The other heart attack risks - anger - grief - fear
By Judy Foreman
06/24/1996

But just as you can protect against physical triggers, you can protect against the dangers of emotional stress.

This suggested, at least to Harvard School of Public Health epidemiologist Dimitrios Trichopoulos, that mental stress had triggered the increased deaths, most of them from heart attacks.

Back in 1983, when Trichopoulos published his findings in a medical journal, the notion that strong emotions could trigger a nearly-instant heart attack was anathema to many doctors, though lay people were often inclined to believe it.

Although it had been popular since the mid-70s to think that people with hard-driving ``Type A'' personalities were more prone to heart attacks than others, these early attempts to link emotions to heart disease had looked mainly at lifelong traits, not at a person's mood right before a heart attack.

But after years of focusing on longterm personality styles and chronic physical factors like high blood pressure and cholesterol, researchers are now finding considerable evidence that heart attacks can be ``triggered'' by immediate events as well, including powerful emotions like grief, fear and anger in the hours before an attack.

Lest merely reading about such triggers set hearts dangerously aflutter, a bit of perspective:

``We all have stressful experiences and most of us don't have heart attacks'' because of them, points out David S. Krantz, a medical psychologist at the Uniformed Services University in Bethesda.

Furthermore, most of the people who do have a heart attack after an identifiable triggering event have underlying heart disease that puts them at higher risk, says Dr. James Muller, chief of the cardiovascular division at Deaconess Hospital.

``And even people with underlying heart disease may not be vulnerable to a trigger, including emotional stress, at any given moment,'' he adds.

Yet heart specialists are taking emotional triggers increasingly seriously because both mental stress and cardiovascular disease are so common. Cardiovascular disease is the No. 1 cause of death in America, killing one person every 34 seconds. About 1.5 million Americans have a heart attack every year, and a quarter of a million die before reaching a hospital.

Futhermore, evidence is mounting that emotions can trigger heart attacks, especially in people with heart disease. The primary villains:

-- Anger. Last year, in a study of more than 1,600 heart attack survivors, Dr. Murray Mittleman and others at Deaconess found that in the two-hour period after someone feels intense anger, heart attack risk more than doubles, just as it does in the two hours after sex.

To be sure, says Mittleman, because the baseline risk of a heart attack is about one in a million for a healthy 50-year-old man in any given hour, this means anger -- or sex -- temporarily raises the risk to just 2 in a million, a seemingly small hazard. For people with known heart disease, the average baseline risk is 10 in a million in any given hour; anger or sex raises it to 20 in a million.

``But while this may seem trivial,'' he says, ``it's not, because people get angry far more often than they have sex.''

In fact, people who are chronically angry -- especially those with what researchers now call a ``hostile'' rather than a Type A personality -- are at increased risk of dying not just from heart attacks but from all causes, says Dr. Redford Williams, a Duke University internist and author of the 1993 book, ``Anger Kills.''

Hostility is defined as an unlovely combination of cynicism, anger and aggressiveness.

-- Grief. In a study of 1,774 heart attack patients reported at an American Heart Association meeting, Mittleman found that the death of a loved one raises the risk of heart attack 14-fold for the next 24 hours -- significantly more than anger or sex.

As with anger and sex, grief seems to pose the greatest risk for people with underlying heart disease. But unlike anger and sex, the heightened risk from grief declines very slowly, often persisting a month or more, albeit at ever-lower levels.

-- Fear. Israeli researchers reported last year that on the January day in 1991 that the SCUD missile attack began during the Gulf War, there was a marked increase in deaths, even though nobody died of injuries caused by the missiles.

Most of the deaths were attributed to cardiovascular disease, including sudden cardiac death, which can be caused by blockages in arteriesor by abnormal heart rhythms. This year, other researchers also found the incidence of sudden cardiac death was higher in the first 10 days of the Gulf war, but not enough to be statistically significant.

Yet researchers say there is virtually no question that fear played a role in the nearly 5-fold increase in deaths from cardiac causes on the day of the 1994 Los Angeles quake.

-- Stress. This month, Duke University researchers led by psychologist James A. Blumenthal found that stress -- like public speaking anddoing arithmetic -- significantly increased the risk of potentially fatal heart problems and ischemia, or decreased blood flow to the heart, at least in people who have heart disease and score poorly on exercise treadmill tests.

The more researchers study emotional triggers of heart attacks, the more they think mental stresses affect the heart in ways different from physical stresses like sudden exertion.

Both types of stress cause a surge of hormones, including adrenalin and noradrenalin, that make blood pressure and heart rate soar. The increase in the force and flow of blood through arteries can cause fatty plaques in artery walls to rupture, allowing clots to form and block blood flow to the heart.

Adrenalin can also trigger potentially fatal disturbances in heart rhythm, especially in people with heart disease. And it can make platelets in the blood more likely to clot and cause spasms in arteries, causing them to constrict too much.

In healthy people, a physical stress like running makes the arteries dilate, sending more blood to the heart to meet its increased demand, says medical psychologist Krantz.

But in someone with coronary artery disease, the arteries do not dilate properly, which means the heart gets too little blood. Angina, or chest pain, often results.

With emotional stresses, however, the heart does not ``demand'' as much blood as it does with physical stress, says Krantz. But because blood vessels often constrict in emotional stress, the heart may still get less blood than it needs.

Unlike ischemia caused by physical stress, ischemia from emotional stress is more often painless.

Fortunately, researchers are finding ways to reduce heart attack risk from both physical and emotional causes.

To combat longterm, chronic risk, Mittleman says, the old standbys still hold: Quit smoking, eat sensibly and exercise to keep blood pressure and cholesterol down.

In fact, if you're sedentary and have heart disease, regular exercise can virtually abolish the risk of heart attack from sudden exertion.

And if it's acute triggers like anger that worry you, there's also lots you can do, including taking aspirin.

``It's like the straw the broke the camel's back,'' says Mittleman. ``The longterm, chronic things like high blood pressure are the straws that have accumulated over time.

``Anger or other strong emotions can be the final trigger. But it's all the risk factors together that determine whether or when a heart attack occurs.''

To reduce risk further, you might also consider taking aspirin -- if your doctor agrees. Aspirin can reduce chronic heart disease risk, probably by making it harder for the blood to clot, and there is evidence it protects against damage from anger, too.

Other drugs, including beta-blockers that dampen the effect of adrenalin and calcium channel blockers that dilate blood vessels, may also combat heart problems triggered by emotional stress, researchers say, though this has not been proven.

Psychological approaches may also reduce risk.

Recent research has shown that socially isolated people fare more poorly after a heart attack than others. That has prompted a consortium of researchers from Harvard, Yale and other centers to begin a study called ENRICHD to see if cognitive or group therapy improve outcomes in such people after a heart attack.

Dr. Herbert Benson, president of the Mind/Body Institute at Deaconess Hospital, advocates ``the relaxation response'' to offset emotional stress. If you meditate for 10 to 20 minutes a day for several weeks, he says, the stress hormone adrenalin has less effect. People who meditate also get less angry, he says.

And if you do get angry, how you manage that anger counts, too, says Mara Julius, a psychosocial epidemiologist emeritus at the University of Michigan School of Public Health.

The evidence is mixed, but she says expressing anger may be more healthful keeping it in. The best approach, she says, may be to practice ``reflective coping'' -- rationally trying to solve the problem that prompted the anger in the first place.

Dr. Redford Williams, a Duke University internist, says when you get angry, you should ask yourself three questions:

• Is this really important to me?
• Is my anger appropriate to the situation?
• Is there anything I can do to fix the situation?

If you answer no to any one of these, just chill out.

If you answer yes to all three, he says, ``action is called for. If it's a problem with another person, the solution is to be assertive, rather than blowing up or screaming.''

``If it's a situational problem and there is no other person to be assertive with, like when an airline cancels your flight, go out and run to discharge adrenalin,'' he says, and if you can't do that, meditate or think about your next vacation.

``This is all damage control when you're angry,'' he says. But it's better to reduce anger in the first place, which may be easier than you think.

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To General Medicine 1996