Grieving a Loved One Increases Mortality Risk in HF Patients

The psychological stress of losing a close family member such as a spouse or child can contribute to increased risk of death among patients with heart failure (HF), a Swedish study shows.

Regardless of whether the loved one’s death was sudden or the result of illness, HF patients had nearly a 30% increased risk of dying, with the greatest risks occurring in the first week after the relative’s death and in instances where more than one family member died. The impact of grief on mortality in HF patients also was more pronounced in those over age 75.

“This is one of the very first studies to look at how severe stress impacts mortality in patients with heart failure,” senior study author Krisztina D. László, PhD (Karolinska Institutet, Stockholm, Sweden), told TCTMD. While it is premature to draw strong conclusions about clinical implications of the data, she said, the findings should motivate clinicians to be supportive of their HF patients who are grieving and to be more aware that they may need help with activities of daily living after losing a close family member.

“I think [this study] does kind of raise a flag that this could be a period of increased risk that warrants further attention among providers,” said Kristie Harris, PhD (Yale School of Medicine, New Haven, CT), who authored a recent review article that documented emerging evidence on how psychological stress in HF patients can worsen their disease course and compound the existing stress of living with chronic illness.

Commenting on the study for TCTMD, Harris noted that the authors acknowledge not being able to rule out some of the deaths being related to Takotsubo cardiomyopathy, also known as “broken heart syndrome,” but added that the richness and diversity of the Swedish data support the role that chronic stress resulting from grief and bereavement may play in leading to adverse HF outcomes.

In the paper, published online July 6, 2022, ahead of print in JACC: HF, László and colleagues led by Hua Chen, MSc (Karolinska Institutet), hypothesize that the long-term stress may negatively affect how HF patients manage their health condition and self-care. For some older patients, they note, the loss of one person can result in major disruption to their social support network, with those who are frail being even more vulnerable to the effects of grief.

Swedish Registry Findings

For the study, Chen and colleagues examined data between 2000 and 2018 on patients from the Swedish Heart Failure Registry as well as data from 1987 to 2018 on those with a primary diagnosis of HF from the Swedish Patient Register, for a total of 490,527 individuals. Over the follow-up period, 383,674 patients died, as did 58,949 loved ones.

Compared with baseline risk, the mortality risk for those who lost a family member was 10% higher after the death of a child, 20% higher after the death of a spouse/partner, 5% higher after the death of a grandchild, and 13% higher after the death of a sibling. No increased risk was seen after the death of a parent, which the researchers say likely is due to the median age in the study being just shy of 80 years and parent death being an expected life event.

While the risk of dying from HF was highest in the first week after a loved one’s death (RR 1.78; 95% CI 1.61-1.98), the increase in risk was found to persist throughout the follow-up. The main findings were similar regardless of LVEF or NYHA functional class. They also were not affected by adjustment for education level or exclusion of patients who experienced a death in the year before baseline.

In addition to compounding stress, Chen and colleagues say grief over a loved one may trigger certain biological mechanisms, including activation of the hypothalamic-pituitary-adrenal (HPA) axis, which helps regulate stress and emotional response. Grieving also may lead to a reaction in the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system. Changes in these systems, they add, can promote “the progression of HF by accelerating adverse left ventricular remodeling and catecholamine-induced cardiotoxicity.”

According to Harris, there is a significant knowledge gap in terms of understanding how certain types of stress promote HF progression as well as how individual responses mitigate the stress reactions.

“Big studies like this one, showing us on this epidemiological level, in very large data sets, that there is an association, are what we need to motivate people to look more specifically at these mechanisms. It could be that the chronic stress of going through that grief reaction is activating all of those physiological processes, which are adversely impacting the functioning of the heart muscles and the overall autonomic system,” she explained.

“It also could be that the patient is stressed, so they're not taking care of themselves anymore. Maybe the person they lost was the one that was getting them to the doctor's office and helping them keep track of all of their medication and appointments,” said Harris. “There’s probably a lot of individual variation in what the mechanisms are . . . no one's really nailed that down definitively and with good data to support it at this point.”

László agreed: “Understanding these underlying mechanisms . . . is important for us to know how we can help these patients.” In the meantime, for relative or friends of a HF patient who has experienced a close death in the family, “maybe it might motivate [them] to be supportive and see that the relative is staying healthy and taking care of themselves,” she added.