Unmarried Coronary Artery Disease Patients Fare Worse

Marlene Busko  

December 27, 2017

ATLANTA, GEORGIA — In a large study of patients with coronary artery disease (CAD), those who were widowed, divorced/separated, or never married were more likely to die from cardiovascular causes or have a nonfatal MI than married patients over a period of about 4 years[1].

The study, by Dr William M Schultz (Emory Clinical Cardiovascular Research Institute, Atlanta, GA) and colleagues, was published December 20 in the Journal of the American Heart Association.

"The mechanisms remain to be described," senior author Dr Arshed A Quyyumi (Emory Clinical Cardiovascular Research Institute) told theheart.org | Medscape Cardiology, but lack of social support appears to be the main driver behind the worse survival in the unmarried CAD patients.

Cardiologists "are generally more focused on measurements...like blood pressure or cholesterol," as opposed to thinking about patients' psychosocial status, he said.

These findings "should raise [alarm] bells in our minds when somebody comes in and says, 'My wife [or my husband] died since I last saw you,'" he added. Such patients already have a high risk of cardiovascular death or MI because they have CAD, and with the loss of a spouse they have an even higher risk.  

Invited to comment, American Heart Association spokesperson Dr Nieca Goldberg (NYU Langone Health, New York) agreed.

"It's important for us not only to address the standard cardiovascular risk factors, but also to engage with the patients to understand their mental health and see if you can have a positive influence on that." 

Other studies have shown that being in a positive, productive relationship with a partner is associated with lower stress levels, although this is not true if the relationship is toxic, she noted.

Like Quyyumi, she said, "It's important for us when it comes to cardiovascular disease not only to take care of the cholesterol and blood pressure and get people to exercise and quit smoking, but also [to consider] their mental health."

Loss of Spouse or No Spouse in High-Risk Patients

Divorced individuals in the general population have a higher risk of death, but the association between marital status and outcomes in patients with cardiovascular disease is not clear, Schultz and colleagues write.

To investigate this, they identified 6051 adults with known or suspected CAD who underwent cardiac catheterization at their center from 2003 to 2015 and were followed for a median of 3.7 years.

Patients replied to a questionnaire and indicated if they were married, divorced/separated, widowed, or never married. Those who were living with a partner but not married probably would have reported they were married or never married, Quyyumi noted.

The patients were an average age of 63 years and 23% were black. Most had obstructive CAD (70%) and 8% had an acute MI.

More than two-thirds (68%) were married; and the rest were divorced/separated (14%), widowed (11%), or never married (7%).

The individuals who were never married were younger (mean age 53 years), than those who were divorced/separated (mean age 60 years), or widowed (mean age 73 years).

Unmarried patients were more likely to be women, black, and have hypertension, heart failure, and high cholesterol, and less likely to be smokers than married patients.

The primary outcome was combined cardiovascular death (including fatal MI, stroke, sudden cardiac death) and nonfatal MI. Secondary outcomes included all-cause death and cardiovascular death alone.

During follow-up, 1085 patients (18%) died, 688 patients (11%) died from cardiovascular causes, and 272 patients (4.5%) had a nonfatal MI.

Compared with married patients, unmarried patients had a 24% higher risk of all-cause death, a 45% higher risk of cardiovascular death, and a 52% higher risk of cardiovascular death or MI (all significant), after adjusting for clinical characteristics.

Diving deeper revealed that widowed patients had a 71% increased risk of cardiovascular death or MI, and divorced/separated patients had a 41% increased risk of the outcome (both significant), after adjusting for clinical characteristics.

Never-married patients had a 40% increased risk of the outcome, but this was not significant, possibly because the number of patients in this group was too small. 

Among the unmarried patients, those younger than age 65 years had a higher risk of all-cause mortality than older patients. Unmarried men and women had similar outcomes, unlike in some other studies in which unmarried men had worse outcomes.

The association between marital status and outcomes persisted after adjusting for medications and factors such as education and employment status. 

Patients who become divorced or widowed may become depressed, more sedentary, and forgo healthy foods, and they may become less compliant with medications, which might explain why they are at higher risk of death or MI, Quyyumi speculated.

"Individuals with coronary artery disease who are at high risk for adverse cardiovascular outcomes should be identified," Schultz and colleagues conclude.

"Further investigation is needed to determine whether more aggressive treatment strategies can positively alter outcomes for unmarried patients."

The authors have no relevant financial disclosures.

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