Don't Get Too Tired It's Bad for Your Heart
Abstract & Commentary
By Harold L. Karpman, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman reports no financial relationship to this field of study.
Synopsis: Vital exhaustion predicts long-term risk for adverse cardiac events in men and women, independent of established biomedical risk factors.
Source: Williams JE, et al. Vital exhaustion as a risk factor for adverse cardiac events (from the Athersclerosis Risk In Communities [ARIC] Study). Am J Cardiol 2010;105:1661-1665.
Vital exhaustion, which had been defined as a state of excessive fatigue, increased irritability, and demoralization, has been associated with an increased incidence of coronary artery disease (CAD) in many published studies coming from Europe. However, there have been no population-based studies measuring the effect of vital exhaustion on acute coronary syndromes in the U.S. population. Therefore, Williams and associates decided to examine the predictive value of vital exhaustion for incident myocardial infarction or fatal CAD in middle-aged men and women.
They carefully analyzed the data from the Atherosclerosis Risk In Communities (ARIC) study,1 which was a large population-based study of the cause and natural history of atherosclerosis. They attempted to determine whether subjects with high vital exhaustion were at increased risk for incident myocardial infarction (MI) and fatal CAD compared to their low-exhaustion counterparts. Vital exhaustion was assessed using the 21-item Maastricht Questionnaire.2 Participants were 12,895 black and white men and women in the ARIC study who were followed for the occurrence of cardiac morbidity and mortality from 1990 through 2002 with a maximum follow-up of 13 years. Persons with high vital exhaustion scores were found to have a significant increase in the number of adverse cardiac events in analyses that were further adjusted for educational level, body mass index, LDL and HDL lipoprotein levels, systolic and diastolic blood pressure levels, presence or absence of diabetes mellitus, cigarette smoking status, and pack-years of cigarette smoking. The authors concluded that persons with vital exhaustion have a higher long-term risk for adverse cardiac events than do those individuals with low vital exhaustion scores, independent of established biomedical risk factors.
Commentary
The biological mechanism that may link vital exhaustion to adverse cardiac events is not well understood; however, it is interesting to note that it is associated with several metabolic, hemodynamic, and immunologic responses that are known to be important in the development and progression of cardiovascular disease. These abnormalities include abnormal lipid metabolism,3 decreased fibrinolysis,4,5 daytime fluctuation in fibrinolytic activity, and low heart rate variability.6 The findings also confirm the results of previous studies, which have demonstrated that women have higher vital exhaustion scores compared to men and a greater frequency of exhaustion just prior to a myocardial infarction,7 and finally, that there exists an inverse association between exhaustion scores and socioeconomic status.8 Also, higher vital exhaustion measurements were obtained in African Americans compared to Caucasian patients. All of these associations may be secondary to increased chronic stress, which occurs more often in African Americans and in people from lower socioeconomic classes. The prospective design of the Williams analysis and the long-term follow-up period of 13 years strengthen the long-term predictive value of the ARIC study findings; however, one must recognize the potential for response biases in the self-reported data, especially the possible inaccuracies resulting from poor recall and/or motivating factors.
In summary, vital exhaustion should be avoided for many reasons, but none more important than the fact that its existence in anyone significantly increases the long-term risk for adverse cardiac events independent of whether established medical risk factors are present. Encouraging adequate rest and avoiding chronic stress are important recommendations for all patients, but are even more important now that we have additional information on the effects of these negative stimuli on the incidence of adverse cardiac events.
References
1. The ARIC investigators. The Athersclerosis Risk In Communities (ARIC) Study: Design and objectives. Am J Epidemiol 1989;129:687-702.
2. Appels A, et al. A questionnaire to assess premonitory symptoms of myocardial infarction. Int J Cardiol 1987;17:15-24.
3. Koertge JC, et al. Vital exhaustion in relation to lifestyle and lipid profile in healthy women. Int J Behav Med 2003;10:44-55.
4. Kop WJ, et al. Relationship of blood coagulation and fibrinolysis to vital exhaustion. Psychosom Med 1998;60:352-358.
5. von Kanel R, et al. Independent relations of vital exhaustion and inflammation to fibrinolysis in apparently healthy subjects. Scand Cardiovasc J 2004;38:28-32.
6. Wantanabe T, et al. Effects of vital exhaustion on cardiac autonomic nervous functions assessed by heart rate variability at rest in middle-aged male workers. Int J Behav Med 2002;9:68-75.
7. Uuskula M, et al. Psychological differences between young male and female survivors of myocardial infarction. Psychother Psyschosom 1996;65:327-330.
8. Schuitemaker GE, et al. Assessment of vital exhaustion and identification of subjects at increased risk of myocardial infarction in general practice. Psychosomatics 2004;45:414-418.
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