Vital Exhaustion as a Risk Factor for Adverse Cardiac Events (from the Atherosclerosis Risk in Communities [ARIC] Study)

Abstract

Conclusion: In both men and women, vital exhaustion independently predicts long-term risk for adverse cardiac events. Summary: Vital exhaustion is defined as a state of excessive fatigue, increased irritability, and demoralization. European studies have suggested a link between vital exhaustion and coronary heart disease. The authors attempted to use data from the Atherosclerosis Risk In Communities (ARIC) study to provide United States data on the role of vital exhaustion and acute coronary syndromes. The goal was to determine whether individuals with low exhaustion compared with those with high vital exhaustion were at increased risk for myocardial infarction and fatal coronary heart disease. ARIC participants were black or white men and women aged 48 to 67 years. ARIC is a large population-based prospective study of the cause and natural history of atherosclerosis. Patients are derived from Washington County, Maryland; suburban Minneapolis; Forsyth County, North Carolina; and Jackson, Mississippi. Patients were initially enrolled between 1987 and 1989 and have returned at approximately 3-year intervals for three follow-up clinical examinations. Hospitalizations and death during follow-up are identified through annual telephone interviews and hospital surveillance. In this study, 12,895 participants in ARIC were monitored for occurrence of cardiac morbidity and mortality from 1990 to 2002 (maximum follow-up, 13.0 years). Assessment of vital exhaustion was with the 21-item Maastricht Questionnaire. Scores were divided in quartiles for statistical analysis. Those scoring in the fourth quartile were considered to have high vital exhaustion. High vital exhaustion predicted adverse cardiac events in age-, gender-, and race-adjusted analyses (1.69, 95% confidence interval [CI], 1.40-2.05). High vital exhaustion also predicted adverse cardiac events when adjusted for educational level, body mass index, plasma low-density lipoprotein and high-density lipoprotein cholesterol levels, systolic and diastolic blood pressure, diabetes mellitus, smoking, and past years of smoking (1.46, 95% CI, 1.20-1.79). Risks for adverse cardiac events increased from the first to the fourth quartile of vital exhaustion, and probabilities of adverse cardiac events were higher over time in patients with high vital exhaustion compared with those with low exhaustion levels (P = .002). Vitally exhausted participants in this study, compared with nonexhausted peers, were more likely to be women, black, and have less formal education. Comment: Vital exhaustion is closely linked to depression, and the two conditions share common characteristics such as irritability and fatigue. Fatigue does appear to be a real and measurable risk factor for cardiovascular disease. Clearly, fatigue is associated with myocardial infarction. This is especially so in women: >70% of women in a recent study reported unusual fatigue before myocardial infarction, with about 30% of men reporting fatigue preceding myocardial infarction (McSweeney JC, et al, Circulation 2003;108:2619- 23). Other studies have also suggested an inverse relationship between exhaustion and social and economic status (Schuitemaker GE, et al, Psychosomatics 2004;45:414-8). The Maastricht Questionnaire examines only the presence or absence of vital exhaustion but not the etiology. It is possible that residual or unmeasured confounders, such as the underlying etiology of vital exhaustion, may be additive risk factors for cardiovascular events.