Author + information
- Loes Smeijers, PhD,
- Elizabeth Mostofsky, MPH, ScD,
- Geoffrey H. Tofler, MD,
- James E. Muller, MD,
- Willem J. Kop, PhD and
- Murray A. Mittleman, MD, DrPH∗ ()
- ↵∗Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, 375 Longwood Avenue, Room 441, Boston, Massachusetts 02215
Transient episodes of heavy physical exertion (1) and psychological stressors, such as high levels of anger and anxiety (2), are associated with an immediately higher risk of myocardial infarction (MI) and other cardiovascular events, but little is known about the long-term prognosis of patients surviving an MI after these potential acute triggers. In this study, we evaluated whether high levels of physical exertion, anger, and anxiety in the 2 h before MI is associated with a higher rate of 10-year all-cause mortality.
As described previously (1,2), 3,886 MI patients were recruited between 1989 and 1996. Anger and anxiety data were available for 2,176 participants, comprising the present study population. Within a median of 4 days after MI admission, participants were interviewed about the time of symptom onset; the last time they experienced high levels of anger, anxiety, and exertion; and, for comparison purposes, their exposure 24 to 26 h before MI. High physical exertion was defined as self-reported exertion ≥6 metabolic equivalents. High anger and anxiety was defined as a State-Trait Personality Inventory score modified to assess the 2-h short-term exposures above the 90th percentile (2). The primary outcome was 10-year all-cause mortality based on the National Death Index, as described previously (3).
We used Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CI). Multivariable models were adjusted for covariates selected a priori including demographics (age, sex, age*sex, race, marital status, education, income), health behaviors (smoking status, alcohol consumption, body mass index, usual frequency of physical exertion), medical history (history of MI; congestive heart failure; angina; hypertension; diabetes mellitus; noncardiac comorbidities including stroke, cancer, respiratory disease, and renal failure), thrombolytic therapy, peak creatine kinase, and medication use.
Among 2,176 participants (mean 60.1 ± 12.5 years of age, 29.2% women, 89.0% white), 26% had a prior MI, and the peak creatine kinase level was 1.5 ± 1.9 U/l. In the 2 h before MI, high levels of physical exertion, anger, or anxiety were reported by 128 (6%), 205 (9%), and 204 (9%) patients, respectively.
Over 10 years of follow-up, 580 (27%) patients died. Compared to people reporting no anxiety before MI, the mortality rate was 44% higher (adjusted HR: 1.44; 95% CI: 1.09 to 1.91) for people reporting anxiety in the 2 h before MI. High levels of anger (adjusted HR: 1.34; 95% CI: 0.98 to 1.82) and physical exertion (HR: 1.15; 95% CI: 0.73 to 1.79) before MI were associated with higher mortality rates, but the associations did not reach statistical significance. After adjusting for anxiety in the 24 to 26 h before MI, anxiety during the 2 h before MI remained a statistically significant predictor of mortality (HR: 1.44; 95% CI: 1.01 to 2.06).
Prior research by Brodov et al. (4) found that among 662 MI patients there was no association between physical or emotional precipitants of MI and 1-year mortality, which may in part reflect low statistical power. Arnold et al. (5) found perceived stress at the time of MI was associated with a 42% (95% CI: 1.15 to 1.76) higher rate of 2-year mortality. However, the measure used did not evaluate acute stress before MI. We did not find an association between exposure to high levels of physical exertion before MI and subsequent mortality, possibly because patients with an MI preceded by physical exertion were relatively young with less comorbidity. There were also fewer participants who reported heavy physical exertion immediately before MI onset compared to the number who reported anger and anxiety. The analyses for anger and anxiety 0 to 2 h before MI did not change when adjusting for exposure 24 to 26 h before MI, but this does not rule out the potential role of trait levels of these psychological factors.
In conclusion, anxiety immediately before MI onset is associated with a higher 10-year all-cause mortality rate. Future research is needed to determine the characteristics of patients who are at risk of MI immediately after emotional stressors and whether specific subgroups have a worse prognosis after MIs preceded by emotional stressors.
Please note: This work was supported by grant HL-120505 from the U.S. National Institutes of Health to Dr. Mostofsky, and by an intramural grant from Center of Research on Psychology in Somatic Diseases (CoRPS), Tilburg University, the Netherlands, to Dr. Smeijers and Dr. Kop. No funding organization had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation of the manuscript. Dr. Muller is the Chief Medical Officer of Infraredx, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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