Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Psychosocial factors in sudden cardiac arrest

Geoffrey H Tofler, MD
Section Editor
Jonathan M Silver, MD
Deputy Editor
David Solomon, MD


Awareness of the ability of severe emotional stress to provoke sudden death has been present throughout recorded history. However, the relationship of psychosocial factors to cardiovascular disease, and in particular sudden cardiac death, has been difficult to quantify. This has been due to several reasons:

It is difficult to objectively quantify emotional stress

Research has until recently been more focused on the chronic factors leading to the development of coronary artery disease rather than on the precipitation of acute coronary syndromes once such disease is present

The division between the social science and medical science investigators have impeded dialogue

There are inherent difficulties in accurately assessing the triggers of sudden death.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Oct 04, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hemingway H, Malik M, Marmot M. Social and psychosocial influences on sudden cardiac death, ventricular arrhythmia and cardiac autonomic function. Eur Heart J 2001; 22:1082.
  2. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999; 99:2192.
  3. Muller JE, Ludmer PL, Willich SN, et al. Circadian variation in the frequency of sudden cardiac death. Circulation 1987; 75:131.
  4. Willich SN, Levy D, Rocco MB, et al. Circadian variation in the incidence of sudden cardiac death in the Framingham Heart Study population. Am J Cardiol 1987; 60:801.
  5. Levine RL, Pepe PE, Fromm RE Jr, et al. Prospective evidence of a circadian rhythm for out-of-hospital cardiac arrests. JAMA 1992; 267:2935.
  6. Arntz HR, Willich SN, Oeff M, et al. Circadian variation of sudden cardiac death reflects age-related variability in ventricular fibrillation. Circulation 1993; 88:2284.
  7. Willich SN, Goldberg RJ, Maclure M, et al. Increased onset of sudden cardiac death in the first three hours after awakening. Am J Cardiol 1992; 70:65.
  8. Arntz HR, Willich SN, Schreiber C, et al. Diurnal, weekly and seasonal variation of sudden death. Population-based analysis of 24,061 consecutive cases. Eur Heart J 2000; 21:315.
  9. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Circadian variations in the occurrence of cardiac arrests: initial and repeat episodes. Circulation 1998; 98:31.
  10. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Weekly and seasonal variation in the incidence of cardiac arrests. Am Heart J 1999; 137:512.
  11. Kloner RA, Poole WK, Perritt RL. When throughout the year is coronary death most likely to occur? A 12-year population-based analysis of more than 220 000 cases. Circulation 1999; 100:1630.
  12. Canada WB, Woodward W, Lee G, et al. Circadian rhythm of hourly ventricular arrhythmia frequency in man. Angiology 1983; 34:274.
  13. Twidale N, Taylor S, Heddle WF, et al. Morning increase in the time of onset of sustained ventricular tachycardia. Am J Cardiol 1989; 64:1204.
  14. Tofler GH, Gebara OC, Mittleman MA, et al. Morning peak in ventricular tachyarrhythmias detected by time of implantable cardioverter/defibrillator therapy. The CPI Investigators. Circulation 1995; 92:1203.
  15. Lampert R, Rosenfeld L, Batsford W, et al. Circadian variation of sustained ventricular tachycardia in patients with coronary artery disease and implantable cardioverter-defibrillators. Circulation 1994; 90:241.
  16. Englund A, Behrens S, Wegscheider K, Rowland E. Circadian variation of malignant ventricular arrhythmias in patients with ischemic and nonischemic heart disease after cardioverter defibrillator implantation. European 7219 Jewel Investigators. J Am Coll Cardiol 1999; 34:1560.
  17. Whang W, Albert CM, Sears SF Jr, et al. Depression as a predictor for appropriate shocks among patients with implantable cardioverter-defibrillators: results from the Triggers of Ventricular Arrhythmias (TOVA) study. J Am Coll Cardiol 2005; 45:1090.
  18. Selwyn AP, Shea M, Deanfield JE, et al. Character of transient ischemia in angina pectoris. Am J Cardiol 1986; 58:21B.
  19. Nademanee K, Intarachot V, Josephson MA, Singh BN. Circadian variation in occurrence of transient overt and silent myocardial ischemia in chronic stable angina and comparison with Prinzmetal angina in men. Am J Cardiol 1987; 60:494.
  20. Rocco MB, Barry J, Campbell S, et al. Circadian variation of transient myocardial ischemia in patients with coronary artery disease. Circulation 1987; 75:395.
  21. Barry J, Selwyn AP, Nabel EG, et al. Frequency of ST-segment depression produced by mental stress in stable angina pectoris from coronary artery disease. Am J Cardiol 1988; 61:989.
  22. Peters RW, Muller JE, Goldstein S, et al. Propranolol and the morning increase in the frequency of sudden cardiac death (BHAT Study). Am J Cardiol 1989; 63:1518.
  23. Behrens S, Ehlers C, Brüggemann T, et al. Modification of the circadian pattern of ventricular tachyarrhythmias by beta-blocker therapy. Clin Cardiol 1997; 20:253.
  24. Peters RW, Mitchell LB, Brooks MM, et al. Circadian pattern of arrhythmic death in patients receiving encainide, flecainide or moricizine in the Cardiac Arrhythmia Suppression Trial (CAST). J Am Coll Cardiol 1994; 23:283.
  25. Behrens S, Ney G, Fisher SG, et al. Effects of amiodarone on the circadian pattern of sudden cardiac death (Department of Veterans Affairs Congestive Heart Failure-Survival Trial of Antiarrhythmic Therapy). Am J Cardiol 1997; 80:45.
  26. Reich P, DeSilva RA, Lown B, Murawski BJ. Acute psychological disturbances preceding life-threatening ventricular arrhythmias. JAMA 1981; 246:233.
  27. Mittleman MA, Maclure M, Sherwood JB, et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation 1995; 92:1720.
  28. Lampert R, Jain D, Burg MM, et al. Destabilizing effects of mental stress on ventricular arrhythmias in patients with implantable cardioverter-defibrillators. Circulation 2000; 101:158.
  29. Kloner RA, Leor J, Poole WK, Perritt R. Population-based analysis of the effect of the Northridge Earthquake on cardiac death in Los Angeles County, California. J Am Coll Cardiol 1997; 30:1174.
  30. Steinberg JS, Arshad A, Kowalski M, et al. Increased incidence of life-threatening ventricular arrhythmias in implantable defibrillator patients after the World Trade Center attack. J Am Coll Cardiol 2004; 44:1261.
  31. Shedd OL, Sears SF Jr, Harvill JL, et al. The World Trade Center attack: increased frequency of defibrillator shocks for ventricular arrhythmias in patients living remotely from New York City. J Am Coll Cardiol 2004; 44:1265.
  32. Fang F, Fall K, Mittleman MA, et al. Suicide and cardiovascular death after a cancer diagnosis. N Engl J Med 2012; 366:1310.
  33. Januzzi JL Jr, Stern TA, Pasternak RC, DeSanctis RW. The influence of anxiety and depression on outcomes of patients with coronary artery disease. Arch Intern Med 2000; 160:1913.
  34. Kawachi I, Colditz GA, Ascherio A, et al. Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation 1994; 89:1992.
  35. Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation 1994; 90:2225.
  36. Ruberman W, Weinblatt E, Goldberg JD, Chaudhary BS. Psychosocial influences on mortality after myocardial infarction. N Engl J Med 1984; 311:552.
  37. Barefoot JC, Dahlstrom WG, Williams RB Jr. Hostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians. Psychosom Med 1983; 45:59.
  38. Frasure-Smith N. In-hospital symptoms of psychological stress as predictors of long-term outcome after acute myocardial infarction in men. Am J Cardiol 1991; 67:121.
  39. Tofler GH, Muller JE, Stone PH, et al. Comparison of long-term outcome after acute myocardial infarction in patients never graduated from high school with that in more educated patients. Multicenter Investigation of the Limitation of Infarct Size (MILIS). Am J Cardiol 1993; 71:1031.
  40. Williams RB, Barefoot JC, Califf RM, et al. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA 1992; 267:520.
  41. Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction. A prospective, population-based study of the elderly. Ann Intern Med 1992; 117:1003.
  42. Rahe RH, Romo M, Bennett L, Siltanen P. Recent life changes, myocardial infarction, and abrupt coronary death. Studies in Helsinki. Arch Intern Med 1974; 133:221.
  43. Parkes CM, Benjamin B, Fitzgerald RG. Broken heart: a statistical study of increased mortality among widowers. Br Med J 1969; 1:740.
  44. Merritt JM, Stickgold R, Pace-Schott E, et al. Emotional profiles in the dreams of men and women. Conscious Cogn 1994; 3:46.
  45. MacWilliam, JA. Blood pressure and heart action in sleep and dreams: Their relation to hemorrhages, angina and sudden death. Br Med J 1923; 22:1196.
  46. Hobson JA. Sleep and dreaming. J Neurosci 1990; 10:371.
  47. Lown B, Temte JV, Reich P, et al. Basis for recurring ventricular fibrillation in the absence of coronary heart disease and its management. N Engl J Med 1976; 294:623.
  48. Smith OA, DeVito JL. Central neural integration for the control of autonomic responses associated with emotion. Annu Rev Neurosci 1984; 7:43.
  49. Hockman CH, Mauck HP Jr, Hoff EC. ECG changes resulting from cerebral stimulation. II. A spectrum of ventricular arrhythmias of sympathetic origin. Am Heart J 1966; 71:695.
  50. Verrier RL, Calvert A, Lown B. Effect of posterior hypothalamic stimulation on ventricular fibrillation threshold. Am J Physiol 1975; 228:923.
  51. Verrier RL, Hagestad EL, Lown B. Delayed myocardial ischemia induced by anger. Circulation 1987; 75:249.
  52. Milstein S, Buetikofer J, Lesser J, et al. Cardiac asystole: a manifestation of neurally mediated hypotension-bradycardia. J Am Coll Cardiol 1989; 14:1626.
  53. Boltwood MD, Taylor CB, Burke MB, et al. Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments. Am J Cardiol 1993; 72:1361.
  54. Verrier RL, Thompson PL, Lown B. Ventricular vulnerability during sympathetic stimulation: role of heart rate and blood pressure. Cardiovasc Res 1974; 8:602.
  55. Lown B, Verrier R, Corbalan R. Psychologic stress and threshold for repetitive ventricular response. Science 1973; 182:834.
  56. Lombardi F, Verrier RL, Lown B. Relationship between sympathetic neural activity, coronary dynamics, and vulnerability to ventricular fibrillation during myocardial ischemia and reperfusion. Am Heart J 1983; 105:958.
  57. Nearing BD, Huang AH, Verrier RL. Dynamic tracking of cardiac vulnerability by complex demodulation of the T wave. Science 1991; 252:437.
  58. Corbalan R, Verrier RL, Lown B. Differing mechanisms for ventricular vulnerability during coronary artery occlusion and release. Am Heart J 1976; 92:223.
  59. Corr, PB, Yamada, KA, Witkowski, FX. Mechanisms controlling cardiac autonomic function and their relation to arrhythmogenesis. In: The heart and cardiovascular system, Fozzard, HA, Haber, H, Jennings, RB, et al (Eds), Raven Press, New York 1986.
  60. Brown MJ, Brown DC, Murphy MB. Hypokalemia from beta2-receptor stimulation by circulating epinephrine. N Engl J Med 1983; 309:1414.
  61. Kent KM, Smith ER, Redwood DR, Epstein SE. Electrical stability of acutely ischemic myocardium. Influences of heart rate and vagal stimulation. Circulation 1973; 47:291.
  62. Kleiger RE, Miller JP, Bigger JT Jr, Moss AJ. Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. Am J Cardiol 1987; 59:256.
  63. Muller JE, Abela GS, Nesto RW, Tofler GH. Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier. J Am Coll Cardiol 1994; 23:809.
  64. Kario K, Matsuo T, Kobayashi H, et al. Earthquake-induced potentiation of acute risk factors in hypertensive elderly patients: possible triggering of cardiovascular events after a major earthquake. J Am Coll Cardiol 1997; 29:926.
  65. Hansteen V, Møinichen E, Lorentsen E, et al. One year's treatment with propranolol after myocardial infarction: preliminary report of Norwegian multicentre trial. Br Med J (Clin Res Ed) 1982; 284:155.
  66. Frishman WH. Multifactorial actions of beta-adrenergic blocking drugs in ischemic heart disease: current concepts. Circulation 1983; 67:I11.
  67. Nanthakumar K, Newman D, Paquette M, et al. Circadian variation of sustained ventricular tachycardia in patients subject to standard adrenergic blockade. Am Heart J 1997; 134:752.
  68. Schwartz PJ, La Rovere MT, Vanoli E. Autonomic nervous system and sudden cardiac death. Experimental basis and clinical observations for post-myocardial infarction risk stratification. Circulation 1992; 85:I77.
  69. Cook JR, Bigger JT Jr, Kleiger RE, et al. Effect of atenolol and diltiazem on heart period variability in normal persons. J Am Coll Cardiol 1991; 17:480.
  70. Coumel P, Hermida JS, Wennerblöm B, et al. Heart rate variability in left ventricular hypertrophy and heart failure, and the effects of beta-blockade. A non-spectral analysis of heart rate variability in the frequency domain and in the time domain. Eur Heart J 1991; 12:412.
  71. Frasure-Smith N, Lespérance F, Gravel G, et al. Long-term survival differences among low-anxious, high-anxious and repressive copers enrolled in the Montreal heart attack readjustment trial. Psychosom Med 2002; 64:571.