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Patients who undergo urgent or elective percutaneous coronary intervention (PCI) and who are married have superior short- and long-term outcomes up to 1 year compared with unmarried patients, according to a study published online September 3, 2013, ahead of print in the American Heart Journal.
Ron Waksman, MD, of MedStar Washington Hospital Center (Washington, DC), and colleagues culled data on 11,216 consecutive patients (55% married) who underwent emergency or elective PCI from 2003 to 2011.
Dramatic Difference in Adverse Events
In-hospital and 30-day mortality was substantially higher for unmarried vs. married patients (P < 0.001 for both). At 1 year, the primary combined endpoint of death, MI, and TLR was lower for those who were married vs. unmarried. This was primary driven by a twofold increase in all-cause mortality, Q-wave MI, and stent thrombosis in unmarried patients (table 1).
Table 1. Clinical Outcomes at 1 Year
Married(n = 6,141)
Unmarried(n = 5,075)
Multivariable analysis showed that married status was an independent predictor of lower 1-year MACE (HR 0.79; 95% CI 0.67-0.93). Other independent predictors included:
Further, married status (HR 0.89; 95% CI 0.81-0.97), hypertension (HR 0.8; 95% CI 0.72-0.9), diabetes (HR 0.86; 95% CI 0.78-0.94), and current smoking (HR 0.89; 95% CI 0.8-0.99) were associated with a lower risk of early clopidogrel cessation.
Subgroup analyses of unmarried patients according to their single status—divorced, separated, single, or widowed—showed no differences in outcomes despite variation in age, gender, hypertension, diabetes, hypercholesterolemia, and smoking rates at baseline.
While patterns were similar when men and women were analyzed separately, married men seemed to benefit more than women compared with their unmarried counterparts. For example, reductions in 1-year MACE for married men was driven by secondary outcomes including all-cause mortality, MI, and TLR, while the overall cohort was only affected by all-cause mortality. Still, multivariable analysis found no interaction between gender and marital status with respect to 1-year MACE (HR 0.82; 95% CI 0.59-1.14; P = 0.24).
Emotional Support May Foster Healthy Behavior, Compliance
“There are several general theoretical models believed to be associated with improved health and outcomes of married individuals,” Dr. Waksman and colleagues write. “The most acknowledged models are considered to be related to selection mechanisms, social causation mechanisms, and stress-buffering effects.”
Selection bias mechanisms confer that healthier people choose marriage more frequently than unhealthy people, they explain. The social causation theory shows that marriage has “health-promoting or health-protective effects, and “the buffering hypothesis proposes that social relationships may provide informational or emotional resources that promote adaptive behavioral or perhaps even neuroendocrine responses to acute or chronic stressors.”
In an interview with TCTMD, Sorin J. Brener, MD, of Weil Cornell Medical College (New York, NY), said the benefit in long-term outcomes stems from “something immeasurable,” perhaps compliance with medical therapy in general. When “another person is paying attention that you are doing what you are supposed to be doing like exercising and eating better,” your risk of adverse events is lower, he explained.
The “data are pretty clear,” Dr. Brener said, noting the previously shown correlation between depression and worse outcomes in coronary artery disease. “Whether people who are married are less depressed than people who are not married, I’m not sure,” he added
‘Maybe We Should Recommend Marriage’
But “we’re missing a mechanism here. It’s obviously not that you have a ring on your finger, there’s something else,” Dr. Brener observed. To understand this mechanism, he suggested conducting quality of life surveys among married and unmarried patients, adjusting for happiness, and looking at outcomes.
“There’s also the issue of sex, which has been linked with better outcomes,” he added. “So if you adjusted for the possibility of sex, you could say that people who are not married are less likely to have sex . . . maybe there wouldn’t be any difference.”
While physicians cannot prescribe marriage to their patients, they “can target populations at higher risk for recurrent events,” Dr. Brener said, adding that more frequent follow-up should be done in unmarried patients. “Or you can say suggest they go to a support group or insist they go to rehab even more so.”
Still, the “enormous” mortality difference is undeniable. “We don’t have any medicine that reduces mortality by 50%, so maybe we should recommend marriage,” he concluded. “Take an aspirin and get married.”
In a telephone interview with TCTMD, Dr. Waksman said to advance this theory further, relationships beyond marriage should be studied. “If we want to go to the next level, we have to be more granular and see if this is related to a marriage partnership, or if it’s just about living alone versus living with someone,” he concluded.
The average age was 64 years, and 65% of patients were men. PCI was performed for stable angina pectoris (28%), unstable angina (46%), and acute MI (13%).