Outbursts of Anger as a Trigger of Acute Cardiovascular Events: A Systematic Review and Meta-Analysis

Study Questions:

Do brief episodes of anger trigger the onset of acute myocardial infarction (MI), acute coronary syndromes (ACS), ischemic and hemorrhagic stroke, and ventricular arrhythmia?


A systematic review was conducted 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. The literature search included 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January 1966 to June 2013 and reviewed the reference lists of retrieved articles and included meeting abstracts and unpublished results from experts in the field.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), ischemic stroke (two), ruptured intracranial aneurysm (one), and ventricular arrhythmia (two).There was evidence of substantial heterogeneity between the studies (I2 = 92.5% for MI/ACS and 89.8% for ischemic stroke). Despite the heterogeneity, all studies found that, compared with other times, there was a higher rate of cardiovascular events in the 2 hours following outbursts of anger.


The authors concluded that there is a higher risk of cardiovascular events shortly after outbursts of anger.


The standard definition for anger is an outburst within 2 hours of the event, as measured by the ‘Onset Anger Scale.’ The pathogenesis of an acute coronary event including plaque rupture and acute thrombosis being related to acute anger associated with an increase in catecholamines is logical and supported in the systemic review, but the number of participants is quite low. Among the clinical options to reduce anger outbursts include relaxation techniques such as mindfulness meditation, serotonin re-uptake inhibitors, and beta-blockers. Interestingly, in the REACH Registry of nearly 22,000 patients evaluated with a propensity score-matched analysis, beta-blockers were not associated with a reduction in the composite outcome of cardiovascular death, nonfatal MI, or nonfatal stroke, with the exception of those with an MI within the past year.

Clinical Topics: Acute Coronary Syndromes, Vascular Medicine

Keywords: Mindfulness, Risk, Myocardial Infarction, Stroke, Acute Coronary Syndrome, Propensity Score, Relaxation Therapy, Cross-Over Studies, Catecholamines, Thrombosis, Confidence Intervals, Intracranial Aneurysm, Meditation

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