**4. Mental stress-induced cardiomyopathy**

There is increasing evidence that, in addition to traditional factors, mental stress plays an important role in the occurrence and development of cardiovascular disease [55]. The psychological stress generated in daily life and work can lead to the occurrence of myocardial ischemia, which is clinically referred to as mental stress-induced cardiomyopathy (MSIC) [56]. In addition to affecting the quality of life of patients, mental stress-induced myocardial ischemia (MSIMI) can also lead to a worsening clinical prognosis and an increased risk of death. Its pathogenesis and pathogenesis are different from those of exercise stress or drug-related myocardial ischemia. The incidence of MSIMI is 20–70%, and it will double the adverse cardiac events [57]. Therefore, in-depth understanding of the pathogenesis of MSIMI and timely diagnosis and treatment, is of great clinical significance.

#### **4.1 Features of MSIC**

Understanding the clinical features of MSIC will help clinicians identify MSIC patients early and treat them in a timely manner.

#### *4.1.1 Depression or anxiety*

Depression and anxiety are risk factors for cardiomyopathy, aggravate the process of heart disease, and affect the prognosis of heart disease. Patients with heart disease complicated by depression or anxiety have a higher incidence of MSIC after mental stress [58].

#### *4.1.2 Brain function*

During mental stress, changes in brain function are related to the occurrence of MSIC. Studies have shown that compared with patients with heart disease without

depression, patients with heart disease and severe depression have increased activity in the parietal cortex after mental stress stimulation [59]. Another study showed that mental stress-induced vasoconstriction is associated with modulation of brain function, with stress increasing activation in the insula and parietal cortex but decreasing activation in the medial prefrontal cortex [60].

#### *4.1.3 Cardiac markers*

Changes in cardiac markers may be associated with MSIC. Highly sensitivity cardiac troponin I (hs-cTnI) is an indicator of myocardial infarction or myocardial injury and is associated with myocardial ischemia caused by mental stress. Studies have shown that compared with heart disease patients without MSIC, patients with heart disease combined with MSIMI have higher serum hs-cTnI levels, and increased N-terminal pro-B-type natriuretic peptide and mean systolic blood pressure after mental stress [55]. Numerous studies have shown that myocardial hypoxia can lead to the elevation of B-type natriuretic peptide (BNP). Elevated BNP levels may be a marker of myocardial ischemia in a meta-analysis of 2784 patients eligible for standard noninvasive stress testing [61].

## *4.1.4 Other factors*

After psychological stress, coronary heart disease patients with severe left ventricular dysfunction have a higher risk of MSIC than patients with normal left ventricular function [62]. The product of heart rate and systolic blood pressure and peripheral arterial tension were measured in resting state and 30 min after mental stress, respectively. It was found that higher hemodynamics and vasoconstriction response were high risk factors for MSIC [63].
