The Many Emotions of the Heart
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP
Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV
Dr. Gupta reports no financial relationships relevant to this field of study.
Synopsis: In the study of myocardial infarction survivors with 10 years of follow-up, high level of anxiety was associated with an increase in all-cause mortality, with the association being strongest in the first 3 years.
Source: Wrenn KC, et al. Anxiety, anger, and mortality risk among survivors of myocardial infarction. Am J Med 2013; Sep 28. [Epub ahead of print].
Heart disease is the leading cause of death for both men and women in the United States. Each year, it is estimated that approximately 600,000 people die from heart disease, accounting for 1 in every 4 deaths. Approximately 715,000 Americans have a myocardial infarction (MI) each year.1 A significant number of patients have recurrent MI. When lost productivity costs are included, coronary heart disease costs our nation $108.9 billion each year.
There is increasing evidence that various psychosocial stressors such as anxiety, depression, and anger may lead to a higher rate of acute cardiovascular events. such as MI and sudden cardiac death. However, when studies have been conducted, the results have not been conclusive. While some studies have demonstrated that type A personality traits such as anger, hostility, and cynicism are associated with increased long-term cardiovascular risk, others have failed to demonstrate that link.2,3 The conflicting results may be attributed to inconsistent study methodologies applied, including different follow-up periods and study measurement instruments.
Wrenn et al conducted a prospective cohort study of 1968 participants who were recruited at the time of hospital admission for MI between 1989 and 1996 from 64 medical centers. These participants were then followed for all-cause mortality through December 31, 2007 using the National Death Index. The average age of the study participants was 60.2 years and 30.6% were women. Approximately 25.8% had a history of prior MI. Study participants were administered the anxiety and anger subscales of a widely utilized and validated research instrument called the State-Trait Personality Inventory. Over 10 years of follow-up, 525 (27%) participants died, including 326 who died of cardiovascular disease.
The researchers found that an anxiety score rating of > 90th percentile was associated with a 1.31 times higher all-cause mortality rate (95% confidence interval [CI], 0.93-1.84) compared to those with lower scores. Although this overall association was not statistically significant, there was a statistically significant association for higher all-cause mortality in the first 3 years (hazard ratio [HR], 1.78; 95% CI, 1.08-2.93), but not afterward. An anger score rating of > 90th percentile was associated with a 1.25-times higher all-cause mortality rate (95% CI, 0.87-1.80) with a stronger association in the first 3 years than in subsequent years, but neither was statistically significant. In a secondary analysis of cardiovascular mortality, there was a higher rate of cardiovascular death among those with higher anxiety scores. Compared with those scoring low on the anxiety scale, a score rating of > 90th percentile was associated with an HR of 1.17 (95% CI, 0.74-1.86) over 10 years.
The study authors concluded that in the study of MI survivors, a high level of anxiety was associated with an increase in all-cause mortality, with the strongest association in the first 3 years of follow-up.
Links between the heart and emotion have been postulated for centuries. However, it is only recently that data supporting this connection have become available. In the current study of MI survivors, Wrenn et al found that high levels of anxiety were significantly associated with a higher rate of all-cause mortality with the strongest association being in the first 3 years of follow-up. These data support the growing body of evidence suggesting that negative affective states, including anxiety, can lead to an increased risk for cardiovascular disease development, recurrent disease, and poor long-term prognosis. Although a wide range of evidence supporting depression as a risk factor for cardiovascular disease exists, there has not been such a clear proven link between cardiovascular disease, all-cause mortality, and anxiety. While it is not yet clear whether anxiety leads to a more rapid progression of coronary artery disease, there may be several hypothesized mechanisms by which emotional stress and anxiety might trigger an acute myocardial event. Such mechanisms may include increases in blood pressure, heart rate, vascular tone, and platelet aggregation that may ultimately cause plaque instability and rupture leading to an acute event.
It is, therefore, important that we address and manage anxiety as a symptom, especially in those patients who have existing coronary heart disease since there is evidence that psychological treatments appear effective in treating patients with these symptoms. However, uncertainty still remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.4 While I would address anxiety in my patients, I also hope we can conduct more research to evaluate whether such treatments would not only prevent recurrent myocardial events but also lead to a reduction in cardiovascular and all-cause mortality.
- Go AS, et al. Executive summary: Heart disease and stroke statistics - 2013 update: A report from the American Heart Association. Circulation 2013;127:143-152.
- Chida Y, Steptoe A. The association of anger and hostility with future coronary heart disease: A meta-analytic review of prospective evidence. J Am Coll Cardiol 2009; 53:936-946.
- Nakamura S, et al. Prognostic value of depression, anxiety, and anger in hospitalized cardiovascular disease patients for predicting adverse cardiac outcomes. Am J Cardiol 2013;111:1432-1436.
- Whalley B, et al. Psychological interventions for coronary heart disease: Cochrane Systematic Review and Meta-analysis. Int J Behav Med 2012; Nov 24. [Epub ahead of print].