Bereavement is associated with an increased risk of cardiovascular disease and heart attack

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The increased risk of heart attack or “a broken heart” in early bereavement could be reduced by using common medication in a novel way, according to a world-first study led by the University of Sydney and funded by Heart Research Australia.

Lead Investigator Professor Geoffrey Tofler said while most people gradually adjust to the loss of a loved one, there is an increase in heart attack and death among bereaved people, particularly those grieving a spouse or child.

“The increased risk of heart attack can last up to six months.

It is highest in the first days following bereavement and remains at four times the risk between seven days to one month after the loss.”

The study, published in the American Heart Journal, is the first randomized controlled clinical trial to show it is possible to reduce several cardiac risk factors during this time, without adversely affecting the grieving process.

“Bereavement following the death of a loved one is one of the most stressful experiences to which almost every human is exposed,” said Professor Tofler, Professor of Preventative Cardiology at the University of Sydney’s Faculty of Medicine and Health, and Senior Staff Cardiologist at Royal North Shore Hospital.

“Our study is the first clinical trial to examine how the cardiac risk factors could be mitigated during early bereavement.”

About the study

The research team from the University of Sydney, Royal North Shore Hospital and the Kolling Institute enrolled 85 spouses or parents in the study within two weeks of losing their family member.

Forty-two participants received low daily doses of a beta blocker and aspirin for six weeks, while 43 were given placebos.

Heart rate and blood pressure were carefully monitored, and blood tests assessed blood clotting changes.

“The main finding was that the active medication, used in a low dose once a day, successfully reduced spikes in blood pressure and heart rate, as well as demonstrating some positive change in blood clotting tendency,” said Professor Tofler.

The investigators also carefully monitored the grief reaction of participants.

“We were reassured that the medication had no adverse effect on the psychological responses, and indeed lessened symptoms of anxiety and depression,” said Professor Tofler.

“Encouragingly, and to our surprise, reduced levels of anxiety and blood pressure persisted even after stopping the six weeks of daily beta blocker and aspirin.”

Co-investigator Associate Professor Tom Buckley said the study builds on the team’s novel work in this area with their earlier studies among the first to identify the physiological correlates of bereavement.

“While beta blockers and aspirin have been commonly used long term to reduce cardiovascular risk, they have not previously been used in this way as a short-term preventative therapy during bereavement,” said Associate Professor Buckley of the University of Sydney Susan Wakil School of Nursing and Midwifery.

Implications and next steps

The authors acknowledge that larger long-term studies are needed to identify who would benefit most however the findings provide encouragement for health care professionals to consider this preventative strategy among individuals that they consider to be at high risk associated with early bereavement.

“Our finding on the potentially protective benefit of this treatment is also a good reminder for clinicians to consider the well-being of the bereaved,” said Associate Professor Buckley.

“Our study is the first clinical trial to examine how the cardiac risk factors could be mitigated during early bereavement.”

“Future studies are needed to assess if these medications could be used for other short periods of severe emotional stress such as after natural disasters or mass bereavement where currently there are no guidelines to inform clinicians.”

Co-investigator Dr. Holly Prigerson, Co-Director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York, said, “This is an important study because it shows ways to improve the physical and mental health of at-risk bereaved people.

It is a preventive intervention that is potentially practice-changing, using inexpensive, commonly available medicines.”

People experiencing cardiac symptoms should discuss their condition with a health care professional before taking medication as incorrect use could be harmful.

Funding: The study was funded by Heart Research Australia. The study protocol was approved by the Institutional Review Board of Northern Sydney Health Ethics Committee, Australia. The authors declare no competing interests.


The relation between bereavement and mortality was different in men and women and varied by CVD status. Bereavement decreased mortality in women with CVD and increased mortality in men without CVD.

It is well documented that late-life spousal bereavement is associated with excess risk of mortality. (1,2)

Excess mortality in widowed populations is highest in the early months after bereavement and decreases over time. (3,4) Even though the mortality of bereavement has been described in several populations, the role of modifying factors after bereavement such as incident cardiovascular disease (CVD) and depressive symptoms are not well understood.

(3) Bereavement increases the risk for cardiovascular events (5) and depressive symptoms (6). Each of these factors—bereavement, (14) CVD, (7) and depression (7) – have been independently linked to mortality, but they have not been examined together in a single study.

It is not known whether CVD and depression modify the association between bereavement and mortality.

The goals of this study are to determine whether or not CVD and depression modify the association of bereavement with 3-year mortality in older men and women.

We also want to determine whether depression after spousal death attenuates the association between bereavement and mortality.

Traditional perspectives of bereavement (cumulative stress hypotheses) suggest that spousal death is a significant source of psychological stress.

Individuals must cope with the loss of their spouse and at the same time cope with the stressors associated with the new role of being a widow/widower. (8)

Those who are overwhelmed by grief may discontinue daily tasks that are essential for the maintenance of their health, which increases the risk for early death. Both CVD and depression also increase the risk for early death in older adults. (7)

The cumulative stress perspective would argue that the combined effects of spousal death, CVD, and/or depression deplete older adults’ coping resources making them even more vulnerable to early death.

We would expect that older adults with CVD and older adults with high levels of depression are particularly vulnerable to the increased mortality risk after bereavement.

A more recent opposing perspective (stress reduction hypotheses) suggests that spousal death is associated with stress reduction and relief when it occurs in the context of long term chronic illness with high levels of patient suffering prior to death. (911)

The process of dying likely entails intense spousal caregiving demands along with exposure to the suffering of a loved one. (10,12)

According to this view, spousal death results in the removal of these stressors, which may contribute to survival.

Based on this perspective, women may benefit more from the death of their spouse than men because they are more sensitive to the suffering of their spouse and are more likely to be involved in providing care for their spouse. (12)

Existing research on bereavement, CVD, and mortality has a number of limitations. First, most studies follow participants for an average of 11 years even though the increased risk of death has been most consistently observed in the first few years after bereavement. (1)

Second, studies have relied on self-report methods to determine physical health status, (1317) and several of these studies limit their analyses to baseline prevalent disease assessed before becoming bereaved. (1315)

Third, among the bereavement studies that examine physical health status as a predictor of mortality, none include depressive symptoms as a covariate in testing predictive models. (11317)

The present study addresses these limitations by testing the association of spousal loss to 3-year mortality and whether or not the association differs by sex, CVD status or in the presence of post-bereavement depressive symptoms.

Our study had two objectives.

First, we examined the relation between spousal loss and 3-year all-cause mortality. We hypothesized that bereaved elders would be at increased risk of mortality compared to age- and sex-matched married controls.

Because the effects of spousal chronic illness and suffering are typically greater on women than men, we hypothesized that spousal loss would interact with participant sex such that the impact of bereavement on mortality would be less negative for women than for men (10).

We also hypothesized that spousal loss would interact with prevalent CVD status prior to death to affect mortality.

Second, we expanded on previous research by examining post-bereavement variables in our model including incident CVD and depression.

We hypothesized that bereavement would interact with CVD to affect mortality. We also hypothesized bereavement would interact with post-bereavement depressive symptoms to affect mortality. We expected that bereaved elders with a greater frequency of depressive symptoms post-bereavement would be at increased risk for mortality compared to bereaved elders with less frequency of depressive symptoms.

Finally, we also examined whether depression after spousal loss is the process or mechanism linking bereavement to mortality. We expected that depression would attenuate the relation between bereavement and mortality.

Discussion

Adjusting for sociodemographic variables and subclinical disease prior to spousal death, these data show that the relation between bereavement and 3-year mortality varies by participant sex.

Bereavement decreased the risk of mortality in women and increased the risk of mortality in men. Within sex, the association of bereavement with mortality differed according to CVD status. We found that bereavement decreases mortality risk in women with CVD prior to and shortly after their husband’s death.

Bereavement did not affect mortality for men with CVD. However, bereaved men without CVD had significantly higher mortality rates than married men without CVD.

Finally, high levels of depressive symptoms were significantly associated with mortality. High levels of depressive symptoms attenuated the association between bereavement and mortality in men.

These findings pose two important questions: Given the existing literature suggesting bereavement increases mortality risk, [1] why did we find this association only for bereaved men without CVD, and [2] why was bereavement protective for women with CVD?

The increased mortality among bereaved compared to non-bereaved men without CVD is consistent with a small number of studies that have found that good physical health does not protect individuals from mortality after bereavement. (161725).

These studies hypothesize that good physical health is not protective in the context of spousal loss because most of the excess mortality after bereavement is due to unexpected cardiac and respiratory events. (152428).

It is important to note that the lack of an association between bereavement and mortality in men with CVD may be partially attributable to the fact that most CVD in men is fatal. (29)

The effect of CVD on mortality in men may be so strong that experiencing spousal loss does not increase risk of death.

Men in good physical health may also experience the greatest relative impact of bereavement on mortality. Indeed, we found that depression attenuated the association between bereavement and mortality in men without CVD.

High levels of depressive symptoms after spousal death may be the process or mechanism linking bereavement to early mortality in men in good physical health. This is an important finding that should be explored in future studies.

Bereaved women with CVD might benefit more in terms of reduced mortality rates when compared to married women with CVD because the death of their spouse eliminates a major life stressor for them (stress reduction perspective).

Women are more likely than men to provide care to their physically declining spouse and are more negatively affected by the suffering of a dying spouse. (1012)

Thus, spousal death would eliminate the stress of caregiving and exposure to suffering, allowing bereaved women with CVD to focus on managing their own chronic and incident disease, which in turn would promote their survival. (1012)

Bereaved women with existing or incident CVD may also be more vigilant and protective of their health than married women with chronic disease.

The death of one’s husband may heighten perceptions of vulnerability among women with chronic disease and possibly foster better self-care. Research is needed to determine whether the removal of caregiver stress or perceptions of vulnerability are the mechanisms linking bereavement to survival in women with CVD.

Contrary to our hypothesis, we did not find a significant interaction between depressive symptoms and bereavement. There were also no differences in the association of depressive symptoms with CVD status.

There are several possible explanations for why we did not find a significant interaction between depressive symptoms and bereavement. First, the mental health effects of bereavement include a combination of symptoms that include depression, post-traumatic stress, and/or grief. (130)

Including only one mental health outcome in our bereavement model may not have provided a comprehensive view of psychological adjustment following spousal death.

Second, to the extent that the depression-mortality link may be driven by cardiovascular, metabolic, inflammatory, and behavioral pathways, our length of follow-up (3 years) may have been too short to observe a significant depressive effect. (31)

One study that found a significant association between depression and mortality after bereavement included a 7 year follow-up. (32)

The present study had several limitations. First, we did not have available data on subclinical disease at every interview visit prior to spousal death.

In order to preserve our sample size, we examined subclinical disease status at the closest interview visit prior to spousal death (1989/1999, 1992/1993 or 1998/1999). Second, we did not have information on clinical diagnoses of major depressive disorder.

It is possible that the association of bereavement with mortality would be mitigated among those who successfully completed depression treatment in the early months after bereavement.

Third, we do not have information about the length of the marriage and do not know if this was their first (or second) marriage or if they were previously bereaved.

Finally, we did not have available data on social support (emotional, tangible) and behavioral (nutrition, physical activity, sleep) changes at every interview visit prior to and after spousal death. Future studies should focus on these mechanisms underlying the association between bereavement and mortality.

In conclusion, our findings suggest that the relation between bereavement and mortality differs in men and women and varies by cardiovascular disease status. Bereavement decreased mortality in women with CVD and increased mortality in men without CVD. Depressive symptoms post-bereavement may be the mechanism linking bereavement to mortality in physically healthy men.

These findings support the notion that bereavement is a time-dependent dynamic process. It is possible that women with CVD exhibited stress reduction effects and men without CVD showed cumulative stress effects.

However, there is a need for further research on older women with CVD to understand how they are differentially affected by bereavement compared to older women without CVD.

Additional research is also needed to understand why physically healthy men are at the greatest risk of mortality after bereavement.

Given these complex interactions, we encourage replication of our tested model with a focus on possible mechanisms underlying the bereavement by CVD difference in men in women. Finally, these findings highlight the need for health care professionals to monitor the physical health of bereaved individuals and to offer universal support after spousal death to improve longevity.


Source:
University of Sydney

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