David Sheffield

Cardiovascular Reactivity and Development of Preclinical and Clinical Disease States

Objective The objective of this review is to evaluate the evidence for the hypothesis that cardiovascular reactivity can predict the development of preclinical (elevated blood pressure, ventricular remodeling, carotid atherosclerosis) and/or clinical cardiovascular disease states. Methods A review of the literature was conducted examining prospective studies. Results Three large epidemiological studies with long-term follow-up periods (20 years or more) have found blood pressure responses to the cold pressor task to be predictive of subsequent essential hypertension in initially normotensive samples. Studies showing less consistent results have tended to use shorter-term follow-up periods. A larger body of literature demonstrates consistent associations between stress-related cardiovascular reactivity and blood pressure elevations in youth over the course of 1 to 6 years; such relationships have not been consistently shown among adult samples. Moderately consistent evidence points to a positive relationship between reactivity and other measures of subclinical disease (increased left ventricular mass and carotid atherosclerosis) among the few prospective studies that have examined these issues to date. A number of additional factors, however, such as baseline levels of disease risk and exposure to psychosocial stress, seem to moderate these relationships. Health status at baseline also seems to moderate the association between reactivity and clinical coronary heart disease in recent reports: two of three existing studies in initially healthy samples show no evidence of a relationship between reactivity and clinical outcomes, whereas three of four studies in samples with preexisting coronary heart disease or essential hypertension show a positive relationship between reactivity and subsequent disease states. Conclusions There is reasonable evidence to suggest that cardiovascular reactivity can predict the development of some preclinical states (eg, increased left ventricular mass and blood pressure) states and perhaps even new clinical events in some patients with essential hypertension or coronary heart disease. However, much more information is needed concerning moderating and potentially confounding variables before the robustness of the positive relationships can become clinically useful.

Heart rate variability in patients with coronary artery disease: Differences in patients with higher and lower depression scores.

Objective This study tested the hypothesis that coronary artery disease patients with higher depression scores have lower heart rate variability during daily life. Method: Thirty-three men and nine women, ranging in age from 46 to 79, with coronary artery disease and exercise-induced ischemia were studied. The standard deviation of normal R-R intervals (SDNN) and average heart rate were obtained from 24-hour ambulatory electrocardiographic monitoring. Patients were grouped by a median split of the Minnesota Multiphasic Personality Inventory (MMPI-D) score. Results: SDNN was lower (p =.009) and average heart rate was higher (p =.003) in patients with higher depression scores. These relationships remained substantially unaltered after statistically adjusting for the only demographic/clinical factor that varied between the groups: gender. Conclusions: In comparison to the lower depression score group, those with higher depression scores had lower heart rate variability during daily life. These findings may be related to the reported relationship between depression and survival risk in patients with coronary artery disease.

Race and sex differences in cutaneous pain perception

Objective The purpose of this study was to determine race and sex differences in cutaneous pain perception. Methods Pain perception was measured using a suprathreshold evaluation of pain intensity and pain unpleasantness to a series of thermal stimuli in 27 whites (14 men and 13 women) and 24 African Americans (12 men and 12 women). Blood pressure, depressive symptoms, anxiety state levels, and negative mood were assessed before pain testing to examine whether they might account for any sex or race differences in pain perception that emerged. Results African Americans rated the stimuli as more unpleasant and showed a tendency to rate it as more intense than whites. Women showed a tendency to rate the stimuli as more unpleasant and more intense than men. In addition, systolic blood pressure was inversely related to pain intensity. After statistically adjusting for systolic blood pressure, sex differences in pain unpleasantness were reduced and sex differences in pain intensity were abolished; race differences were unaltered. Conclusions These differences in pain perception may be associated with different pain mechanisms: in the case of sex, differences in opioid activity and baroreceptor-regulated pain systems; in the case of race, unmeasured psychological characteristics are suggested by the larger differences in ratings of pain unpleasantness than pain intensity.

Mental Stress-Induced Ischemia and All-Cause Mortality in Patients With Coronary Artery Disease Results From the Psychophysiological Investigations of Myocardial Ischemia Study

Background—Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates. Methods and Results—To determine whether mental stress–induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5±0.4 years and 5.2±0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (P =0.04) and significantly predicted death (rate ratio=3.0; 95% CI, 1.04 to 8.36;P =0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (P =0.9) and did not predict death even after adjusting for resting ejection fraction (P =0.63), which was similar in both groups (mean, 56.4 versus 59.7;P =0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise. Conclusions—In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stress–induced ischemia predicts subsequent death.

Racial/ethnic differences in the experience of chronic pain.

&NA; The purpose of this study was to examine racial/ethnic‐related differences in a four‐stage model of the processing of chronic pain. The subjects were 1557 chronic pain patients (White=1084, African American=473) evaluated at a pain management clinic at a large southeastern university medical center. Using an analysis of covariance controlling for pain duration and education, African American patients reported significantly higher levels of pain unpleasantness, emotional response to pain, and pain behavior, but not pain intensity than Whites. Differences were largest for the unpleasantness and emotion measures, particularly depression and fear. The groups differed by approximately 1.0 visual analogue scale unit, a magnitude that may be clinically significant. Racial/ethnic differences in the linear relationship between stages were also tested using structural equation modeling and LISREL‐8. The results indicate differences in linear associations between pain measures with African Americans showing a stronger link between emotions and pain behavior than Whites.

Sex, Gender, and Blood Pressure: Contributions to Experimental Pain Report

Objective The current study investigated whether the relationship between sex and experimental pain report was explained by systolic blood pressure (SBP) at rest or during pain task, by gender-role socialization as assessed by the Bem Sex Role Inventory, or both. The influence of gender-role socialization on pain report is often inferred but rarely studied. Methods Fifty female and 54 male healthy, young adults completed the Bem Sex Role Inventory and then underwent a cold pressor task. Blood pressure was assessed before and during pain testing. Results Univariate analyses indicated significant sex-related differences in pain threshold and pain tolerance. Baseline SBP was positively related to pain tolerance but did not explain sex differences, in accord with previous research. The Bem Sex Role Inventory demonstrated a relationship with pain, but did not explain sex differences. Conclusions We suggest that context-specific measures of gender are needed to assess gender-related pain behaviors in specific situations. Results from the current study support our contention that gender is part of sex as commonly measured. Also, blood pressure does not appear to fully account for sex-related differences in pain.

Pressor reactions to psychological stress and prediction of future blood pressure : data from the Whitehall II Study

Abstract Objective: To examine whether reactions of blood pressure to psychological stress predict future blood pressure. Design: Blood pressure was recorded at a medical screening examination after which pressor reactions to a psychological stress task were determined. Follow up measurement of blood pressure was undertaken, on average, 4.9 years later. Setting: 20 civil service departments in London. Subjects: 1003 male civil servants aged between 35 and 55 years at entry to the study. Main outcome measure: Blood pressure at follow up screening. Results: Reactions of systolic blood pressure to stress correlated positively with systolic blood pressure at follow up screening (r=0.22, P<0.01). The dominant correlate of follow up blood pressure was blood pressure at initial screening (r=0.60; P<0.01 between initial and follow up systolic blood pressure; r=0.59, P<0.01 between initial and follow up diastolic blood pressure). Stepwise multiple regression analysis indicated that reactions to the stressor provided minimal prediction of follow up blood pressure over and above that afforded by blood pressure at initial screening. In the case of follow up systolic blood pressure, systolic reactions to stress accounted for only 1% of follow up variance; systolic blood pressure at initial screening accounted for 34%. With regard to diastolic blood pressure at follow up, the independent contribution from diastolic reactions to stress was less than 1%. Conclusion: Pressor reactions to psychological stress provide minimal independent prediction of blood pressure at follow up. Measurement of reactivity is not a useful clinical index of the course of future blood pressure. Key messages Key messages Reactions of blood pressure to psychological stress are less predictive of future blood pressure than either resting laboratory or casual blood pressure Reactions of blood pressure to psychological stress afford minimal prediction of future blood pressure independently of initial blood pressure Reactions of blood pressure to stress cannot be advocated as a useful clinical index of the course of future blood pressure Reactions of blood pressure to psychological stress may have little or no role in the aetiology of hypertension

Stress, social support, and psychological and physical wellbeing in secondary school teachers

Abstract In order to evaluate the relationship between stress and social support, on the one hand, and indices of psychological and physical health, on the other, questionnaires were administered to 120 secondary school teachers. Full data were retrieved from 88 teachers, a response rate of 73%. Bivariate correlational analysis revealed associations between life stress and job stress and a variety of General Health Questionnaire measures of psychological wellbeing. Job stress was also correlated with self-reported short-term sickness absences from work. Social support measures were not. in the main, predictive of psychological health outcome measures. In contrast, neither stress nor social support measures were related to self-reported physical health problems or long-term sickness absences. It would appear that self-reported stress is largely associated with psychological wellbeing, and is not substantially related to indices of physical wellbeing. The former relationship does not appear to be substantia...

Social support and cardiovascular reactions to active laboratory stressors.

In order to examine the hypothesis that social support attenuates cardiovascular reactions to standard laboratory stressors. 60 male and 60 female undergraduates were first tested alone and then in one of three conditions: alone, or with a friend or a stranger present. Those tested with a partner, be it friend or stranger, displayed cardiovascular reactions of a similar magnitude to those who remained alone. Subsequent analysis following reallocation of subjects in the partnered conditions to groupings based on their ratings of how supportive or prying they found their partners did yield some effects. However, they occurred as interactive effects with sex, appeared on some cardiovascular indices but not others, and were modest in size, frequently failing to emerge as reliable on post hoc analysis. It was concluded that future tests of the social support-reactivity hypothesis need to be conducted in more realistic social settings.

The relationship between resting systolic blood pressure and cutaneous pain perception in cardiac patients with angina pectoris and controls

Abstract In order to determine the influence of resting systolic blood pressure and stable angina on cutaneous pain perception, we studied 19 male cardiac patients with stable angina and 16 male controls. Pain perception was measured using a suprathreshold evaluation of pain intensity and pain unpleasantness to a series of thermal stimuli. We found that men with higher resting blood pressure had a decrease in the perception of pain intensity and pain unpleasantness. Similarly, we found that patients with stable angina perceived pain as less intense and unpleasant than controls. These differences in pain perception may be associated with different pain mechanisms: in the case of blood pressure, differences in opioid activity and baroreceptor‐regulated pain systems; in the case of stable angina, patients may adapt to continued experiences of pain, altering internal frames of reference.