1. Endothelial Function and Vascular Response to Mental Stress are Impaired in Patients with Apical Ballooning Syndrome Elizabeth A. Martin, PhD; Abhiram Prasad, MD; Charanjit S. Rihal, MD; Lilach O. Lerman, MD, PhD and Amir Lerman, MD Division of Cardiovascular Diseases Division of Nephrology and Hypertension Mayo Clinic and Foundation 200 1 st Street SW Rochester, Minnesota 55905 Martin EA, Prasad A, Rihal CS, Lerman LO, Lerman A. J Am Coll Cardiol 2010;56:1840-1846.

2. Background Apical ballooning syndrome is a transient cardiomyopathy, which occurs predominantly in postmenopausal women and may be triggered by acute mental stress – the mechanism for ABS is unknown Objectives The aim of the current study was to test the hypothesis that vascular and endothelial functional responses to acute mental stress are abnormal in ABS patients Martin EA, Prasad A, Rihal CS, Lerman LO, Lerman A. J Am Coll Cardiol 2010;56:1840-1846.

3. Methods Forearm reactive hyperemia as a parameter of endothelial function and vascular responses to acute mental stress were measured using peripheral arterial tonometry at baseline and following 3 acute mental stress tests in female ABS patients (n=12, at least 6 months after being hospitalized or diagnosed with ABS), postmenopausal female control subjects (n=12) and female myocardial infarction patients (n=4); plasma catecholamine levels were measured at baseline and following the 3 mental stress tests Martin EA, Prasad A, Rihal CS, Lerman LO, Lerman A. J Am Coll Cardiol 2010;56:1840-1846.

4. Stress PAT score Postmenopausal controls MI patients ABS patients Acute mental stress test *†*†*†*† *†*†*†*† *†*†*†*† Stress PAT Score in Responses to Mental Stress Tests

5. Reactive hyperemia PAT score Postmenopausal controls MI patients ABS patients *†*†*†*† Endothelial Function at Baseline and in Response to Mental Stress Martin EA, Prasad A, Rihal CS, Lerman LO, Lerman A. J Am Coll Cardiol 2010;56:1840-1846.

6. Epinephrine (pg/mL) Dopamine (pg/mL) Norepinephrine (pg/mL) *†*†*†*† *†*†*†*† Control subjects ABS patients The Effect of Mental Stress on Plasma Catecholamine Levels Martin EA, Prasad A, Rihal CS, Lerman LO, Lerman A. J Am Coll Cardiol 2010;56:1840-1846.

7.  plasma norepinephrine (%) Decrease in reactive hyperemia PAT score (%) r 2 =0.40 Correlation Between Reactive Hyperemia and PAT Scores and Plasma Norepinephrine Levels

8. Conclusion There is increased vascular reactivity and decreased endothelial function in response to acute mental stress in patients with a prior episode of ABS; the findings implicate vasomotor dysfunction as a potential mechanism involved in the pathogenesis of this unique cardiomyopathy Martin EA, Prasad A, Rihal CS, Lerman LO, Lerman A. J Am Coll Cardiol 2010;56:1840-1846.