Anger Is Fast Trigger for Heart Attack or Stroke


A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a 1) ___. As a result, the affected area of the brain cannot function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. Risk factors for stroke include old age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. It is the second leading cause of 2) ___ worldwide.


Cardiovascular disease (also called heart disease) is a class of diseases that involve the heart, the blood vessels (arteries, capillaries, and veins) or both. Cardiovascular disease refers to any disease that affects the cardiovascular system, principally cardiac disease, vascular diseases of the brain and kidney, and peripheral arterial disease. The causes of cardiovascular disease are diverse but atherosclerosis and/or hypertension are the most common. In addition, with aging come a number of physiological and morphological changes that alter cardiovascular function and lead to increased risk of cardiovascular disease, even in healthy asymptomatic individuals. Cardiovascular disease is the leading cause of deaths worldwide, though, since the 1970s, cardiovascular 3) ___ rates have declined in many high-income countries. At the same time, cardiovascular deaths and disease have increased at a fast rate in low- and middle-income countries. Although cardiovascular disease usually affects older adults, the antecedents of cardiovascular disease, notably atherosclerosis, begin in early life, making primary prevention efforts necessary from childhood. There is therefore increased emphasis on preventing atherosclerosis by modifying risk factors, such as healthy eating, exercise, and avoidance of smoking tobacco. Some of these risk factors, such as age, gender or family history, are immutable; however, many important cardiovascular risk factors are modifiable by lifestyle change, social change, drug treatment and prevention of Serrano’s Cardiac Triad: hypertension, hyperlipidemia, and 4) ___.


Interesting research is being done on the relationship between a lifestyle change of anger management and cardiovascular event or stroke. A flash of anger may send the body down a path ending in a heart attack or stroke, a systemic review showed. Note that the magnitude of increased risks were higher for individuals who had a greater cardiovascular risk initially. Although relatively few studies have explored the link between short bouts of 5) ___ and cardiovascular events in the hours immediately following the outburst, the evidence is consistent in showing a direct relationship, according to Murray Mittleman, Dr PH, of the Harvard School of Public Health, and colleagues. But it’s not clear how substantial the risk is, the authors reported online in the European Heart Journal. “The relative risks estimated in this meta-analysis indicate that there is a higher risk of cardiovascular 6) ___ after outbursts of anger among individuals at risk of a cardiovascular event, but because each episode may be infrequent and the effect period is transient, the net absolute impact on disease burden is extremely low,“ they wrote. “However, with increasing frequency of anger episodes, these transient effects may accumulate, leading to a larger clinical impact.“


Several smaller studies have examined the link between anger and cardiovascular health, but Mittleman and colleagues set out to explore the consistency of the association. A review of the literature turned up nine independent case-crossover studies conducted in the U.S., Sweden, England, Israel, and the Netherlands. Outcomes included myocardial 7) ___, acute coronary syndromes, stroke, and ventricular arrhythmia in the 2 hours following angry outbursts. In pooled results of four of the studies, the risk of MI or acute coronary syndrome was 4.74-fold higher in the hours after an outburst. In pooled results of two studies, the risk of ischemic stroke was not significantly elevated. One study evaluated intracranial hemorrhage and showed that the risk was higher in the hour after a bout of anger. Two studies had ventricular arrhythmia in patients with implantable cardioverter-defibrillators as an outcome, although the results could not be combined because of differences in the measurement of anger, study design, and hazard periods. One showed that risk was significantly higher in the 15 minutes after an outburst and the other showed that the 8) ___ was higher in the hour after the angry episode. Mittleman and colleagues noted that magnitude of increased risks was higher for individuals who had a greater cardiovascular risk initially. For MI/acute coronary syndrome, for example, “the absolute impact of one episode of anger per month is only one excess cardiovascular event per 10,000 individuals per year at low (5%) 10-year cardiovascular risk and four excess cardiovascular events per 10,000 individuals per year at high (20%) 10-year 9) ___ risk.“ In an accompanying editorial, Suzanne Arnold, MD, of Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and colleagues discussed some of the potential mechanisms tying anger to cardiovascular events and stated that “Mediated through increases in circulating catecholamines, increased myocardial oxygen demand, coronary vasospasm, and increased platelet aggregability, anger can cause transient ischemia, disruption of vulnerable plaques, and increased thrombotic potential, and that these changes can then result in myocardial or cerebral ischemia or malignant arrhythmias.“ They authors also pointed out that the review was limited by the small number of available studies and the significant heterogeneity between them, but said that the findings highlight the consistency of results linking acute anger and increased cardiovascular risk. “However, how to move forward in reducing the burden of these risk factors in patients and, hopefully, its impact on cardiovascular health is still in question,“ they wrote. “Given the lessons we have learned from trying to treat depression after MI, treating anger in isolation is unlikely to be impactful. Instead, a broader and more comprehensive approach to treating acute and chronic mental stress, and its associated psychological stressors, is likely to be needed to heal a hostile heart.“ Mittleman and colleagues noted in their paper that studies of 10) ___ — including beta-blockers and selective serotonin reuptake inhibitors — have not shown substantial benefits, and said that psychological interventions might help.


In an email to MedPage Today, Redford Williams, MD, of Duke University, said that beta-blockers could ease some of the negative consequences of angry outbursts but that their use would be limited by side effects. He agreed the 11) ___ interventions might be worthwhile. “Behavioral interventions that train folks to reduce angry outbursts and/or the accompanying physiological arousal could be an effective means of reducing the health damage associated with angry outbursts,“ he said, backing that up with three prior studies. The first showed that a group-based psychosocial intervention designed to reduce stress, cut mortality among women with coronary heart disease. The second demonstrated that cognitive behavioral therapy with a focus on stress management lowered the risk of recurrent cardiovascular events in men and women with established coronary heart disease. And the final paper cited by Williams showed that a psychosocial skills training workshop reduced anger 12) ___ and the size of the increases in blood pressure and heart rate that accompanied the recall of situations that made men who had undergone CABG, angry.



1.    American Heart Association: Trait Antagonism and the Progression of Arterial Thickening

2.    European Heart Journal: Mostofsky E, et al “Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis“ Eur Heart J 2014; DOI: 10.1093/eurheartj/ehu033.

3.    European Heart Journal: Arnold S, et al “The hostile heart: anger as a trigger for acute cardiovascular events“ Eur Heart J 2014; DOI: 10.1093/eurheartj/ehu097;



ANSWERS: 1) hemorrhage; 2) death; 3)Mortality; 4) diabetes; 5) anger; 6) events; 7) infarction; 8) risk; 9) cardiovascular; 10) medications; 11) psychological; 12) levels


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