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09-06-2011 | Cardiology | Article

Fear of dying in ACS patients linked to increased inflammation


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MedWire News: Intense distress and fear of dying during acute coronary syndrome (ACS) is linked to increased inflammation, and could contribute to worse outcomes in the long term, a UK study suggests.

Fear of dying and intense distress during ACS may have implications for prognostically significant biological processes, write Andrew Steptoe (University College London) and colleagues in the European Heart Journal.

As plasma tumor necrosis factor (TNF)α is involved in inducing systemic inflammation, "the first aim of this study was to evaluate the association between acute distress and fear of dying and TNFα during ACS," they explain.

The second aim was to establish whether elevated TNFα and fear of dying during ACS correlate with reduced heart rate variability (HRV), which indicates poor heart function, and low cortisol levels, which may lead to failure to control inflammation.

The study included 208 ACS patients admitted to St George's Hospital in South London. All participants rated their fear of dying in interviews conducted 2 days after admission. The researchers categorized the patients into three groups based on their scores: no distress and fear, moderate distress and fear, and intense distress and fear.

The team also measured TNFα levels upon admission, and assessed HRV and salivary cortisol 3 weeks after admission.

Findings showed that 21.7% of patients experienced intense distress and fear of dying, while 66.1% experienced moderate levels. Fear of dying was more common in patients who were younger, unmarried, and of low socioeconomic status.

After controlling for sociodemographic factors, clinical risk, and pain intensity, patients with an intense fear of dying were 4.67 times more likely to have raised plasma TNFα (≥12 pg/ml) on admission, than those with low fear of dying.

After adjusting for clinical and sociodemographic factors, and medication, elevated TNFα was also significantly associated with reduced HRV 3 weeks later (p=0.019), while fear of dying was associated with reduced cortisol output (p=0.004). "These processes may contribute to poor outcomes in the long term," commented Steptoe.

In a related commentary, Susanne Pedersen (Tilburg University, The Netherlands), and colleagues hailed Steptoe and team's research as "seminal" for the progress of translational and cardiovascular medicine and behavioral cardiology.

"In order to optimize the management and care of coronary heart disease patients, we need to acknowledge that emotions carry independent additional risk, with particular subsets of patients dying prematurely due to their psychological vulnerability," they concluded.

MedWire ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2011

By Piriya Mahendra

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