Heart disease patients who are unmarried may have a higher risk of mortality than their married counterparts, according to a study of more than 6,000 patients undergoing cardiac catheterization for coronary artery disease (CAD).
Compared with patients who were married, those who were unmarried had a higher risk of all-cause mortality (hazard ratio 1.24, 95% CI 1.06 to 1.47, cardiovascular death (HR 1.45, 95% CI 1.18 to 1.78), and cardiovascular death or myocardial infarction (HR 1.52, 95% CI 1.27 to 1.83), reported Arshed Quyyumi, MD, of Emory University in Atlanta, and colleagues.
Similar increases in cardiovascular death or MI were found for patients who were divorced or separated (HR 1.41, 95% CI 1.10 to 1.81), widowed (HR 1.71, 95% CI 1.32 to 2.20), or never married (HR 1.40, 95% CI 0.97 to 2.03) compared with married patients, they wrote online in the Journal of the American Heart Association.
The results remained significant even after adjustment for medication prescriptions and socioeconomic risk factors, the authors noted.
“I was somewhat surprised by the magnitude of the influence of being married has (on heart patients),” said Quyyumi. “Social support provided by marriage, and perhaps many other benefits of companionship, are important for people with heart disease.”
Quyyumi’s group studied 6,051 patients from the Emory Cardiovascular Biobank, a prospective cohort of patients who underwent cardiac catheterization for suspected or known CAD at Emory Healthcare hospitals from 2003 to 2015. Exclusion criteria included severe valvular heart disease, congenital heart disease, severe anemia, recent blood transfusion, myocarditis, active inflammatory diseases, and active cancer.
Marital status was derived from a self-administered questionnaire at baseline, consisting of married (n=4,088) versus unmarried (n=1,963), never married (n=451), divorced or separated (n=842), or widowed (n=670). Of the overall cohort, 4,256 patients (70.3%) had obstructive CAD and 490 (8%) presented with acute MI, the researchers reported.
Follow-up data was collected via phone interview, electronic health record review, Social Security death index, and state records.
Quyyumi ‘s group reported 1,085 (18%) deaths from all causes, 688 (11%) cardiovascular-related deaths, and 272 (4.5%) incident MI events over a median follow-up period of 3.7 years.
They found a significant interaction between age and all-cause mortality in the unmarried cohort, but not with cardiovascular death or cardiovascular death/MI.
Younger (ages <65 years) unmarried individuals were at higher risk for all-cause mortality (HR: 1.43; 95% CI, 1.09 to 1.89) than those aged ≥65 years, although the rates of cardiovascular death or cardiovascular death/MI were higher in unmarried individuals regardless of age.
After adjustment, widowed patients had a significant increased risk of cardiovascular death (subdistribution hazard ratio: 1.62; 95% CI, 1.23 to 2.13), and cardiovascular death/MI (sHR: 1.71; 95% CI, 1.32 to 2.20) compared with married patients.
Compared with married patients , unmarried patients were more likely to be female and black, less likely to be smokers, and more likely to have hypertension, heart failure, reduced eGFR, or elevated LDL or HDL levels.
Both divorced or separated patients and widowed patients were also more likely to female and black. However, divorced or separated patients tended to be younger with LDL and HDL cholesterol levels, while widowed patients were older with reduced eGFR and a history of hypertension, diabetes mellitus, obstructive CAD, heart failure, presentation with acute MI, or higher HDL level.
The authors concluded that further investigation is needed to determine whether more aggressive treatment strategies can influence outcomes for unmarried patients. “Accounting for unmarried status in the management of patients with CAD, consideration of associated psychological conditions, and potentially more aggressive follow-up and therapy need to be considered in future studies,” they wrote.
The researchers listed the large sample size, diverse multiethnic population, representation of sex and race, and long-term follow-up as study strengths. Limitations included the retrospective analysis, single-center study, and lack of follow-up regarding continued marital status.
Quyyumi and co-authors disclosed no relevant relationships with industry.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner