Tension, Frustration, Sadness, and Myocardial Ischemia


Synopsis: Feelings of tension, frustration, and sadness can more than double the risk of myocardial ischemia in the subsequent hour.

Source: Gullett ECD, et al. JAMA 1997;227:1521-1526.

Gullett and colleagues sought to determine the relative risk of myocardial ischemia triggered by specific emotions during daily life. Outpatients at Duke University Medical Center underwent 48 hours of ambulatory electrocardiographic (ECG) monitoring with concurrent self-report measures of activities and emotions. Occurrences of negative emotions in the hour before the onset of myocardial ischemia were compared with their usual frequency based on all hours in which ischemia did not occur.

From a sample of 132 patients with coronary artery disease and recent evidence of exercise-induced ischemia who underwent 48 hours of ambulatory ECG monitoring, 58 patients exhibited ambulatory ischemia and were included in the analysis.

Myocardial ischemia during 48-hour ECG monitoring was defined as horizontal or downsloping ST-segment depression of 1 mm (0.1 mV) or more for one minute or longer compared with resting baseline. The ECG data were cross-tabulated with subjects’ concurrent diary rating of three negative emotions—tension, sadness, and frustration—and two positive emotions—happiness and feeling in control—on a five-point scale of intensity.

The unadjusted relative risk of occurrence of myocardial ischemia in the hour following high levels of negative emotions was 3.0 (P < 0.01) for tension, 2.9 (P < 0.05) for sadness, and 2.6 (P < 0.01) for frustration.

Mental stress during daily life, including reported feelings of tension, frustration, and sadness, can more than double the risk of myocardial ischemia in the subsequent hour. The clinical significance of mental stress-induced ischemia during daily life needs to be further evaluated.


The incidence of myocardial ischemia is a significant predictor of future cardiac events. Early studies by Ellestad et al have shown that ischemia could be induced by mental stress as well as exercise.1

Forty-four percent of the patients in this small study had evidence of ischemia with mild-to-moderate exercise and mental stress, which was addressed as tension, sadness, and frustration. Anger was not used in this study.

In the late ’70s, I had the opportunity to study a group of patients with Holter monitors for a 24-hour period. These were patients in a cardiac rehabilitation program I helped direct. Without quantitating the data we collected for clinical and patient management purposes, I was impressed with the incidence of significant ECG changes (1-2+ mm ST segment depression) that occurred with anger and walking in temperatures of up to 40°F. These episodes were not usually accompanied by chest discomfort or pain.

The effect of anger has been particularly impressive.2 One noteworthy experience occurred in a 61-year-old friend who held the masters world record for the 400 meter dash and 400 meter hurdle events. A day prior to having a myocardial infarction, he ran 6 ´ 220 yards in practice, all under 30 seconds (try that at 61 years of age). The following morning, he became very angry at an employee and had chest pain with a documented myocardial infarction.

The thesis of Gullet et al is "for patients vulnerable to mental stress-induced ischemia, the therapeutic value of non-pharmacologic therapy such as exercise or stress management training should be evaluated."

Incidentally, most cardiac exercise rehabilitation programs devote considerable time to stress management along with other patient education activities.


1. Ellestad MH. Prog Cardiovas Dis 1979;21:431-460.

2. Gabbay FH. J Am Coll Cardiol 1996;21:585-592.