Volume2 Number8, 1989 2ndInternational Montreux Congress on Stress November19-21, Hotel Excelsior, Montreux, Switzerland Stateof theart presentationson Stressand Cardiovascular Disease include the Pathogenesis of MitralValveProlapse in Anxiety Disorders and Stress, The Stress Connection to Sudden Deaith,Stress-Related Cardiovascular Hypeneactivity in the Pathogenesisof Atherosclerosisand CoronaryHeart Di€ease,The Role of Stressand the SympatheticNeruous System in the Pathogenesisol Hypertension,and Hypertension.asa Disorder af Communication.Other sessionsare devotedto Stress, Emotions,Personality and Health, and include an updateon PersonalityTraits As Predictorsof Mortality from Cardiovascular Diseaseand Cancerand the BeneficialEffects of StressReduction Strategies. Other segmentsare devotedto the Stress ReductionEffects of Spa Therapy,How to Designand Deliver an Effective Stress Reduction Program, Psychophysiologic Stress Assessment Techniques,etc. The concludingpresentations are devoted to the BiobehavioralEffects of Low Emission ElectromagneticEnergr and their usein the treatmentof insomnia,depression, anxiety and addictivedisrders. In respone€ to a nurnber of requeste, we will be devoting certain iseuec of the Newcletter to apecific topics. The forraat will include an introductory general overview followed by curnlnary articlea reporting on recent relevant reeearch reporte. Thie issue focuses on 9tress and Sudden Deatt. Stressand death" in cases where expiration takes place in less than five minutes,If one adheresto the World SuddenDeath Health Organizationdefinition, then it is quite clear Sudden death is usually viewed as an unexpected that suddendeath is the leadingcause of mortality in expiration occurring within 24 hours of onset of the United States.Almost one-halfmillion individuals symptoms,in a previouslyambulatory individual. The "unex- are affected annually, with men having a four- to World Health Organizationdefines it as an fivefold gireaterrisk than wom€n. pected patients nontraumatic,non-self-inflicted htality in In most instancesdeath is dueto anabrupt disturbance preexistingdisease, with or without whodie withinsix in heartrhythm, or severefall in blood pressure,and hours of onsetof the terminalev€nt." Other authori- sometimesboth. Suddendeath may alsoresult from ties believe that the term should be reserved for damage to vital centers in the brain because of fatalities that occur within an hour after the onset of massivecerebral hemonhage in patientswith hyperten- phrase"instantaneous the terminaleventand usethe sion, congenital blood vessel defects, or following severetrauma. However, in these latter instances, ALSO INCLUDED IN THIS ISSUE NervousSystem Pathways of SuddenDeath ........................., 3 death is not as likely to be as instantaneous or dramatic.Deaths which occur within an hour or two Heart Attacks and SuddenDeath .........3 of onsetof symptomsareusuallytheresult of failureof Who Is At Risk for SuddenDeath....... ..4 the heart'sability to functionas a pump.This is most common in patients with severe coronary artery Scaredto Death..,....,... .....,.....4 For further inlormation on the original source of abstracts and other CulturalShock and Sudden Death........... ........5 reprints available on similar subjects, please send a self-addressed stamped envelope to: Reprint Division, American Institute of Stress, Personality,Emotions and Sudden Death ..,........................... 6 124 Park Avenue, Yonkers, NY 10703. Stressand SuddenDeath in Animals ......,.........6 The Newsletterof THE AMERICAN INSTITUTE OF STRESS Stressand SuddenDeath in Japan ...................7 NEWSLETTERis publishedmonthly by The AmericanInstitute ofStress.Subscription rates: $35.00 annually. Copyrighto 1987 SuddenDeath and CircadianRhythms ............,.7 by The AmericanInstitute of Stress.All rights reserved. 2 7heNewsletter of THE AMERICANINSTITUiE oF STRESS only other situation in which these microscopic THEAMIRICAN INSTITUTT OF findings are seen occurs in patients with tumors that secretelarge amounts of these catecholamine chemicals.These hormones can also caus€ ventricu- lar fibrillation,a severedisruption in heart rhythm, which if not corrected, will result in death in a Paul Rotch, J. M.D.,F.A.C.P. matter of minutes.In suchinstances, there may be Editor-in-Chief little evidence of heart muscle damage since at autopsy,it seemsquite likely that the mechanismof Contributlng Editon lrorn The Board of Trurtecr ol most suddencardiac deathsis due to the effectsof The Arnericnn lnetltute of Strece these stress-relatedhormones. f,obert Ader, Ph.D., Rochester,NY Ancient Veraue Modern Strecc Herbert Bcnlon, M.D., Boston,MA Our responsesto stressare automaticand stereo- Norrnan Courine, LosAngeles, CA Michael E. DeBakey, M.D., Houston,TX typed reflex reactions.They are the consequence Joel Elker, M.D., Louisville,KY of exquisite adaptive changes which have been John Laragh, M.D., NewYork,NY progressivelyrefined over the lengthy course of Jarnec J. Lynch, Ph.D., Baltimore,MD purposeful Kenneth B. Pelletier, Ph.D., M.D., Berkeley,CA man's evolution. Originally, they were Ray H. Rotenrnan, M.D., MenloPark, CA and life saving for our primitive ancestors, when Charlea F. Stroebel, Ph.D., M.D., Hartford,CT suddenlyconfronted by a potentiallylethal physical Alvin Toffler, NewYork, NY Sue Thomar, nN, Ph.D., Baltimore,MD threat, The great physiologist, Walter Cannon, labeled these complex but coordinated activities "fight the or flight" response.His careful research studies demonstrated that they were the conse- Stress and Sudden Death quenceof a marked stimulationof the sympathetic (Continuedfrom pageone) nervoussystem and an outpouringof adrenalin-like diseasewho suffer a myocardialinfarction.Autopsy substancesfrom the adrenalglands. These exerted studiesr€veal that threeout of four suddencardiac powerfuland widespread influences affecting almost death victims have advancedarteriosclerotic every organ and tissue in the body. There was an changesin their coronaryvessels, compared with increase in heart rate and blood pressure and anincidence of only38 percent for autopsypatients dilatation of the vesselssupplying blood flow to the in all categories.However, in such suddendeath brain, to aid in decisionmaking. The pupilswidened patients,the locationand extent of coronaryartery and vision was improved. Body fuel stores were diseaseis not distinctiveor evenparticularly remark- rapidly metabolizedto boost levelsof blood sugar able.Quite often it appearscompatible with many and nutrients for increased energy. The blood future yearsof a satisfactorycardiac function and clotted more quickly, reducing loss from lacera- life.This suggeststhe possibilitythat the fatalblow tions or internalhemorrhage. Blood flow and tension mighthave been severe coronary vasospasm causing was increasedin the large musclesof the arms and prolongedocclusion of a major vesselthat was legs,providing greater strength to fight, or speedier alreadynarrowed by atheroscleroticplaque. Much flight away from a sceneof potentialperil. more severecoronary diseaseis often seen in However,the nature of stressfor modern man is no individualsdying from accidentsor non-cardiac longeran occasionalphysicalthreatfrom a sabre- disorders,who have never experienced any signs or tooth tiger or ferocious assailant.Contemporary symptomsof heartdisease. stressesare more apt to be of emotionalorigin, and Theseobservations suggest that emotionalstress are frequently experienced several times a day. may triggersudden cardiac death in patientswho Unfortunately, our responsescontinue to remain wouldotherwise have enjoyed many future years of those that existed hundreds of thousandsof years active life. Further support comesfrom autopsy ago. While life-savingfor primitive man, they have studiesof patientswho died suddenlyfollowing now becomenot only inappropriate,but potentially extreme,but non-physicalstress. In most instan- harmful.Repeatedly called into play, it is not difficult ces,there is no evidenceof coronaryocclusion or to understandhow theycancontribute to hyperten- evensignificant atherosclerosis. However, caref ul sion,heart attacks,cerebral hemorrhage, and sudden examindtionwill usuallydisclose typical discrete death.Major psychosocialstresses, such as the loss areas of damage,which, under the microscope, of importantemotional relationships, persistent frus- revealcharacteristic "contraction bands" consis. tration, feelingsof helplessnessand hopelessness, are apt to be more insidiousand chronic than the tent with chemicaldestruction of heart muscle "fight tissue.These findingsare identicalto those ob- acute challengeswhich trigger the or flight" servedin laboratoryanimals following injections of response.Nevertheless, as we shall see, they are largeamounts of adrenalinand nor-adrenalin.The (continuedon page3) TheNewsletter of THEAMERICAN INSTITUTE OF STRESS are apt to rcfer to such symptoms as severe or Stress and SuddenDeath prolongedangina or coronary insufficiency,The (continuedfrom page2) primarydistinction is that the interruptionof blood also associatedwith an increased incidence of flow to heart muscleis temporaryand not associ- suddendeath, via similarand other neurohumoral atedwith structuraldamage.There are permanent activities.As our understandingof the pathogenesis changesin the electrocardiogramor elevationin of suddendeath due to stresshas expanded, it has blood enzymes indicative of tissue destruction. "heart beenpossible to developavariety of preventiveand