To the Editor.
—The article by Case et al1 concerned with the long-term prognostic impact of living alone after a myocardial infarction (MI) is a major contribution to the growing evidence that psychosocial factors have important prognostic significance following MI. It was therefore surprising to see that in the authors' consideration of hypothetical mechanisms linking social isolation with poor outcome (including a possible neuroendocrine response to human contact), no reference was made to the potential intervening role of negative emotions including anxiety and depression.There is increasing evidence that psychological factors are linked to neurohormonal and cardiovascular changes that may result in atherosclerosis, ischemia, MI, and sudden death.2 In addition, several recent studies have demonstrated a relationship between measures of post-MI psychological status (eg, anxiety, depression, and emotional distress) and prognosis, independent of standard cardiac risk variables.3-5 Thus, it could be hypothesized that one reason that the
Frasure-Smith N, Lespérance F. Social and Economic Factors in Patients With Coronary Disease. JAMA. 1992;268(2):195. doi:10.1001/jama.1992.03490020039013