A randomised cross-over trial of QT response to hyperventilation-induced anxiety and diaphragmatic breathing in patients with stress cardiomyopathy and in control patients
Open accessAbstract
Objectives: The most perfect example of the mind-body interaction in all of medicine is provided by stress cardiomyopathy. In stress cardiomyopathy, what is initially a purely emotional event may become rapidly fatal. Prolongation of the QT interval is a cardinal feature of the condition, but the mechanism of the prolongation is unknown. We undertook a randomised controlled trial of stress with a cross-over design, comparing the cardiac response of women with a history of stress cardiomyopathy to age-matched controls to explore the mind-body interaction. Our hypothesis is that the hearts of women with a history of stress cardiomyopathy will respond differently to emotional stress than those of the controls. Method: This is a randomised cross-over study. Each patient underwent two separate 24-hour Holter monitors performed at least 5 days apart. Baseline recording was followed by either the stress intervention (hyperventilation) or control (diaphragmatic breathing). Our primary endpoint is change in QTc interval over the first hour. Secondary endpoints were change in QTc over 24 hours, and change in SDNN, a measure of heart rate variability. As a secondary stressor, each participant was telephoned four times during their stressed recording and asked to complete a questionnaire. Results: Twelve stress cardiomyopathy patients and twelve control patients were recruited. Baseline characteristics did not differ between cases and controls. With hyperventilation, there was a significant initial difference in anxiety (p<0.001), heart rate response (p<0.0001), and QTc (p<0.0002) compared to diaphragmatic breathing, but no differences between the cases and controls. Only first phone call caused an increase in QTc in cases and controls (p = 0.0098). SDNN increased with hyperventilation (p<0.0001) but did not differ between cases and controls. Conclusions: QTc response in women with a history of stress cardiomyopathy does not differ from controls. The relevance of QT prolongation and sensitivity in the autonomic response to the pathogenesis of stress cardiomyopathy remains uncertain.
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Stress reduction may have been hindered by fast-only breathing in Watson et al. and by discomfort of deep diaphragmatic breathing after abdominal surgery in Aktas et al.
“Regarding the latter, stress reduction may have also been hindered by fast-only breathing in Watson and colleague’s intervention and by the discomfort of doing deep diaphragmatic breathing after abdominal surgery in Aktas and colleagues’ intervention [39,105].”
From Breathing Practices for Stress and Anxiety Reduction: Conceptual Framework of Implementation Guidelines Based on a Systematic Review of the Published Literature (2023) · cites this paper as [105]
The Methods (page unavailable) describe two breathing conditions, not a fast-only intervention: hyperventilation was used to induce anxiety, while diaphragmatic breathing was used as the control because it may relieve anxiety. The Results (page unavailable) report that hyperventilation significantly increased anxiety. Watson et al. therefore do not support the proposed explanation that fast-only breathing hindered stress reduction; the separate claim about Aktas et al. is not assessed here. (LLM, conf=0.87)
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Experimental — accuracy not yet measuredThe presence of core components in the three effective <5 min interventions suggests that short sessions may be particularly sensitive to practice implementation, requiring human guidance, multiple sessions, or long-term practice for effective stress reduction.
“The presence of core components in the three effective interventions [39,105,106] suggests that such short sessions may be particularly sensitive to practice implementation, such that human guidance, multiple sessions, or long-term practice are required for effective stress reduction.”
From Breathing Practices for Stress and Anxiety Reduction: Conceptual Framework of Implementation Guidelines Based on a Systematic Review of the Published Literature (2023) · cites this paper as [105]
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Experimental — accuracy not yet measuredThe two fast-only interventions either lacked framework adherence [48] or incorporated poor study design [105].
“The two fast-only interventions either lacked framework adherence [48] or incorporated poor study design [105].”
From Breathing Practices for Stress and Anxiety Reduction: Conceptual Framework of Implementation Guidelines Based on a Systematic Review of the Published Literature (2023) · cites this paper as [105]
The Methods describe three-minute breathing interventions and state that allocation was not hidden from participants or investigators. The Discussion identifies a study weakness: hyperventilation induced only moderate anxiety. These passages support the presence of design limitations, but the paper does not characterize its overall design as poor. (LLM, conf=0.74)
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Bentley, T. G. K., D’Andrea-Penna, G., Rakic, M., Arce, N., LaFaille, M., Berman, R., Cooley, K., & Sprimont, P. (2023) · Brain Sciences · doi:10.3390/brainsci13121612 · Cited by 111 · see citing works
- Authors
- Watson, G. M., Sutherland, J., Lacey, C., & Bridgman, P. G.
- Affiliations
- Christchurch Hospital (NZ)
- Corresponding author
- Bridgman, Paul G.
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2022-03-23
- Volume
- 17
- Issue
- 3
- Pages
- e0265607
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC8942223
- OpenAlex
- W4221012117
- Cited by
- 5
- References
- 0
- Citations by year
- 2025: 2 · 2024: 1 · 2023: 2
- FWCI
- 0.87
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- National Heart Foundation of New Zealand
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Takotsubo Cardiomyopathy and Associated Phenomena
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- takotsubo cardiomyopathy, QTc prolongation, diaphragmatic breathing, emotional stress response, mind-body problem, heart rate variability, autonomic responses, women
- MeSH terms
- Anxiety, Electrocardiography, Female, Heart Rate, Humans, Hyperventilation, Long QT Syndrome, Cross-Over Studies, Takotsubo Cardiomyopathy
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