Wednesday, March 12, 2014

Marital Status & Cardiac Mortality: A Matter Of Wife Or Death?



# 8369


As a retired paramedic who plied his modest skills throughout the 1970s across three notorious `cardiac cities’ (Phoenix, AZ, St. Petersburg & Bradenton, FL) – and now reaching `that age’ where I have to think about such things on a more personal level -  I have more than a passing interest in heart disease and heart attacks.


There’s been a good deal of research to show that married men live longer than their divorced or unmarried counterparts (see Harvard Health Watch Marriage and men's health), but far less is known about the health effects of marriage for women.


We’ve an open access study today, published in the journal BMC Medicine, that attempts to answer this question – at least in regards to Ischemic Heart Disease (IHD).  Utilizing the vast stores of data accumulated from the UK's Million Women Study - a comprehensive survey of more than 1.3 million women aged 50 or older recruited between 1996 and 2001- researchers were able to include data from more than 700,000 women in their study.


While they found that women who were married (or living with a partner) had the same risk of developing heart disease as single women, they found that women with partners were 28% less likely to die from heart disease.


First, a look at the abstract (the entire study is available at the link below), then I’ll be back with a bit more.


Marital status and ischemic heart disease incidence and mortality in women: a large prospective study

Sarah Floud*, Angela Balkwill, Dexter Canoy, F Lucy Wright, Gillian K Reeves, Jane Green, Valerie Beral, Benjamin J Cairns and the Million Women Study Collaborators



Being married has been associated with a lower mortality from ischemic heart disease (IHD) in men, but there is less evidence of an association for women, and it is unclear whether the associations with being married are similar for incident and for fatal IHD. We examined the relation between marital status and IHD incidence and mortality in the Million Women Study.


A total of 734,626 women (mean age 60 years) without previous heart disease, stroke or cancer, were followed prospectively for hospital admissions and deaths. Adjusted relative risks (RRs) for IHD were calculated using Cox regression in women who were married or living with a partner versus women who were not. The role of 14 socio-economic, lifestyle and other potential confounding factors was investigated.


81% of women reported being married or living with a partner and they were less likely to live in deprived areas, to smoke or be physically inactive, but had a higher alcohol intake than women who were not married or living with a partner. During 8.8 years of follow-up, 30,747 women had a first IHD event (hospital admission or death) and 2,148 died from IHD. Women who were married or living with a partner had a similar risk of a first IHD event as women who were not (RR = 0.99, 95% confidence interval (CI) 0.96 to 1.02), but a significantly lower risk of IHD mortality (RR = 0.72, 95% CI 0.66 to 0.80, P <0.0001). This lower risk of IHD death was evident both in women with and without a prior IHD hospital admission (respectively: RR = 0.72, 95% CI 0.60 to 0.85, P <0.0001, n = 683; and 0.70, 95% CI 0.62 to 0.78, P <0.0001, n = 1,465). These findings did not vary appreciably between women of different socio-economic groups or by lifestyle and other factors.


After adjustment for socioeconomic, lifestyle and other factors, women who were married or living with a partner had a similar risk of developing IHD but a substantially lower IHD mortality compared to women who were not married or living with a partner.


While this is likely the largest study of this kind, it is not the first to show that married men and women tend to outlive those who live alone.


Roughly a year ago, a Finnish study, published in the European Journal of Preventive Cardiology found that both men and women who lived alone are at a higher risk of having a heart attack, and had a worse prognosis when they did. Being married (or partnered) was linked to a "considerably better prognosis of acute cardiac events both before hospitalization and after reaching the hospital alive".


Prognosis of acute coronary events is worse in patients living alone: the FINAMI myocardial infarction register

Aino Lammintausta1, Juhani KE Airaksinen1, Pirjo Immonen-Räihä1, Jorma Torppa2, Antero Y Kesäniemi3, Matti Ketonen4, Heli Koukkunen5,6, Päivi Kärjä-Koskenkari3, Seppo Lehto6, Veikko Salomaa2


Background Single living has been associated with a worse prognosis of acute coronary syndrome (ACS). We aimed to study the relation of sociodemographic characteristics to the morbidity, mortality, and case fatality (CF) of ACS in a large population-based ACS register.

Methods The population-based FINAMI myocardial infarction register recorded 15,330 cases of ACS among persons aged 35–99 years in Finland in 1993–2002. Record linkage with the files of Statistics Finland provided information on sociodemographic characteristics (marital status, household size).

Results ACS incidence and 28-day mortality rate were higher in unmarried men and women in all age groups. The prehospital CF of incident ACS was higher in single living and/or unmarried 35–64-year-old people. The 28-day CF was 26% (95% confidence interval, CI, 24–29%) in married men, 42% (95% CI 37–47%) in men who had previously been married, and 51% (95% CI 46–57%) in never-married men. Among women, the corresponding figures were 20% (95% CI 15–24%), 32% (95% CI 25–39%), and 43% (95% CI 31–56%). Most of these CF differences were apparent already at the prehospital phase. The only difference in treatment was that middle-aged men living alone or unmarried received thrombolysis less often. The disparities in ACS morbidity and mortality by marital status tended to widen during the study period.

Conclusions Single living and/or being unmarried increases the risk of having a heart attack and worsens its prognosis both in men and women regardless of age. Most of the excess mortality appears already before the hospital admission and seems not to be related to differences in treatment of ACS.


Higher pre-hospital mortality from cardiac events among single people is likely explained – at least in part – to not having someone to call for help, or initiate CPR, in a timely fashion. But this study also found that 28-day mortality rates were significantly higher in both unmarried men (60%-168%) and  unmarried women (71%-175%) than their married counterparts.


Heart attacks are not – as once believed – predominantly a `male problem’.  Thirty years ago, if a man  experienced `chest pain’, doctors would immediately suspect a heart attack, but if a similarly aged woman presented with the same symptoms, they’d think first `gall bladder’


Complicating matters, women don’t always show the same classic symptoms (e.g. crushing chest pain radiating down the left arm, dyspnea, diaphoresis) that men usually do when having a heart attack. The American Heart Association’s article Heart Attack Symptoms in Women explains some of the differences.


In Deadlier Than For The Male, we looked at research that examined the impact of coronary heart disease on women, and differences in their symptoms and the treatment they receive.  Their conclusion: Contrary to long held beliefs, heart attacks for women can actually be deadlier than for the male.


Exactly why partnered people fare better when it comes to cardiac events isn’t really understood, although a number of theories (more emotional & physical support, better diet, better adherence to meds, etc.) have been proposed.  And it should also be noted that these studies focused on cardiac events and mortality.


Future studies are needed to look at marriage’s effects on other factors and events, such as strokes and cancer.


According to The American Heart Association (data for 2009) every year an estimated 785,000 Americans experience their first heart attack, and another 470,000 suffer a recurrent heart attack. They also estimate another 195,000 `silent’ myocardial infarctions occur each year.

So now would be a good time to remind my readers (partnered, or otherwise) to of the importance of learning CPR. 


Compression-only CPR is now the standard for laypeople, and so you don’t have to worry about doing mouth-to-mouth. While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.


A class only takes a few hours, and it could end up helping you save the life of someone you love.


To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.