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Abstract & Commentary
Synopsis: Those participants who had the highest level of negative emotions experienced the greatest incidence of CHD.
Source: Todaro JF, et al. Am J Cardiol. 2003;92:901-906.
Numerous published studies have strongly suggested that negative emotions such as depression and anxiety contribute to the development of symptomatic coronary artery heart disease (CHD).1-5 A meta-analysis of 11 epidemiologic studies6 concluded that the overall relative risk odds ratio for the development of CHD in depressed subjects was 1.64. Further evidence
linking negative emotions to the development of CHD was found in a 32-year follow-up of men; those subjects who reported at least 2 symptoms of anxiety at baseline were found to be at increased risk of fatal manifestations of CHD (odds ratio, 3.20) and sudden death (odds ratio, 5.73).5 These findings certainly seem to confirm the observation made by a famous physician, Dr. William Harvey, in 1628 when he noted that "every affectation of the mind that is attended with either pain or pleasure, hope or fear, is a cause of agitation whose influence extends to the heart."
Todaro and associates prospectively examined the relationship between negative emotions, such as depression and anxiety, and incident CHD in 2280 older men (mean age, 60.3) participating in the Normative Aging Study (NAS). A subset study group consisting of 498 predominantly Caucasian high school graduates who completed the Minnesota Multiphasic Personality Inventory was carefully analyzed. The study was designed to extend the results of previous studies by examining the relationship between negative emotions and CHD while controlling for components of the metabolic syndrome (ie, obesity, insulin resistance, hypoglycemia, dyslipidemia, and hypertension) and stress hormones (ie, epinephrine and norepinephrine). The results revealed that those participants who had the highest level of negative emotions experienced the greatest incidence of CHD.
Comment by Harold L. Karpman, MD, FACC, FACP
The results of Todaro et al appear to confirm previously reported data examining the relationship between negative emotions and CHD by providing additional evidence that negative emotions are independent risk factors for the development of CHD even after controlling for traditional risk factors and those associated with the metabolic syndrome and for the effects of sympathetic nervous activity. Social anxiousness and/or cognitive interference significantly predicted the development of CHD. However, depressed mood, which has been reported in a number of previous studies to be an independent risk factor for cardiac morbidity and mortality, was only marginally related to CHD incidence. A number of study limitations (ie, sample size and selection, character of events considered in the measurement of CHD incidence, overall small number of events, etc) may have contributed to the results that were not in complete agreement with previous studies. However, it is also quite possible that when depressed mood is isolated from other aspects of the depressive experience, its impact on the development of CHD is weakened.
In summary, the biological effects of stress are multifaceted and may be manifested by a variety of psychiatric and mood abnormalities. Although the depressed mood may be only marginally related to CHD incidence, other stress-related reactions such as anger, hostility and/or aggression have all been shown to influence the occurrence of symptomatic CHD. In fact, it would be well for all of us to pay close attention to the conclusions of that famous 18th-century surgeon John Hunter who, when commenting upon the occurrence of sudden, unexpected death, indicated, "My life is at the mercy of any scoundrel who chooses to put me in a passion."
Dr. Karpman, Clinical Professor of Medicine, UCLA School of Medicine, is Associate Editor of Internal Medicine Alert.
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2. Shulz R, et al. Arch Intern Med. 2000;160:1761-1768.
3. Anda R, et al. Epidemiology. 1993;4:285-294.
4. Kubzansky LD, et al. Circulation. 1997;95:818-824.
5. Kawachi I, et al. Circulation. 1994;98:225-229.
6. Anda R, et al. Epidemiology. 1993;4:285-294.