Fifteen years ago, at 10: 53 on a February evening, the people of Athens, Greece, were jolted by an earthquake that measured 6.7 on the Richter scale. Within an hour of the quake and for three days afterward, terrified Athenians were dropping dead at more than twice the normal rate.
This suggested, at least to Harvard School of Public Health epidemiologist Dimitrios Trichopoulos, that mental stress had triggered the increased deaths, most of them from heart attacks.
Back in 1983, when Trichopoulos published his findings in a medical journal, the notion that strong emotions could trigger a nearly-instant heart attack was anathema to many doctors, though lay people were often inclined to believe it.
Although it had been popular since the mid-'70s to think that people with hard-driving, "Type A" personalities were more prone to heart attacks than others, these early attempts to link emotions to heart disease had looked mainly at lifelong traits, not at a person's mood right before a heart attack.
But after years of focusing on long-term personality styles and chronic physical factors like high blood pressure and cholesterol, researchers are now finding considerable evidence that heart attacks can be "triggered" by immediate events as well, including powerful emotions like grief, fear and anger in the hours before an attack.
Lest merely reading about such triggers set hearts dangerously aflutter, a bit of perspective:
"We all have stressful experiences and most of us don't have heart attacks" because of them, points out David S. Krantz, a medical psychologist at the Uniformed Services University in Bethesda.
Furthermore, most people who do have a heart attack after an identifiable triggering event have underlying heart disease that puts them at higher risk, says Dr. James Muller, chief of the cardiovascular division at Deaconess Hospital in Boston.
"And even people with underlying heart disease may not be vulnerable to a trigger, including emotional stress, at any given moment," he adds.
Yet heart specialists are taking emotional triggers increasingly seriously because both mental stress and cardiovascular disease are so common. Cardiovascular disease is the No. 1 cause of death in America, killing one person every 34 seconds. About 1.5 million Americans have a heart attack every year, and a quarter of a million die before reaching a hospital.
Futhermore, evidence is mounting that emotions can trigger heart attacks, especially in people with heart disease. The primary villains:
Last year, in a study of more than 1,600 heart attack survivors, Dr. Murray Mittleman and others at Deaconess found that in the two-hour period after someone feels intense anger, heart attack risk more than doubles, just as it does in the two hours after sex.
To be sure, says Mittleman, because the baseline risk of a heart attack is about one in a million for a healthy 50-year-old man in any given hour, this means anger -- or sex -- temporarily raises the risk to just 2 in a million, a seemingly small hazard. For people with known heart disease, the average baseline risk is 10 in a million in any given hour; anger or sex raises it to 20 in a million.
"But while this may seem trivial," he says, "it's not, because people get angry far more often than they have sex."
In fact, people who are chronically angry -- especially those with what researchers now call a "hostile" rather than a Type A personality -- are at increased risk of dying not just from heart attacks but from all causes, says Dr. Redford Williams, a Duke University internist and author of the 1993 book "Anger Kills."
Hostility is defined as an unlovely combination of cynicism, anger and aggressiveness.
In a study of 1,774 heart attack patients reported at an American Heart Association meeting, Mittleman found that the death of a loved one raises the risk of heart attack 14-fold for the next 24 hours -- significantly more than anger or sex.
As with anger and sex, grief seems to pose the greatest risk for people with underlying heart disease. But unlike anger and sex, the heightened risk from grief declines very slowly, often persisting a month or more, albeit at ever-lower levels.
Israeli researchers reported last year that on the January day in 1991 that the Scud missile attack began during the Gulf War, there was a marked increase in deaths, even though nobody died of injuries caused by the missiles.
Most of the deaths were attributed to cardiovascular disease, including sudden cardiac death, which can be caused by blockages in arteries or by abnormal heart rhythms. This year, other researchers also found the incidence of sudden cardiac death was higher in the first 10 days of the Gulf War, but not enough to be statistically significant.
Yet researchers say there is virtually no question fear played a role in the nearly 5-fold increase in deaths from cardiac causes on the day of the 1994 Los Angeles quake.
This month, Duke University researchers led by psychologist James A. Blumenthal found that stress -- like public speaking and doing arithmetic -- significantly increased the risk of potentially fatal heart problems and ischemia, or decreased blood flow to the heart, at least in people who have heart disease and score poorly on exercise treadmill tests.
The more researchers study emotional triggers of heart attacks, the more they think mental stresses affect the heart in ways different from physical stresses like sudden exertion.
Both types of stress cause a surge of hormones, including adrenalin and noradrenalin, that make blood pressure and heart rate soar. The increase in the force and flow of blood through arteries can cause fatty plaques in artery walls to rupture, allowing clots to form and block flow to the heart.
Adrenalin can also trigger potentially fatal disturbances in heart rhythm, especially in people with heart disease.
Fortunately, researchers are finding ways to reduce heart attack risk from both physical and emotional causes. To combat long-term, chronic risk, Mittleman says, the old standbys still hold: Quit smoking, eat sensibly and exercise to keep blood pressure and cholesterol down.
In fact, if you're sedentary and have heart disease, regular exercise can virtually abolish the risk of heart attack from sudden exertion. And if acute triggers like anger worry you, there's also lots you can do, including taking aspirin, meditating and learning how to handle anger more effectively.
Don't get mad, get a grip
Dr. Redford Williams, a Duke University internist, says when you get angry, you should ask yourself three questions: Is this really important to me? Is my anger appropriate to the situation? Is there anything I can do to fix the situation? If you answer no to any one of these, just chill out. If you answer yes to all three, he says, "action is called for. If it's a problem with another person, the solution is to be assertive, rather than blowing up or screaming." "If it's a situational problem and there is no other person to be assertive with, like when an airline cancels your flight, go out and run to discharge adrenalin," he says, and if you can't do that, meditate or think about your next vacation. "This is all damage control when you're angry," he says. But it's better to reduce anger in the first place, which may be easier than you think.
Pub Date: 7/02/96