Heart failure

Bereavement linked to worse prognosis in heart failure

Heart failure patients experiencing bereavement are at an increased risk of death, particularly during the first week following the death of a close family member, new research shows.

While depression, anxiety and low social support have previously been associated with poor prognosis in HF patients, few studies have looked at links between grief and HF outcomes, according to researchers at the Karolinska Institutet in Stockholm, Sweden.

Their study looked at HF mortality risk in 58,949 people enrolled in the Swedish Heart Failure Registry and/or patients with a primary diagnosis of HF from the Swedish Patient Register, all of whom experienced bereavement during the mean 3.7 years of follow-up.

A significant association between bereavement and increased HF mortality risk was observed after death of a child (a 10% increased risk), spouse/partner (a 20% increased risk), grandchild (a 5% increased risk) or sibling (a 13% increased risk), but not after death of a parent.

The risk of dying from HF after the loss of any family member was highest during the first week of bereavement (a 78% increased risk), particularly in the case of death of a child (a 31% increased risk) or spouse/partner (a 113% increased risk); it was also higher in the case of two losses (a 35% increased risk) as opposed to one loss (a 28% increased risk).

“The association between bereavement and mortality was not only observed in cases of loss due to cardiovascular disease and other natural causes, but also in cases of unnatural deaths,” said Dr Hua Chen, lead author of the study from the Institute’s Department of Global Public Health.

“Our finding that bereavement was associated with mortality in HF patients contributes to and extends the existing literature regarding role of stress in prognosis of HF and is consistent with studies reporting associations between bereavement and increased risk of incident cardiovascular conditions.”

The study authors postulated that bereavement may lead to the activation of the hypothalamic-pituitary-adrenocortical axis, the renin-angiotensin-aldosterone system, and the sympathetic nervous system.

“The changes in the latter two systems are the main features of the neuroendocrine response in the pathophysiology of HF, both being initially characterised by compensatory mechanisms but subsequently promoting the progression of HF by accelerating adverse left ventricular remodelling and catecholamine-induced cardiotoxicity,” they noted

Catecholamines have been suggested to play a major role in the pathophysiology of takotsubo syndrome, which is primarily triggered by emotional factors, including the death of a close family member, they said

Furthermore, cortisol may be directly involved in the progression of HF by acting as a cardiac mineralocorticoid receptor agonist to mimic the effects of aldosterone, which in turn leads to vasoconstriction as well as salt and water retention to accelerate the development of HF, they added.

“The findings of the study may call for increased attention from family members, friends and involved professionals for bereaved heart failure patients, particularly in the period shortly after the loss,” said Krisztina László, senior author of the study and an associate professor from the Department of Global Public Health at Karolinska Institutet.

Future studies are needed to investigate whether less severe sources of stress may also contribute to poor HF prognosis, the study authors said.

The study was published in JACC: Heart Failure.

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