Physicians' Academy for Cardiovascular Education

Increased incidence of major CV events after death of partner

Literature - Carey IM et al., JAMA Intern Med. 2014 - JAMA Intern Med. February 24, 2014

 

Increased Risk of Acute Cardiovascular Events After Partner Bereavement - A Matched Cohort Study

 
Carey IM, Shah SM, DeWilde S et al.
JAMA Intern Med. February 24, 2014. doi:10.1001/jamainternmed.2013.14558
 

Background

Bereavement has long been recognised as a risk factor for increased mortality, specifically from cardiovascular (CV) disease [1]. Two recent meta-analyses summarised the available literature, one of which estimated a 41% increase in mortality in the first 6 months after the death of a spouse [2,3]. Specific association with CV mortality have been investigated, but statistical power was generally insufficient to obtain precise estimates [4,5].
Bereavement may be an exemplar for a range of adverse acute life events, such as unemployment or divorce, for which effects may persist. The effect of bereavement across a range of life-threatening acute CV events is, however, unclear.
This study uses a large UK  primary care database (The Health Improvement Network: THIN [6]) to examine the incidence of fatal and non-fatal myocardial infarction (MI), stroke, acute coronary syndrome (ACS) and pulmonary embolism (PE) in the months after a partner has passed away. 83588 controls were matched to 30447 bereaved individuals (3 to 1 matching), all from different-sex couples (aged 60-89 at study initiation) with an age difference of 10 years or less.
 

Main results

  • Within 30 days after their partner’s death, 50 bereaved (0.16%) individuals had experienced an MI or stroke, as opposed to 67 nonbereaved (0.08%) persons. After 1 year 390 bereaved individuals (1.28%) had experienced MI or stroke, and 927 nonbereaved controls (1.11%).
  • Incidence rate ratios (IRRs) for bereaved vs. control individuals 30 days after bereavement was 2.20 (95%CI: 1.52-3.15) for an MI or stroke. After 90 days, risk had attenuated, to IRR: 1.35 (95%CI: 1.03-1.76), and no difference was seen for the remainder of the first year (IRR: 1.00, 95%CI: 0.88-1.15).
  • Considering the risk of MI or stroke separately gave similarly increased risk estimates, as well as for a composite outcome including ACS and PE.
  • Not enough events occurred in the first 30 days for non-MI ACS and PE, but IRRs were similarly raised for both during the first 90 days, as for MI and stroke.
  • Stratification by sex, age at bereavement, prior CV disease and receipt of CV medication hinted at trends towards more MI or stroke in bereaved women as compared with men, and a larger relative effect of bereavement in bereaved patients without prior CV diagnosis or medication, but a lack of statistical power did not allow further study of effect modification.
 

Conclusion

This study showed a marked increase in the incidence of major CV events in older individuals in the months after the death of their partner. MI, stroke, ACS and PE all separately showed this associations. Thus, this study confirms the potential of major life events to lead to short-term increases in the risk of fatal and non-fatal CV events. The novel findings on PE reported here support the hypothesis that bereaved individuals may be predisposed to a prothrombotic state. Understanding of the physiological mechanisms underlying this effect may help find opportunities for prevention and improved clinical care in this period.
 
Find this article online
 

References

1. Parkes CM, Benjamin B, Fitzgerald RG. Broken heart: a statistical study of increased mortality among widowers. Br Med J. 1969;1(5646):740-743.
2. Moon JR, Kondo N, Glymour MM, Subramanian SV.Widowhood and mortality: ameta-analysis. PLoS One. 2011;6(8):e23465. doi:10.1371/journal.pone.0023465.
3. Shor E, Roelfs DJ, Curreli M, et al. Widowhood and mortality: ameta-analysis and meta-regression. Demography. 2012;49(2):575-606.
4. Hart CL, Hole DJ, Lawlor DA, et al. Effect of conjugal bereavement on mortality of the bereaved spouse in participants of the Renfrew/Paisley Study. J Epidemiol Community Health. 2007;61(5):455-460.
5. Kaprio J, Koskenvuo M, Rita H. Mortality after bereavement: a prospective study of 95,647 widowed persons. Am J Public Health. 1987;77(3):283-287.
6. Bourke A, Dattani H, Robinson M. Feasibility study andmethodology to create a quality-evaluated database of primary care data. Inform Prim Care. 2004;12(3):171-177.