Rage Linked to Arrhythmias And Shocks From Defibrillators

CHICAGO – Episodes of extreme anger were linked to ventricular arrhythmias and shocks from implantable cardioverter defibrillators in a study with more than 1,000 patients.

Although the findings do not prove that severe anger triggers arrhythmias, the results are suggestive enough for physicians to advise patients with implantable cardioverter defibrillators (ICDs) to try to stay calm and avoid moments of rage, Dr. Christine A. Albert said while presenting a poster at the annual scientific sessions of the American Heart Association.

“I think that just knowing about the relationship [between anger and shocks] may help people [with ICDs] modify their behavior,” said Dr. Albert, director of the Center for Arrhythmia Prevention at Brigham and Women's Hospital, Boston. “There is a lot of anxiety associated with getting shocks. Patients ask what they can do to minimize their shocks.”

Dr. Albert stopped short of recommending interventions in patients with ICDs who have trouble controlling their anger, but she suggested that physicians may want to refer certain patients to a psychiatrist.

The Triggers of Ventricular Arrhythmia (TOVA) study was done at seven centers in the United States. Patients who had received ICDs were interviewed regarding their usual frequency of anger at entry into the study and at follow-up visits. In addition, following an ICD discharge, patients were interviewed within 72 hours of the shock to collect information on their emotional state during the period just before the shock. Most patients were on an antiarrhythmic drug; about 60% received a β-blocker, and about 25% were taking amiodarone.

During a median follow-up of 562 days, 1,149 patients in the study had a total of 414 shocks, of which 324 were triggered by ventricular tachycardia or fibrillation. Postshock interviews were completed within 72 hours of the episode for 197 of the ventricular arrhythmia shocks, in 161 patients.

Patients were asked to characterize their emotional state on a scale of 1–7, with 1 defined as calm, 4 defined as moderately angry, 5 defined as very angry, 6 defined as furious, and 7 defined as enraged. Of the 197 shocks, 12 (6%) occurred after an episode that the patients classified as grade 4–7 anger.

In a case-crossover analysis, patients who had grade-4 anger or higher had a fivefold increased risk of receiving a shock during the first 30 minutes after the episode, compared with patients who were not as angry. Patients with grade-5 anger or higher had about a 30-fold increased risk of a shock during the first 30 minutes after the episode, and within the first 2 hours after the episode their risk of a shock was elevated about 10-fold compared with calmer patients, Dr. Albert reported.

The effect was magnified in patients with worse ventricular function at baseline, in those who previously received an ICD shock, in patients who had received their ICD within the prior 6 months, and in patients who were employed.

It's not surprising that anger has this effect. Prior findings showed that the simulation of anger in patients with coronary heart disease who were asked to perform mental arithmetic can cause electrophysiologic instability, measured by a change in the T-wave alternans. And a similar link between anger and ICD shocks was seen in a much smaller (49 patients), earlier study. All of the findings suggest that something occurs during anger to make the heart more electrically unstable. And anger activates the sympathetic nervous system, which also probably plays a role in arrhythmias, Dr. Albert said.

CHICAGO – Episodes of extreme anger were linked to ventricular arrhythmias and shocks from implantable cardioverter defibrillators in a study with more than 1,000 patients.

Although the findings do not prove that severe anger triggers arrhythmias, the results are suggestive enough for physicians to advise patients with implantable cardioverter defibrillators (ICDs) to try to stay calm and avoid moments of rage, Dr. Christine A. Albert said while presenting a poster at the annual scientific sessions of the American Heart Association.

“I think that just knowing about the relationship [between anger and shocks] may help people [with ICDs] modify their behavior,” said Dr. Albert, director of the Center for Arrhythmia Prevention at Brigham and Women's Hospital, Boston. “There is a lot of anxiety associated with getting shocks. Patients ask what they can do to minimize their shocks.”

Dr. Albert stopped short of recommending interventions in patients with ICDs who have trouble controlling their anger, but she suggested that physicians may want to refer certain patients to a psychiatrist.

The Triggers of Ventricular Arrhythmia (TOVA) study was done at seven centers in the United States. Patients who had received ICDs were interviewed regarding their usual frequency of anger at entry into the study and at follow-up visits. In addition, following an ICD discharge, patients were interviewed within 72 hours of the shock to collect information on their emotional state during the period just before the shock. Most patients were on an antiarrhythmic drug; about 60% received a β-blocker, and about 25% were taking amiodarone.

During a median follow-up of 562 days, 1,149 patients in the study had a total of 414 shocks, of which 324 were triggered by ventricular tachycardia or fibrillation. Postshock interviews were completed within 72 hours of the episode for 197 of the ventricular arrhythmia shocks, in 161 patients.

Patients were asked to characterize their emotional state on a scale of 1–7, with 1 defined as calm, 4 defined as moderately angry, 5 defined as very angry, 6 defined as furious, and 7 defined as enraged. Of the 197 shocks, 12 (6%) occurred after an episode that the patients classified as grade 4–7 anger.

In a case-crossover analysis, patients who had grade-4 anger or higher had a fivefold increased risk of receiving a shock during the first 30 minutes after the episode, compared with patients who were not as angry. Patients with grade-5 anger or higher had about a 30-fold increased risk of a shock during the first 30 minutes after the episode, and within the first 2 hours after the episode their risk of a shock was elevated about 10-fold compared with calmer patients, Dr. Albert reported.

The effect was magnified in patients with worse ventricular function at baseline, in those who previously received an ICD shock, in patients who had received their ICD within the prior 6 months, and in patients who were employed.

It's not surprising that anger has this effect. Prior findings showed that the simulation of anger in patients with coronary heart disease who were asked to perform mental arithmetic can cause electrophysiologic instability, measured by a change in the T-wave alternans. And a similar link between anger and ICD shocks was seen in a much smaller (49 patients), earlier study. All of the findings suggest that something occurs during anger to make the heart more electrically unstable. And anger activates the sympathetic nervous system, which also probably plays a role in arrhythmias, Dr. Albert said.

CHICAGO – Episodes of extreme anger were linked to ventricular arrhythmias and shocks from implantable cardioverter defibrillators in a study with more than 1,000 patients.

Although the findings do not prove that severe anger triggers arrhythmias, the results are suggestive enough for physicians to advise patients with implantable cardioverter defibrillators (ICDs) to try to stay calm and avoid moments of rage, Dr. Christine A. Albert said while presenting a poster at the annual scientific sessions of the American Heart Association.

“I think that just knowing about the relationship [between anger and shocks] may help people [with ICDs] modify their behavior,” said Dr. Albert, director of the Center for Arrhythmia Prevention at Brigham and Women's Hospital, Boston. “There is a lot of anxiety associated with getting shocks. Patients ask what they can do to minimize their shocks.”

Dr. Albert stopped short of recommending interventions in patients with ICDs who have trouble controlling their anger, but she suggested that physicians may want to refer certain patients to a psychiatrist.

The Triggers of Ventricular Arrhythmia (TOVA) study was done at seven centers in the United States. Patients who had received ICDs were interviewed regarding their usual frequency of anger at entry into the study and at follow-up visits. In addition, following an ICD discharge, patients were interviewed within 72 hours of the shock to collect information on their emotional state during the period just before the shock. Most patients were on an antiarrhythmic drug; about 60% received a β-blocker, and about 25% were taking amiodarone.

During a median follow-up of 562 days, 1,149 patients in the study had a total of 414 shocks, of which 324 were triggered by ventricular tachycardia or fibrillation. Postshock interviews were completed within 72 hours of the episode for 197 of the ventricular arrhythmia shocks, in 161 patients.

Patients were asked to characterize their emotional state on a scale of 1–7, with 1 defined as calm, 4 defined as moderately angry, 5 defined as very angry, 6 defined as furious, and 7 defined as enraged. Of the 197 shocks, 12 (6%) occurred after an episode that the patients classified as grade 4–7 anger.

In a case-crossover analysis, patients who had grade-4 anger or higher had a fivefold increased risk of receiving a shock during the first 30 minutes after the episode, compared with patients who were not as angry. Patients with grade-5 anger or higher had about a 30-fold increased risk of a shock during the first 30 minutes after the episode, and within the first 2 hours after the episode their risk of a shock was elevated about 10-fold compared with calmer patients, Dr. Albert reported.

The effect was magnified in patients with worse ventricular function at baseline, in those who previously received an ICD shock, in patients who had received their ICD within the prior 6 months, and in patients who were employed.

It's not surprising that anger has this effect. Prior findings showed that the simulation of anger in patients with coronary heart disease who were asked to perform mental arithmetic can cause electrophysiologic instability, measured by a change in the T-wave alternans. And a similar link between anger and ICD shocks was seen in a much smaller (49 patients), earlier study. All of the findings suggest that something occurs during anger to make the heart more electrically unstable. And anger activates the sympathetic nervous system, which also probably plays a role in arrhythmias, Dr. Albert said.