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.
Keywords
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References
- Triggering of sudden death from cardiac causes by vigorous exertion.N. Engl. J. Med. 2000; 343: 1355-1361
- Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women.Circulation. 2005; 111: 480-487
- Diurnal, weekly and seasonal variation of sudden death. Population-based analysis of 24,061 consecutive cases.Eur. Heart J. 2000; 21: 315-320
- Brain responses and self-reported indices of interoception: heartbeat evoked potentials are inversely associated with worrying about body sensations.Physiol. Behav. 2017; 180: 1-7
- Baroreceptor reflex control of heart rate: a predictor of sudden cardiac death.Circulation. 1982; 66: 874-880
- "Voodoo" death.Am. Anthropol. 1942; 44 (new series): 169-181
- Stress markers for mental states and biotypes of depression and anxiety: a scoping review and preliminary illustrative analysis.Chronic Stress (Thousand Oaks). 2021; 524705470211000338
- Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction.New Engl. J. Med. 1989; 321: 406-412
- Sudden death in athletes.Int. J. Cardiol. 2017; 237: 67-70
- Interaction between cognition, emotion, and the autonomic nervous system.in: Buijs R.M. Swaab D.F. Handbook of Clinical Neurology. Vol. 117. Elsevier B.V, 2013
- Clinical depression and risk of out-of-hospital cardiac arrest.Arch. Intern. Med. 2006; 166: 195-200
- Etiology of sudden death in sports: insights from a United Kingdom Regional Registry.J. Am. Coll. Cardiol. 2016; 67: 2108-2115
- Heart rate as a prognostic risk factor in patients with coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a subgroup analysis of a randomised controlled trial.Lancet. 2008; 372: 817-821
- A comprehensive overview on stress neurobiology: basic concepts and clinical implications.Front. Behav. Neurosci. 2018; 12: 127
- A cortical potential reflecting cardiac function.Proc. Natl. Acad. Sci. U. S. A. 2007; 104: 6818-6823
- Anxiety and risk of ventricular arrhythmias or mortality in patients with an implantable cardioverter defibrillator.Psychosom. Med. 2013; 75: 36-41
- Phobic anxiety and ischaemic heart disease.Br. Med. J. (Clin. Res. Ed.). 1987; 295: 297-299
- Nonuniform recovery of excitability in ventricular muscle.Circ. Res. 1964; 14: 44-60
- The induction of arrhythmias by sympathetic activity before and after occlusion of a coronary artery in the canine heart.J. Electrocardiol. 1971; 4: 34-43
- The spectrum of epidemiology underlying sudden cardiac death.Circ. Res. 2015; 116: 1887-1906
- Sexual activity and the postcoronary patient.Arch. Intern. Med. 1970; 125: 987-999
- Congenital deaf-mutism, functional heart disease with prolongation of the Q-T interval and sudden death.Am. Heart J. 1957; 54: 59-68
- Heart-rate profile during exercise as a predictor of sudden death.N. Engl. J. Med. 2005; 352: 1951-1958
- Excessive heart rate increase during mild mental stress in preparation for exercise predicts sudden death in the general population.Eur. Heart J. 2009; 30: 1703-1710
- Prospective study of phobic anxiety and risk of coronary heart disease in men.Circulation. 1994; 89: 1992-1997
- Symptoms of anxiety and risk of coronary heart disease.The Normative Aging Study.. 1994; 90: 2225-2229
- Electrical stability of acutely ischemic myocardium. Influences of heart rate and vagal stimulation.Circulation. 1973; 47: 291-298
- Effects of stress on the development and progression of cardiovascular disease.Nat. Rev. Cardiol. 2018; 15: 215-229
- Population-based analysis of the effect of the Northridge Earthquake on cardiac death in Los Angeles County, California.J. Am. Coll. Cardiol. 1997; 30: 1174-1180
- When throughout the year is coronary death most likely to occur? A 12-year population-based analysis of more than 220 000 cases.Circulation. 1999; 100
- Int. J. Cardiol. 2015; 187: 307-308
- Angerlike behavioral state potentiates myocardial ischemia-induced T-wave alternans in canines.J. Am. Coll. Cardiol. 2001; 37: 1719-1725
- Sudden cardiac death with stress and restraint: the association with sudden adult death syndrome, cardiomyopathy and coronary artery disease.. 2016; 56: 85-90
- Baroreflex sensitivity, clinical correlates, and cardiovascular mortality among patients with a first myocardial infarction.A prospective study.. 1988; 78: 816-824
- Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction. ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction) investigators.Lancet. 1998; 351: 478-484
- Baroreflex sensitivity and heart rate variability in the identification of patients at risk for life-threatening arrhythmias: implications for clinical trials.Circulation. 2001; 103: 2072-2077
- Clinical value of baroreflex sensitivity.. 2013; 21: 61-63
- Autonomic control of the heart and its clinical impact.A personal perspective.. 2020; 11: 582
- Anger and ventricular arrhythmias.Curr. Opin. Cardiol. 2010; 25: 46-52
- Emotional and physical precipitants of ventricular arrhythmia.Circulation. 2002; 106: 1800-1805
- Anger-induced T-wave alternans predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators.J. Am. Coll. Cardiol. 2009; 53: 774-778
- Impaired baroreflex sensitivity is correlated with hemodynamic deterioration of sustained ventricular tachycardia.J. Am. Coll. Cardiol. 1997; 29: 568-575
- Induction of lateralized sympathetic input to the heart by the CNS during emotional arousal: a possible neurophysiologic trigger of sudden cardiac death.Psychosom. Med. 1987; 49: 274-284
- Psychological stress preceding idiopathic ventricular fibrillation.Psychosom. Med. 2005; 67: 359-365
- Study on the correlation of the autonomic nervous system responses to a stressor of high discomfort with personality traits.Physiol. Behav. 2004; 82: 647-652
- Sudden cardiac death triggered by an earthquake.N. Engl. J. Med. 1996; 334: 413-419
- Psychological health, well-being, and the mind-heart-body connection: a scientific statement from the American Heart Association.Circulation. 2021; 143: e763-e783
- Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association.Circulation. 2014; 129: 1350-1369
- Can exaggerated stress reactivity and prolonged recovery predict negative health outcomes? The case of cardiovascular disease.Psychosom. Med. 2015; 77: 212-214
- Stress and Health. Biological and Psychological Interactions.Third edition. SAGE Publications, 2016
- Psychologic stress and threshold for repetitive ventricular response.Science. 1973; 182: 834-836
- Depressive symptoms and the risk of sudden cardiac death among the elderly.Eur. Heart J. 2003; 24: 2021-2026
- Stock volatility as a risk factor for coronary heart disease death.Eur. Heart J. 2011; 32: 1006-1011
- Understanding depressive symptoms through psychological traits and physiological stress reactivity.CogentPsychol. 2019; 6
- A sympathetic reflex elicited by experimental coronary occlusion.Am. J. Phys. 1969; 217: 703-709
- Repetitive extrasystole as an index of vulnerability to ventricular fibrillation.Am. J. Phys. 1976; 230: 1469-1473
- Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians.Lancet. 1991; 338: 660-661
- Clinical characteristics and circumstances of death in the sudden arrhythmic death syndrome.Circ. Arrhythm. Electrophysiol. 2014; 7: 1078-1083
- Increased incidence of tachyarrhythmias and heart failure hospitalization in patients with implanted cardiac devices after the great East Japan earthquake disaster.. 2012; 76: 1283-1285
- Cardiovascular recovery from psychological and physiological challenge and risk for adverse cardiovascular outcomes and all-cause mortality.Psychosom. Med. 2015; 77: 215-226
- Acute psychological disturbances preceding life-threatening ventricular arrhythmias.JAMA. 1981; 246: 233-235
- On the phenomenon of sudden death in animals and man.Psychosom. Med. 1957; 19: 191-198
- Do animal models have clinical value?.Am. J. Cardiol. 1998; 81: 14D-20D
- Cardiac sympathetic denervation to prevent life-threatening arrhythmias.Nat. Rev. Cardiol. 2014; 11: 346-353
- The long QT syndrome: a transatlantic clinical approach to diagnosis and therapy.Eur. Heart J. 2013; 34: 3109-3116
- Cardiac arrhythmias elicited by interaction between acute myocardial ischemia and sympathetic hyperactivity: a new experimental model for the study of antiarrhythmic drugs.J. Cardiovasc. Pharmacol. 1981; 3: 1251-1259
- The long QT syndrome.Am. Heart J. 1975; 89: 378-390
- Effect of dorsal root section on the arrhythmias associated with coronary occlusion.Am. J. Phys. 1976; 231: 923-928
- Autonomic mechanisms in ventricular fibrillation induced by myocardial ischemia during exercise in dogs with healed myocardial infarction. An experimental preparation for sudden cardiac death.Circulation. 1984; 69: 790-800
- The effect of antiarrhythmic drugs on life-threatening arrhythmias induced by the interaction between acute myocardial ischemia and sympathetic hyperactivity.Am. Heart J. 1985; 109: 937-948
- Autonomic mechanisms and sudden death. New insights from analysis of baroreceptor reflexes in conscious dogs with and without a myocardial infarction.Circulation. 1988; 78: 969-979
- Stress and sudden death. The case of the long QT syndrome.Circulation. 1991; 83: II71-80
- Does amiodarone reduce sudden death and cardiac mortality after myocardial infarction? The European Myocardial Infarct Amiodarone Trial (E.M.I.A.T).Eur. Heart J. 1994; 15: 620-624
- Genotype-phenotype correlation in the long-QT syndrome: gene-specific triggers for life-threatening arrhythmias.Circulation. 2001; 103: 89-95
- Long term vagal stimulation in patients with advanced heart failure: first experience in man.Eur. J. Heart Fail. 2008; 10: 884-891
- Autonomic modulation for the management of patients with chronic heart failure.. 2015; 8: 619-628
- Inherited cardiac arrhythmias.. 2020; 6: 58
- The effect of unexpected bereavement on mortality in older couples.Am. J. Public Health. 2013; 103: 1140-1145
- The world trade center attack: increased frequency of defibrillator shocks for ventricular arrhythmias in patients living remotely from New York City.J. Am. Coll. Cardiol. 2004; 44: 1265-1267
- The incidence of primary cardiac arrest during vigorous exercise.N. Engl. J. Med. 1984; 311: 874-877
- Increased incidence of life-threatening ventricular arrhythmias in implantable defibrillator patients after the world trade center attack.J. Am. Coll. Cardiol. 2004; 44: 1261-1264
- Anger, emotion, and arrhythmias: from brain to heart.Front. Physiol. 2011; 2: 67
- Autonomic characteristics of generalized anxiety disorder and worry.Biol. Psychiatry. 1996; 39: 255-266
- Sudden cardiac death during physical exercise: characteristics of victims and autopsy findings.Ann. Med. 2015; 47: 263-268
- Psychological stress and fatal heart attack: the Athens (1981) earthquake natural experiment.Lancet. 1983; 1: 441-444
- Cardiovascular performance of Alaska sled dogs during exercise.Circ. Res. 1969; 24: 33-42
- Vagal stimulation and prevention of sudden death in conscious dogs with a healed myocardial infarction.Circ. Res. 1991; 68: 1471-1481
- Left ventricular response to severe exertion in untethered dogs.J. Clin. Invest. 1972; 51: 3052-3060
- Central nervous system and behavioural factors in vagal control of cardiac arrhythmogenesis.in: Levy M.N. Schwartz P.J. Vagal Control of the Heart: Experimental Basis and Clinical Implications. Futura Publishing, Armonk, NY1994: 557-577
- Behavioral stress and cardiac arrhythmias.Annu. Rev. Physiol. 1984; 46: 155-176
- Delayed myocardial ischemia induced by anger.Circulation. 1987; 75: 249-254
- Vagus nerve stimulation in brain diseases: therapeutic applications and biological mechanisms.Neurosci. Biobehav. Rev. 2021; 127: 37-53
- A new familial cardiac syndrome in children.J. Irish Med. Assoc. 1964; 54: 103-106
- Isr. J. Med. Sci. 1996; 32: 95-99
- Major life events as potential triggers of sudden cardiac arrest.Epidemiology. 2012; 23: 482-485
- Cardiovascular events during world cup soccer.N. Engl. J. Med. 2008; 358: 475-483
- Anger Kills: Seventeen Strategies for Controlling the Hostility That Can Harm Your Health HarperPerennial.1994
- Increased onset of sudden cardiac death in the first three hours after awakening.Am. J. Cardiol. 1992; 70: 65-68
- Decreased heart rate variability in panic disorder patients: a study of power-spectral analysis of heart rate.Psychiatry Res. 1993; 46: 89-103
- Mortality after the death of a spouse in Norway.Epidemiology. 2015; 26: 289-294
Article info
Publication history
Published online: November 18, 2021
Accepted:
November 15,
2021
Received in revised form:
November 7,
2021
Received:
July 21,
2021
Identification
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© 2021 Elsevier B.V. All rights reserved.
