Grief caused by grief can be fatal in heart failure

The stress caused by the loss of a family member can lead to the early death of patients with heart failure (HF), according to a large Swedish study that highlights the need for greater integration of psychosocial risk factors in the treatment of HF.

The adjusted relative risk (RR) of death was almost 30% higher in bereaved patients with HF (RR 1.29, confidence interval [IC]95%, from 1.27 to 1.30) and slightly higher for those who lost more than one family member (RR 1.35).

The highest risk occurred in the first week after loss (RR 1.78), persisting after 5 years of follow-up (RR 1.30).

“Heart failure is a very difficult disease and has a very bad prognosis, and can be compared to many types of cancer,” he told the Medscape the study’s lead author, Dr. Krisztina László, Ph.D., from the Karolinska Institute, Sweden. “So it’s important for us to be aware of these heightened risks and understand them better.”

The risk of early death may be related to stress-induced cardiomyopathy, also known as Takotsubo syndrome, and activation of the hypothalamic-pituitary-adrenal axis, the renin-angiotensin-aldosterone system, and the sympathetic nervous system, she explained. Long-term increased risks can mean chronic stress, leading to neglected illness and an unhealthy lifestyle.

“If we better understand the underlying mechanisms, perhaps we can give more specific guidance,” said Dr. Kristina. “Right now, I believe that being aware of the risk, trying to follow up with patients (or at least not letting them go without routine follow-up), asking questions and trying to understand what their needs are… Maybe that’s what we can do well. “

A recent position paper by European Association of Preventive Cardiology showed that psychosocial risk factors such as depression and social isolation can exacerbate heart failure. In addition, the document calls for a better integration of psychosocial factors into the treatment of patients with chronic HF.

“We don’t do a very good job in this regard, but I believe these factors are very important,” noted Dr. Stuart D. Russell, advanced CI specialist and professor of medicine at Duke Universityin the United States, who did not participate in the study.

“When we hear about the death of a spouse, we can even call and offer solidarity. However, this is a group of patients that probably should be followed more closely in the next 6 months (on average) to see if there is anything that can be done, both from a medical and social point of view, to avoid part of this increase in mortality,” he told Medscape.

While several studies have linked bereavement with adverse health outcomes, this is only one of two studies that specifically looked at the role of this condition in HF prognosis, noted Dr. Kristina. A 2013 study of 66,000 male veterans reported that widowed men had an almost 38% higher risk of all-cause mortality than married veterans.

The recent study extended these findings to 490,527 patients from the Swedish Registry of Heart Failure between 2000 and 2018 and/or the Swedish Registry of Patients with a primary diagnosis of HF between 1987 and 2018. During a mean follow-up of 3.7 years, 12% of participants lost a family member and 383,674 participants died.

The results showed that the risk of HF mortality increased by 10% after the death of a child, 20% after the death of a spouse/partner, 13% after the death of a sibling and 5% after the death of a grandchild.

No increased risk was observed following the death of a parent, likely due to the patients’ average age of around 75 years, which “matches our expectations at this point in life,” said Dr. Kristina.

An association between grief and mortality risk was observed in cases of losses caused by cardiovascular disease (RR 1.34) and other natural causes (RR 1.27). This also occurred in cases of unnatural deaths, such as suicide (RR 1.13).

Overall findings were similar regardless of left ventricular ejection fraction and functional class according to the criteria of the New York Heart Association (NYHA). They were also unaffected by sex or country of birth.

The Doctor. Stuart agreed that the death of a parent would be expected among older patients with HF, but said that “if the etiologic mechanism really is an increase in stress hormones, as in Takotsubo syndrome, it would be reasonable to think that he would be more intense in the case of the death of a son. That shocked me a little.”

“The strong association between mortality and the loss of a spouse or partner was not surprising, as they are an important source of mutual social support,” he added.

“If a 75-year-old patient’s spouse dies, we need to make sure we have the phone number of the children or others close to us so we can reach out and say, ‘Could you check on him?'” he said. . “We also need to make sure that they are accompanied by someone, as I believe that probably at least half of what patients hear in a clinical consultation goes in one ear and out the other. Having that follow-up would help a lot. So we need to find out who this new patient support person is.”

Asked if there were any initiatives underway to incorporate psychosocial factors into current guidelines in the United States, Dr. Stuart responded, “Certainly, in the context of heart failure, I don’t think we’re actually discussing this issue and this is perhaps the best part of the article. It really makes us think of a different way of approaching these older patients.”

Dr. Krisztina said that future studies are needed to see if less severe sources of stress could also contribute to a poor prognosis in HF.

“In the population studied, 12% of patients were affected, which is a lot, but there are heart failure patients who are subjected to other less severe but chronic sources of stress on a daily basis that affect a large number of individuals,” she said. “This analysis could have important public health implications and would be an important next step.”

The authors reported that they were unable to eliminate residual confounding due to unmeasured genetic, socioeconomic, lifestyle, or health factors shared by family members. Other limitations were the limited ability to detect a moderate effect in some of the subanalyses and the fact that the findings can be generalizable only to countries with similar social, cultural, and health-related backgrounds to Sweden.

The study was supported by grants from the Swedish Council for Professional Life and Social Research, the Karolinska Institute Research Foundation and the China Scholarship Council. Dr. Krisztina also received support from a grant from the Heart and Lungs Foundation of Sweden. All other authors and Dr. Stuart reported no conflicts of interest.

J Am Coll Cardiol HF. Published July 6, 2022. Abstract

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