Why fear of death during a heart attack worsens outcomes
There's no way around being frightened when a heart attack strikes, but according to scientists, if anxiety get too intense, systemic inflammation worsens and weeks later, more heart problems could develop.
Researchers found fear of dying from an acute coronary event causes biological changes that could increase the odds of having a second cardiac event. Results of a study also suggest physicians should talk to their patients about their fears rather than just concentrating on physical outcomes.
Researchers looked at the relationship between intense fear from acute coronary syndrome and release of the inflammatory molecule TNF-alpha, heart rate variability and cortisol levels.
Intense emotion during heart attack promotes more inflammation
Andrew Steptoe, PhD, of University College London, and colleagues, writing online in the European Heart Journal, explained anxiety about dying releases tumor necrosis factor alpha (TNF-alpha), a molecule that promotes widespread inflammation.
Three weeks after a coronary event, patients with high anxiety about death were found to have reduced heart rate variability that is a predictor used to gauge a person’s risk of a future coronary event.
Steptoe says, "Large inflammatory responses are known to be damaging to the heart, and to increase the risk of longer-term cardiac problems such as having another heart attack.” He also explains one in five patients experienced fear of death from a coronary event in the study, even though survival rates have improved over the last decade.
For the research, TNF-alpha levels were measured two to three days after heart attack in 208 patients admitted to George's Hospital (London, UK) between June 2007 and October 2008.
The scientists assessed the patient’s level of distress, finding intense emotions from fear of dying raised inflammatory response four-fold, even for patients whose heart attack was not severe.
Three to four weeks later, home visits were made to the patients to measure heart rate variability (HRV). Low HRV indicates poor heart function. The researchers also measured cortisol – lower levels of the hormone means the body is not controlling inflammation.
Dr. Steptoe says the inflammatory processes that occur from emotions and fear when an acute coronary event occurs “may contribute to poor outcomes in the longer term."
The researchers aren’t certain what causes the release of TNF-alpha, but suggest it might be from injury to the heart, combined with the anxiety of having a heart attack. They also say worse pain, social isolation and being economically deprived could stimulate more intense emotions for patients having acute coronary syndrome (ACS).
"This is an observational study, so we do not know whether helping people overcome their fears would improve the clinical outlook, or whether reducing the levels of acute inflammation would have beneficial emotional effects, but these are possibilities," said Steptoe.
He says the study illustrates the close relationship between emotions and biological responses. A recommendation is for physicians to speak with their patients about the anxiety of having a heart attack, “rather than just concentrating on physical outcomes." The study suggests fear of dying and intense emotions that accompany the event can worsen outcomes.
The authors concluded patients could die prematurely from a heart attack because of their emotions.They say the study "suggests that the 'one size fits all approach' to intervention in (coronary heart disease) patients is unlikely to work and that a personalized medicine approach is warranted."
European Heart Journal. doi:10.1093/eurheartj/ehr132
"Fear of dying and inflammation following acute coronary syndrome"
Andrew Steptoe et al
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