, postural control, gait, strength, and overall physical performance. All of these benefits may contribute to a woman’s ability to maintain an independent, high-quality lifestyle throughout her lifespan.

Study results are published in the article “Dance practice modifies functional fitness, lipid profile, and self-image in postmenopausal women.”

“This study highlights the feasibility of a simple intervention, such as a dance class three times weekly, for improving not only fitness and metabolic profile but also self-image and self-esteem in postmenopausal women. In addition to these benefits, women also probably enjoyed a sense of camaraderie from the shared experience of learning something new,” says Dr. Stephanie Faubion, NAMS medical director.

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