Can anger outbursts trigger acute cardio vascular events? Euro Heart Journal. adv access.March 2014

04.03.2014

Many small studies have reported that episodes of anger are associated with a transiently higher risk of myocardial infarction (MI), acute coronary syndrome (ACS), ischaemic and haemorrhagic stroke and arrhythmia.

Elizabeth Mostofsky, Elizabeth Anne Penner and Murray A. Mittleman from Harvard report the results of a meta analysis looking at these associations.

They included nine independent case-crossover studies, with 4546 cases of MI, 462 ACS, 590 Ischemic stroke, 215 haemorrhagic stroke and 306 arrhythmia cases. Most studies used ‘Onset anger scale’ to rate the anger. Studies differed in cut off scores for exposure and the methods of collecting information.

Results:

 There was a 4.74 (95% CI: 2.50 – 8.99; P , 0.001) times higher risk of MI or ACS in the 2 h following outbursts of anger compared with other times. 4 studies included showed heterogeneity in results. However it is safe to conclude that there is evidence of higher MI/ACS risk following episodes of anger.

There was a 3.62 (95% CI: 0.82–16.08; P 1⁄4 0.09) times higher rate of ischaemic stroke in the 2 h following an outburst of anger compared with other times. Heterogeneity between the two studies limit use of pooled estimate of risk.

One study reported   a 6.30 (95% CI: 1.60 – 25.0) times higher rate of ruptured intracranial aneurysm in the hour following an outburst of anger.

As these anger outbursts are infrequent and transient, absolute risk increase is smallThe absolute risk is higher for individuals with a higher baseline cardiovascular risk and individuals who have frequent outbursts of anger. 

 Absolute risk is small: Based on the  estimate of a 4.74 times higher rate of MI or ACS in the 2 h following outbursts of anger, the absolute impact of one episode of anger per month is only one excess cardiovascular event per 10 000 individuals per year at low (5%) 10-year cardiovascular risk and four excess cardiovascular events per 10 000 individuals per year at high (20%) 10-year cardiovascular risk.

The absolute impact is higher for individuals with more frequent episodes of anger; five episodes of anger per day would result in 158 excess cardiovascular event per 10 000 per year for individuals at low (5%) 10-year cardiovascular risk and a similar frequency of anger outbursts would be associated with 657 excess cardiovascular events per 10000 per year among individuals at high (20%) 10-year cardiovascular risk.

Impact of anger outbursts may be modified by trait anger. It is possible that an individual with an angry temperament is constantly at a relatively high level of physiological activation and is acclimated to the physiological response to anger. Sympathetic activation, haemodynamic changes and stimulation of inflammatory and prothrombotic responses can mediate anger and the above outcomes.

Review establish that there is consistent evidence of a higher risk of cardiovascular events immediately following outbursts of anger. Beta blockers, SSRI and psychosocial interventions may reduce anger outbursts and improve impulse control.   

Conclusion:

There is a higher risk of MI, ACS, ischaemic and haemorrhagic stroke and arrhythmia in the 2 h following outbursts of anger. 

Summary of the article:

Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis. Elizabeth Mostofsky, Elizabeth Anne Penner, and Murray A. Mittleman. European Heart Journal doi:10.1093/eurheartj/ehu033

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