The Anniversary Reaction Phenomenon: Understanding its Triggers and Mechanisms

How much has the anniversary reaction phenomenon been covered in cardiology-related literature? There has been considerable interest in the interaction between emotional state and major cardiovascular events, and there is fairly extensive literature on the correlation between anger and acute coronary events. However, there is only a small amount of literature that has attempted to link emotional state with therapy from defibrillators. For example, there was a publication a couple of years ago that showed an increase in the frequency of defibrillator therapies post 9/11, suggesting that the stress of 9/11 was affecting the population in such a way that people with defibrillators were more likely to have events. In addition, there has been some literature that has tried using various types of psychological instruments to survey patients post-hoc after they ve had defibrillator therapy to ascertain what their mental state might have been at or about the time of the therapy. These various efforts have addressed the poorly understood linkage between the autonomic nervous system and the heart, with the reasonable assumption that the mental state influences the autonomic nervous system and thereby provides a linkage to cardiovascular events. However, in all of the current literature there is not much discussion about the concept of the anniversary reaction. Your first statement is correct; anniversary reaction is a term that exists almost exclusively in psychiatric literature. It was first suggested as a concept by Sigmund Freud in the late 19th century (included as the first reference in our article), although I m not sure if Freud used the term anniversary reaction that actual nomenclature might have appeared in the mid-1950s. In any event, Freud described the idea that the subconscious mind might maintain an awareness of time, and that contemporary emotional events possibly with dramatic physical consequences could be the result of the subconscious interpretation of the passage of time. How did all of this link to our patient s case? Over 20 years ago, while I was still in medical school in Rochester, New York, my co-author, who was then one of my teachers, presented the concept of the anniversary reaction, which stuck in my head. He described the phenomena where for example a widower would drop dead on the one-year anniversary of the death of a spouse or a person would drop dead on receipt of tragic news. It turns out that his interest was initiated by one of his mentors a physician named George Engel, who is cited in our references. Engel was an internist and medical educator who was also very interested in psychology. Engel s interest in anniversary reactions was personally stimulated by his own experience of his first myocardial infarction, which occurred a year to the day that his twin brother died of a myocardial infarction. Through psychoanalysis, he retrieved an unconscious memory that when his brother died he gave himself a year to live. A year later he had and survived a heart attack. He subsequently collected and published a large series of articles about anniversary reaction deaths in which someone would receive tragic news (either in person, by letter, or via telephone) and then literally drop dead within 24 hours of receipt of the tragic news. These reports largely exist in the lay press, which is one of the reasons the public has such an interest in this topic. Conversely, the medical community has largely discounted these reports, since the ability to link the plausible mechanism of sudden death with the potential trigger of tragic news has been lacking; all that the medical community can agree on is that someone died. There are a lot of reasons why human beings might experience sudden death, and establishing that it was the tragic news that caused the death is a very difficult thing to do. We do know, for example, that some forms of genetic heart rhythm disturbances like long QT and Brugada syndromes are exquisitely sensitive to autonomic triggers, so it s easy to imagine that with the right physical substrate one could be scared literally to death. This is not dissimilar from hearing stories about someone receiving tragic news and overnight their hair turned white the cynical view is that it never really happened, but the fact of the matter is that it obviously happens, but we just don t understand why. However, since there is no reasonable explanation, people tend to discount these events. Describe your patient s story. What was your patient s initial diagnosis and treatment plan? What was your reaction when you realized the chain of events that had occurred? I hadn t been thinking about the concept of anniversary reaction until this particular patient s case. My patient was a younger woman with advanced ischemic heart disease who qualified for primary prevention ICD therapy (according to MADIT II guidelines) for coronary disease. She was referred for a defibrillator for prevention of sudden death; it was implanted in September 2004. By definition, she never had spontaneous ventricular arrhythmia. She had an uneventful follow-up until the following April, when during a routine office visit her ICD interrogation revealed that about a month prior she had had an episode of rapid ventricular tachycardia (VT) that was terminated painlessly with anti-tachycardia pacing. She was unaware of the event. It is typically the case that I ask patients what they were doing around the time of their arrhythmia particularly their first arrhythmia because I wonder whether there are any physical triggers that could explain the episode, and that might be useful in their management. The ICD provided a time and date stamp with the recording of her rhythm, so we knew exactly when the episode occurred, and after a little bit of a pause about a minute or so while she was puzzling things over and checking her calendar because she was in disbelief she related a rather astonishing story. She explained that the event occurred while she was attending the funeral of her sister-in-law; specifically, while she was witnessing her sister-in-law s burial. We talked about it further, and it turns out that her sister-in-law had a witnessed cardiac arrest and died upon receiving news by telephone that the patient s father had died unexpectedly one week prior. So the same day that he died, her sister-in-law, with whom he was very close, was informed by phone of his death. She dropped dead in front of the family, and then approximately seven days later, on the approximate one-week anniversary of the father s death and while attending the funeral and witnessing the burial of her sister-in-law, my patient had her one and only episode of VT, which which was terminated by her ICD, thereby aborting a potential sudden cardiac death. She has had no sustained heart rhythm disturbances before or after this event. This triggered in me, of course, the memory of the concept of grief reaction and anniversary reaction. What is unique about anniversary reactions? What is unique is that we now have this small piece of believable scientific evidence. This is the kind of family story that could easily fall into the lay press: the father dies, the sister-in-law receives the news and drops dead while on the phone, the daughter attending funeral of sister-in-law drops dead at the graveside! This certainly would provide for a dramatic moment in the lay press. A typical reaction would be, What? That sounds like complete nonsense! It s probably a coincidence. How do you know what happened to the sister-in-law? How do you know what happened to the daughter? The difference here is that we actually captured an episode of a plausible mechanism of sudden death at the exact time in the context of tremendous personal loss in someone with a substrate susceptible to ventricular arrhythmia. That is how we introduced the concept of grief in an anniversary reaction as potentially triggering sudden death. This is also why grief reactions have captured people s attention, because the average person despite what physicians might say believes that the tragic news could kill you, even though they might not understand how it could happen. The answer is that it probably does only happen to people with some underlying predisposition to a ventricular arrhythmia or other lethal cardiovascular event, such as myocardial infarction or stroke. However, to discount that possibility is to discount the interaction between the autonomic nervous system and the heart, and this is why we thought it was of interest to publish this data in cardiology literature. Are anniversary reactions (and the resulting sudden cardiac arrests) associated with patients of all ages? They primarily occur in the elderly population. For example, let s consider the sister-in-law, who was in her 70s; although my patient did not know her sister-in-law s personal medical history, she did tell me that her sister-in-law had a history of heart problems. Therefore, it is quite likely that the sister-in-law had coronary artery disease and a substrate, a pathophysiologic basis for an arrhythmia or acute myocardial infarction, and either one of the two were triggered by the powerful autonomic reaction to the unexpected receipt of tragic news. If you study the anniversary reaction as it applies to sudden death, a majority of cases are adults. In addition, although the autopsy correlation is nonexistent, if you were to autopsy these patients like has been done in the anger-associated acute myocardial infarction grief population, you ll find that most of these patients had heart disease. Thus, the more likely explanation is that these patients are susceptible to ventricular arrhythmia as a mechanism of death, and that the autonomic nervous system, under extreme circumstances, can trigger their first episode of arrhythmia. The exception to the advanced age patient would be, for example, a younger patient who has a genetically-mediated heart rhythm disturbance such as Brugada or long QT syndrome. We know for sure that these types of genetically-mediated ion channel repolarization abnormalities are highly susceptible to autonomic influence. Ultimately, I believe that the majority of anniversary reactions occur in people of an age group where they probably have undisclosed heart disease. In some tragic instances, these events may be the first manifestation of heart disease. What treatment or precaution, if any, can one take to prevent an anniversary reaction? That is difficult. If you don t know you re at risk for a life-threatening ventricular arrhythmia, then there s not much you can do. It s quite interesting since this article got picked up in the lay press, I ve received emails from people all over the world commenting on their personal experience with an anniversary reaction and other unconscious awareness memories that were triggered by life events. Unfortunately, there isn t an answer to this there would be no way to explicitly protect oneself unless you knew you had a predisposing condition to cardiac arrest, which could then be treated by other means. I will tell you that anniversary reactions are not exclusive to grief alone. I have one patient who has coronary artery disease but had never had a cardiac arrhythmia. However, one day while playing golf, this patient hit a hole-in-one, and while dancing around on the 18th hole, he had a sudden cardiac arrest. It was not grief that caused his cardiac arrest, it was joy. Thankfully he was resuscitated and was implanted with a defibrillator. Therefore, in this case we were discussing grief reactions, but there are also examples of powerful adrenaline surges causing anniversary reactions. Actually, when investigating this topic in the literature, in most of these events the least common reaction is sudden death. A far more common reaction would be depression, sleep disturbance, having a fight with your spouse for reasons you don t understand, and even homicidal ideation or action. The psychiatry literature is absolutely fascinating in this regard. Unfortunately, though, our training in medicine tends to discount things that we can t prove with rules of science. In this case, it does not mean these possibilities aren t true, rather it is that we have a limited imagination to develop the metrics for documenting the linkage between the autonomic nervous system and the arrhythmia. Amongst the hundreds of thousands of American patients each year who are at risk for sudden death and who at one point will potentially qualify for a defibrillator, the most compelling question to ask is not Why did they had a cardiac arrest? We are pretty competent at understanding mechanisms of cardiac arrest. The most compelling question is Why did it happen on a specific day, at a specific time? Specifically, why doesn t it happen all the time? Why doesn t it happen every day? Why would a patient who received a defibrillator and doesn t have a single episode of ventricular arrhythmia for 36 months, then have VT that s terminated by the device, another two years goes by, and they have another event. Why then? Why at that exact time? That is far more compelling than the basic mechanism of arrhythmia, which we can recreate in animal models. Will you be doing any further research on anniversary reactions? It is a possibility. For example, the Heart Rhythm Society has established a national registry for ICD use as part of the collaboration with Medicare on widespread approval for primary prevention. They have a database, which is available for investigations and analysis to HRS members, so we may try to explore that to help link grief reactions with ventricular episodes. However, it s a hard thing to study, as you can imagine. You end up looking at individual cases and trying to figure out in retrospect what happened. I think what made this particular case so striking is the fact that there were two family deaths two in a day and another that would have occurred one week later had she coincidentally not had a defibrillator. That's very dramatic. How is the patient doing today? Is she at all concerned about another anniversary reaction? It s a good question; in fact, it s a good question for a very specific reason. We had a request to do an interview on national television I won t get into the details but the program that had an interest in this would only do it if the patient agreed to participate. Out of courtesy I mentioned it to her, but I already knew what her answer would be there was no way she was going to revisit that! If I were her, I would have been very anxious about revisiting all of that drama while on national TV. It would just be too much. I didn t have to ask her to know that she would have no interest in revisiting the misery of those seven days a year ago when she lost two family members in the course of one day. Do you think her family members could experience a similar reaction? Do you think there could be a genetic connection? From the standpoint of the genetic linkage with coronary artery disease, there is one publication that we cited in our references that did show that merely having coronary artery disease did not anticipate cardiac arrest. We have no idea why this is, and why others are at higher risk for cardiac arrest. There is some evidence that the predisposition to cardiac arrest associated with coronary artery disease may have a familial basis. Therefore, we get back to the same question of why it is that hundreds of thousands of people could have the exact same medical condition of chronic, healed myocardial infarction and reduced left ventricular pump function, but only a minority are destined for cardiac arrest. I m sure there is a cellular level signaling mechanism that we don t yet understand that is conceivably influenced by genetic factors. I believe that people can view this in one of two ways. The cynics will say it is all a coincidence, which is a very small-minded view and an easy way to go through life. The other view is that you can think about it and ask the question Why did my patient have a cardiac arrest that Friday at 8 am and no other time?, but you ll spend the rest of your life trying to answer that question. It is a very complex topic. The purpose of this case report was to introduce the possibility, to add some weight to the idea that it takes more than just having coronary artery disease to have a cardiac arrest. There are probably powerful linkages between the emotional state and the autonomic nervous system and the trigger of cardiac arrest in someone who has been at risk for years and in whom it s never happened. It s hard to prove, but to instead dismiss such things as coincidence is to be of limited imagination. For more information about the anniversary reaction, please see: Sweeney MO, Quill TE. Clustering of sudden death and aborted cardiac arrest associated with a family grief reaction. Heart Rhythm (2007), doi: 10.1016/j.hrthm.2007.02.022