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Stress, the autonomic nervous system, and sudden death

  • Maria Teresa La Rovere
    Correspondence
    Corresponding author at: Via per Montescano, 27040 Montescano, Pavia, Italy.
    Affiliations
    Department of Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Montescano, Pavia, Italy
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  • Author Footnotes
    1 Postal address: Via Santa Sofia 9/a, 20,122 Milan, Italy.
    Alessandra Gorini
    Footnotes
    1 Postal address: Via Santa Sofia 9/a, 20,122 Milan, Italy.
    Affiliations
    Department of Oncology and Hemato-Oncology, University of Milan, Italy
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  • Author Footnotes
    2 Postal address: Via Pier Lombardo 22, 20,135 Milan, Italy.
    Peter J. Schwartz
    Footnotes
    2 Postal address: Via Pier Lombardo 22, 20,135 Milan, Italy.
    Affiliations
    Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy
    Search for articles by this author
  • Author Footnotes
    1 Postal address: Via Santa Sofia 9/a, 20,122 Milan, Italy.
    2 Postal address: Via Pier Lombardo 22, 20,135 Milan, Italy.
Published:November 18, 2021DOI:https://doi.org/10.1016/j.autneu.2021.102921

      Highlights

      • Physical and psychological stressors may trigger SCD.
      • The ANS links stressors to the heart.
      • Animal models elucidate the relationship between stressors and cardiac vulnerability.
      • Specific neural responses to different stress have a different impact on arrhythmic risk.

      Abstract

      The existence of an important relationship between stress, the autonomic nervous system, and sudden cardiac death (SCD) has been long recognized. In the present essay we review the large number of conditions, acting at individual or at population level, that have been causally associated to SCD and discuss the mechanistic and translational value of the studies exploring such associations. These conditions include external stressors (earthquakes, wars) and internal stressors (anger, fear, loss of a loved one) and emotions of even opposite sign. Most situations confirm the time-honored view that increases in sympathetic activity are proarrhythmic whereas increases in vagal activity are protective; however, we will also show and discuss a condition in which the culprit appears to be the excess of vagal activity. The physiologic rationale underlying the most typical situations is on one hand the profibrillatory effect of the increase in the heterogeneity of repolarization secondary to the release of norepinephrine, and on the other the combined effect of acetylcholine to lower heart rate and to antagonize the cardiac effects of norepinephrine at ventricular level. An interesting facet of this potentially lethal relationship is that the elements involved are by no means always exceptional, and they can actually represent part of our everyday life.

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