Does Physical Exhaustion Cause Heart Disease?

abstract & commentary

Synopsis: The results of a prospective observational study confirm that a frequent sense of exhaustion appeared to be independently associated with increased risk of CHD mortality in men.

Source: Cole SR, et al. Am J Cardiol 1999;84:1401-1405.

Vital exhaustion, a combination of fatigue, lack of energy, feelings of hopelessness, loss of libido, and increased irritability, has been suggested to be a significant risk indicator for the development of coronary artery heart disease (CAD).1 The age-adjusted relative risk of developing an acute myocardial infarction in patients afflicted with vital exhaustion has been reported2,3 to be 2.3 (P > 0.001). However, it has been unclear as to whether or not an association existed between vital exhaustion and the development of CAD in those individuals independent of other potentially significant factors such as associated depression, sleep disturbances, and/or physical inactivity.

Cole and associates from the Division of Preventive Medicine of the Brigham and Women’s Hospital and the Harvard Medical School evaluated the degree of vital exhaustion among 5053 male college alumni who were free of cardiovascular disease, cancer, and chronic pulmonary obstructive disease on a health survey in 1980. The subjects were asked, "How often do you experience a sense of exhaustion (except after exercise)?" During a 12-year follow-up period, 15 men died of a variety of illnesses and 25% of these were found to have died of CAD. After adjustment for age, body mass index, smoking status, and history of physician-diagnosed diabetes and/or hypertension, a frequent sense of exhaustion was associated with a two-fold increase in coronary heart disease (CHD) mortality. The significance became somewhat blunted when adjustments were made for insomnia, sleep duration, use of sleeping pills and/or tranquilizers, physical inactivity, history of physician-diagnosed depression, and the degree of regular alcohol intake.

Comment by Harold L. Karpman, MD, FACC, FACP

A previous prospective study has demonstrated that vital exhaustion was associated with an age-adjusted relative risk of 2.3 for myocardial infarction.2,3 A second prospective study of 3365 men followed over a period of 9.5 years revealed that those individuals who reported that "at the end of the day I am completely exhausted mentally and physically" were at risk of cardiac death in a time-dependent fashion with risk ratios of CHD death of 8.96, 6.33, 4.47, and 3.16 for the first 10, 20, 30, and 40 months respectively of the study (P > 0.05 for each risk ratio).4

The results of the prospective observational study reported by Cole et al confirm that a frequent sense of exhaustion appeared to be independently associated with increased risk of CHD mortality in men. Although several previous studies have suggested that sleep complaints have been associated with increased risk of myocardial infarction and CHD mortality,6,7 adjustment for insomnia did not appear to attenuate the association between exhaustion and CHD mortality. In addition, Cole et al’s findings suggested there was no association between exhaustion and CHF mortality in patients regardless of whether they were depressed or not.

It has been hypothesized that a sense of exhaustion may effect CHD end points by decreasing heart rate variability, increasing platelet aggregability, and/or by altering health behaviors. Altered heart rate variability has been implicated as a potential pathway through which anxiety, social psychological stresses, and/or depression may effect the incidence of symptomatic CHD however, it must be clearly recognized that the available data regarding the association between exhaustion and heart rate variability is not conclusive at this time. There has been some suggestion that fibrinolytic capacity is reduced in exhausted patients, but there has been no hard data on the association between exhaustion and fibrinolytic activity or between exhaustion and CHD end points. Finally, it should be recognized that a sense of exhaustion may actually be a sign of subclinical heart disease and may be present before the onset of cardiac symptomatology occurs.

It would seem that regardless of whether a sense of exhaustion causes CHD or simply suggests that subclinical disease of a silent nature is present, the significant findings on this prospective study lend support to previously reported studies suggesting that there is an increased risk of CHD in patients who complain of pervasive exhaustion. Further, well controlled studies in both men and women are certainly indicated. It goes without saying that it is incumbent upon physicians to properly counsel their patients to acquire an adequate amount of sleep and, if they continue to feel exhausted despite having adequate sleep, a complete cardiac workup would be in order to rule out the presence of silent ischemic heart disease and/or the presence of incipient congestive heart failure.


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4. Appels A, et al. Int J Cardiol 1987;17:15-24.

5. Appels A, et al. Activitas Nervosa Superior 1987;29: 147-151.

6. Schwartz SW, et al. Ann Epidemiol 1998;8:384-392.

7. Kop WJ, et al. Psychosom Med 1998;60:352-358.