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Mental Stress, Anger Exacerbate Diastolic Function Among Patients in Heart Failure


Although the effects of stress and anger on ischemic heart disease and arrhythmia are well known, they are less established in heart failure, particularly those with reduced ejection fraction.

Although the effects of mental stress and anger on ischemic heart disease and arrhythmic are well known, their potential clinical implications are less established among patients with heart failure, particularly those with reduced ejection fraction (HFrEF), according to a recent study in Journal of Cardiac Failure.

“Factors such as mental stress and anger often go unrecognized and are under-addressed," Matthew Burg, a Yale clinical psychologist and senior author of the study, said in a statement. "This study contributes to the extensive literature showing that stress and anger affect clinical outcomes for patients with heart disease.”

The 24 study participants were a subset of those enrolled in the Biobehavioral Triggers in HF (BETRHEART) study and recruited from the University of Maryland Medical Center. All had symptomatic heart failure, as measured by New York Heart Association class II-IV disease, for at least 3 months; a history of coronary artery disease; and maximum left ventricular ejection fraction (LVEF) of 40% in the previous year. The mean (SD) patient age was 61.2 (9.4) years.

Following a week of daily questionnaires on stress, anger, and negative emotions, the study participants (n = 23 men), with a mean LVEF of 27% (9%), followed a mental stress protocol of solving challenging math problems and describing a recent stressful experience. Stress scores ranged from 0 to 40; anger, 12 to 60; and negative emotions, 0 to 36.

Thirteen patients had elevated baseline E/e’ (a measure of left ventricular diastolic filling pressure). Two 2-D Doppler echocardiograms were performed for comparison purposes:

  • At baseline
  • During the stress protocol

Overall results show that 63.6% of the patients had baseline worsening E/e’ (lateral E/e’ >13), which the authors likened to stress-induced increases, and that the mean E/e’ change was 6.5 (9.3), “driven primarily by decreases in LV relaxation (e’),” they noted. The patients had to fast and withhold their morning doses of beta-blockers and calcium channel blockers before testing.

A possible link was found between baseline E/e’ and 7-day anger (β =.53; P = .01; adjusted R2 = .23; P = .03), after an age-adjusted linear regression comparison; however, no links were found to exist between baseline E or e’ or between perceived stress/negative emotion and baseline or stress-induced changes in E, e’, or E/e’.

In addition, “Magnitude of baseline to stress change in E, e’, and E/e’ was not associated with these baseline values, nor with baseline to stress changes in patient-reported anger and stress levels (all P > .10),” the authors noted.

Study strengths, the authors added, included that the echocardiograms were performed during times of stress, allowing them to compare differences with baseline resting ventricular function, and that the daily assessments enable patient emotion to be captured during a typical day. Limitations included the small male sample size and the possible influence of anxiety from knowing the mental stress task was forthcoming.

“Further research is needed with larger, more diverse samples of HF patients with both reduced and preserved LVEF using invasive hemodynamic monitoring to promote a better understanding of the effect that stress and negative emotion have on ventricular function in HF,” the authors concluded. “This research should determine whether vulnerability differs among HF phenotypes, if the effect is attenuated by cardiovascular medications, and how this effect contributes to disease outcomes.”


Harris KM, Gottdiener JS, Gottlieb SS, Burg MM, Li S, Krantz DS. Impact of mental stress and asnger on indices of diastolic function in patients with heart failure. J Card Fail. Published online July 31, 2020. doi:10.1016/j.cardfail.2020.07.008

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