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Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis

Elizabeth Mostofsky, Elizabeth Anne Penner, Murray A. Mittleman
DOI: http://dx.doi.org/10.1093/eurheartj/ehu033 1404-1410 First published online: 3 March 2014


Aim Short-term psychological stress is associated with an immediate physiological response and may be associated with a transiently higher risk of cardiovascular events. The aim of this study was to determine whether brief episodes of anger trigger the onset of acute myocardial infarction (MI), acute coronary syndromes (ACS), ischaemic and haemorrhagic stroke, and ventricular arrhythmia.

Methods and results We performed a systematic review of studies evaluating whether outbursts of anger are associated with the short-term risk of heart attacks, strokes, and disturbances in cardiac rhythm that occur in everyday life. We performed a literature search of the CINAHL, Embase, PubMed, and PsycINFO databases from January 1966 to June 2013 and reviewed the reference lists of retrieved articles and included meeting abstracts and unpublished results from experts in the field. Incidence rate ratios and 95% confidence intervals were calculated with inverse-variance-weighted random-effect models. The systematic review included nine independent case-crossover studies of anger outbursts and MI/ACS (four studies), ischaemic stroke (two studies), ruptured intracranial aneurysm (one study), and ventricular arrhythmia (two studies). There was evidence of substantial heterogeneity between the studies (I2 = 92.5% for MI/ACS and 89.8% for ischaemic stroke). Despite the heterogeneity, all studies found that, compared with other times, there was a higher rate of cardiovascular events in the 2h following outbursts of anger.

Conclusion There is a higher risk of cardiovascular events shortly after outbursts of anger.

  • Anger
  • Cardiovascular disease
  • Case-crossover
  • Epidemiology
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