The Role of Stress as a Precipitating Factor in Spontaneous Coronary Artery Dissection

Abstract

Background: The diagnosis of spontaneous coronary artery dissection(SCAD) is increasingly being made, however, the pathophysiology is poorly understood. SCAD is frequently reported to occur at times of physical or emotional stress. Methods: 68 patients diagnosed with SCAD, over a six-year period, were enrolled. We reviewed reported stress prior to SCAD. Emotional stress was assessed using Social-Readjustment Rating Scale(SRRS), a life events inventory with score >150units reflecting life disruption and >50% chance of stress induced event. A representative questionnaire from the INTERHEART study evaluated chronic stress. Results: 49 patients, diagnosed with SCAD, participated(85.3%female). Mean age 53.1years(range 23-73years). 98.5% presented with acute coronary syndrome. 26.5% were smokers, 24.5% had hypertension and 4.1% had diabetes. 71.4% reported underlying emotional or physical stress prior to SCAD. Pre-existing depression was observed in 22.4%. 55.1% reported stress prior to SCAD of which 28.6% reported emotional stress, 20.4% reported physical stress and 6.1% following poly-pharmacy overdoses. Emotional stressors include relationship-breakdown(7.1%), witnessing major trauma(7.1%), bereavement(14.3%), personal/family illness(14.3%) and work stress(57.1%). 26.7% reported earthquake related stress. 28.6% with emotional stress scored >150units on SRRS. Using INTERHEART questionnaire, 44% with emotional stress reported permanent stress and 40% reported major adverse life events. 60% of physical stressors occurred within 24hours of SCAD, 30% after isometric activity and 70% after heightened aerobic activity. Recurrent SCAD occurred in 12% of which 66.6% described acute precipitating stress. Conclusion Our study identifies that acute emotional and physical stress is a common precipitating factor in patients presenting with SCAD. There may be a neuro-cardiology connection, similar to stress cardiomyopathy, which requires further investigation.