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Heart risk 'rises after bereavement'

“Losing a loved one really can break your heart,” reported the Daily Mail. Several other news sources also reported that a study suggests people are 21 times more likely to have a heart attack within a day of being bereaved. In the days that follow, the risk drops to approximately six times higher than normal, and then declines during the following month.

During the study, researchers interviewed 1,985 people who had recently had a heart attack and asked them about whether they had been bereaved in the period immediately before their heart attack. They also asked about bereavement one to six months before their heart attack, which they used to compare the risk of having a heart attack during a period when they had not experienced a loss. They found that compared to this earlier period, the risk of having a heart attack increased 21-fold in the 24 hours after a bereavement.

Most people will experience bereavement infrequently, and the risk of a bereavement-related heart attack is likely to be much lower than one brought on by other heart attack triggers. However, this study highlights that in the first week after losing someone close, people may have an increased risk of a heart attack. Further research is warranted to see whether additional care or advice during this period could reduce this risk.

 

Where did the story come from?

The study was carried out by researchers from Harvard University and was funded by the US National Institutes of Health. The study was published in the peer-reviewed medical journal Circulation.

The newspapers generally covered the research appropriately.

 

What kind of research was this?

This case-crossover study looked at whether intense grief over a recent death may trigger a heart attack. The research looked at deaths of spouses, but also of “significant relationships” such as relatives and close friends.

The research examined the presence or absence of bereavement immediately before people had a heart attack. To do so, the researchers surveyed people who had had a heart attack on whether they had lost someone close to them before their heart attack. This was compared with the presence or absence of bereavement during a period when the individual did not have a heart attack (the control period). They determined the risk of a heart attack during various points in the 30 days immediately after bereavement.

It has long been suggested that it is possible to “die from a broken heart”, and the researchers said that although most people adjust to the loss of a loved one, it has been observed that there is an increased risk of dying in the early weeks and months after a bereavement. This study was particularly interested in whether stress caused by bereavement could affect the likelihood of a heart attack. The researchers thought that grief may affect the heart as it may be associated with psychological symptoms of depression, anxiety and anger, and that such stress may have physical effects on the heart.

 

What did the research involve?

This study used a slightly unusual design, which is often used to investigate how a transient exposure, in this case the death of a significant person in the patient’s life, is associated with heart attack. In this type of study (a form of case-control study), the researchers compared the rates of bereavement in a group of people immediately before a heart attack with the rates in the period six months before the heart attack. In this way, each patient served as their own control.

The study assessed 1,985 people aged 61.6 years old on average, 1,395 of whom were men and 590 women. Between 1989 and 1994, researchers interviewed people attending 22 hospitals and 23 tertiary care centres after a heart attack. All were interviewed within 4 days of their heart attack. They were then followed until December 2007.

The interview asked the participants about standard demographic factors, potential triggers of their heart attack in the past year, and risk factors for heart attacks. In addition, the patients were asked: “During the past year did you hear news of the death of a friend, relative, or someone who was very significant in your life?” If a patient answered “yes”, they were asked to identify the time of occurrence of the death, to describe the relationship to the person who had died and to rate how meaningful this death was to them, choosing between slightly, moderately or extremely.

In their analysis, the researchers looked at the incidence rate of bereavement within 1 day, 2 to 3 days, 3 to 7 days and 7 to 30 days before the heart attack and compared this to a control period of 1 to 6 months before the patient’s heart attack.

 

What were the basic results?

Out of the 1985 patients, 270 (13.6%) reported the death of at least one significant person to them in the 6 months before their heart attack. Of these:

  • 19 people reported the death of a significant person in the 24 hours before the onset of their heart attack
  • 7 people reported the death of a significant person 24–48 hours before their heart attack
  • 5 people reported the death of a significant person 48–72 hours before their heart attack
  • 21 people reported the death of a significant person 4–7 days before their heart attack

Of the people who had a heart attack in the day after the loss of a significant person, 63% said their relationship was moderately or extremely meaningful.

The researchers found that relative to a patient’s risk during the control period, their risk of a heart attack was 21 times greater in the 24 hours after they learned of the death of a significant person. This increased risk then declined steadily with each subsequent day, to a six-fold increased risk by the end of the first week.

 

How did the researchers interpret the results?

The researchers said that the risk of a heart attack was greatly elevated in the first 24 hours after the death of a significant person, and progressively declined over time. They suggested that bereavement may be associated with depression, reduced sleep time, reduced appetite, higher levels of stress hormones and lower levels of proteins influencing heart function. They also said that bereavement may lead to people not taking their medication. However, they also stated that because the largest effects were seen the day after bereavement, it is unlikely that this was due to a missed dose of a drug.

 

Conclusion

This study looked at whether there was an association between a recent bereavement and risk of a heart attack in 1,985 older people. The study had an unusual design. Researchers asked individuals about their bereavement status shortly before a heart attack, and compared this to their status several months before. The researchers calculated that in the 24 hours after a bereavement, the participants had a 21-fold increase in the risk of having a heart attack. The risk then steadily declined after this time.

A key point to consider when viewing these results is that the study looked at the circumstances of people who had had a heart attack, and not the absolute risk of having a heart attack in a group of people who had been bereaved. Therefore, it cannot directly tell us how likely it is that a bereaved person will go on to have a heart attack, a statistic that might be useful when planning ways to care for the recently bereaved.

Also, the research cannot pinpoint the potential mechanisms that might bring on a heart attack after a bereavement. For example, we cannot tell whether it is due to biological causes, such as the release of hormones, or behavioural ones such missing medication. Among the potential reasons the researchers gave were changes in physical activity and stopping or forgetting heart-protective medication, such as aspirin.

The researchers also point out that bereavement of a significant person is likely to be an infrequent event in most people’s lives, and in this study only 270 people had experienced bereavement among the 1,985 interviewed. Among these, only 19 people had had their heart attack within 24 hours of bereavement.

Some other points to note are:

  • As the researchers interviewed people within four days of having their heart attack, the patients may have been looking for reasons to explain their heart attack. Therefore, they may have been more likely to highlight a bereavement immediately before their heart attack than one during the control period.
  • The researchers said that bereavement is rarer than other triggers of a heart attack, such as physical activity or episodes of anger. This means that the absolute lifetime risk of a heart attack associated with bereavement could potentially be extremely low.

In general, this research supports the currently held view that losing a loved one can “break your heart”. However, it does not say much about the mechanism of how this might happen and, crucially, how to avoid the physical effects that may follow a bereavement.

 

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