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Fear of Dying During Heart Attack May Make Matters Worse
Date:6/2/2011

By Amanda Gardner
HealthDay Reporter

WEDNESDAY, June 1 (HealthDay News) -- People who become very afraid of dying in the moments during and days after a heart attack also seem to have more inflammation, an indicator that they may, in the long run, do worse than patients who are less fearful, a small British study suggests.

The finding, published online June 1 in the European Heart Journal, "reminds us of the connection between the mind and the body," said Dr. Suzanne Steinbaum, a preventive cardiologist with Lenox Hill Hospital in New York City.

"This trial shows us that when patients are so fearful, there's an increase in inflammation and decrease in heartbeat variability, which could lead to poor outcomes. So we must address not only the body issues but the mind issues as well," she said.

Added Dr. Robert Gramling, associate professor of family medicine at the University of Rochester Medical Center in New York: "This and the vast literature related to emotions and mind/body interactions are confirmatory that understanding people's emotional response does interplay with the biologic mechanisms. I believe, yes, attending to emotions is extraordinarily important, not only for the well-being of the individual's emotional and mental health but also for physical health and maybe even evolution of myocardial infarction [a heart attack]."

For the new study, researchers assessed 208 patients who had come to St. George's Hospital in London with acute coronary syndrome -- blockage of the coronary arteries -- during an 18-month time frame. They were asked during their hospital stay about their fear of dying. At the same time, the researchers also measured blood levels of tumor necrosis factor (TNF), which is involved in triggering inflammation.

Three weeks later, the researchers visited patients in their homes and measured heart rate variability and levels of the stress hormone cortisol in the saliva.

One in five patients reported feeling extreme distress and fear of dying, while two-thirds experienced more moderate emotional reactions. People who were younger, poorer and unmarried (possibly indicating social isolation) were more likely to have intense reactions, the study found.

Fear of dying was associated with a fourfold increase in TNF levels at time of admission to the hospital. Three weeks later, TNF levels were found to be linked with lower heart rate variability and lower cortisol levels.

Lower heart rate variability levels have been linked with higher death rates after a heart attack, while lower cortisol levels may indicate that the body isn't able to quell the inflammation caused by a heart attack.

To the researchers' surprise, having had a previous heart attack didn't influence how scared the patients were.

The study does have some limitations, including the fact that some 23 percent of the patients dropped out after three weeks; there were few women; and most patients had STEMI (ST-elevation myocardial infarction), the more severe type of heart attack, meaning that the findings can't really be extrapolated to non-STEMI heart attacks.

"It's a very small study, it's predominantly those with STEMI heart attacks and, most of the patients, we don't know all the clinical information," said Dr. Stephen Green, associate chairman of cardiology at North Shore University Hospital in Manhasset, N.Y.

Nor does the study answer the "chicken-and-egg" question of whether emotional distress caused the biological findings or vice versa.

"The study provokes a lot of thoughts in terms of what physicians should do with patients and what patients should do for themselves and [directions for] future research. [But] it's just a beginning in my mind and something that we shouldn't translate into changing our practices at this point," Green said.

More information

The American Heart Association has more on acute coronary syndrome.

SOURCES: Suzanne Steinbaum, D.O., preventive cardiologist, Lenox Hill Hospital, New York City; Robert Gramling, M.D., D.Sc., associate professor of family medicine, University of Rochester Medical Center, Rochester, N.Y.; Stephen Green, M.D., associate chairman of cardiology, North Shore University Hospital, Manhasset, N.Y.; June 1, 2011, European Heart Journal, online


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