title: Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Short-term psychological stress is associated with an immediate physiological response and may be associated with a transiently higher risk of cardiovascular events. The aim of this study was to determine whether brief episodes of anger trigger the onset of acute myocardial infarction (MI), acute coronary syndromes (ACS), ischaemic and haemorrhagic stroke, and ventricular arrhythmia.
  
  
  RESULTS
  We performed a systematic review of studies evaluating whether outbursts of anger are associated with the short-term risk of heart attacks, strokes, and disturbances in cardiac rhythm that occur in everyday life. We performed a literature search of the CINAHL, Embase, PubMed, and PsycINFO databases from January 1966 to June 2013 and reviewed the reference lists of retrieved articles and included meeting abstracts and unpublished results from experts in the field. Incidence rate ratios and 95% confidence intervals were calculated with inverse-variance-weighted random-effect models. The systematic review included nine independent case-crossover studies of anger outbursts and MI/ACS (four studies), ischaemic stroke (two studies), ruptured intracranial aneurysm (one study), and ventricular arrhythmia (two studies). There was evidence of substantial heterogeneity between the studies (I(2) = 92.5% for MI/ACS and 89.8% for ischaemic stroke). Despite the heterogeneity, all studies found that, compared with other times, there was a higher rate of cardiovascular events in the 2h following outbursts of anger.
  
  
  CONCLUSIONS
  There is a higher risk of cardiovascular events shortly after outbursts of anger.
authors.affiliation: Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Room 423, Boston, MA 02215, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Mostofsky
authors.affiliation: Department of Internal Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA.
authors.forename: Elizabeth Anne
authors.initials: EA
authors.lastname: Penner
authors.affiliation: Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Room 423, Boston, MA 02215, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA mmittlem@bidmc.harvard.edu.
authors.forename: Murray A
authors.initials: MA
authors.lastname: Mittleman
mesh_terms: D054058:Acute Coronary Syndrome / Q000523:psychology*; D000786:Anger / Q000502:physiology*; D001145:Arrhythmias, Cardiac / Q000523:psychology*; D006801:Humans; D009203:Myocardial Infarction / Q000523:psychology*; D011379:Prognosis; D012307:Risk Factors; D020521:Stroke / Q000523:psychology*
keywords: Anger; Cardiovascular disease; Case-crossover; Epidemiology