Ortho Communications & Science

Vital exhaustion (Engels)

A risk factor for myocardial infarction and first stroke in primary prevention
Naar aanleiding van het promotieonderzoek dat Gert Schuitemaker uitvoerde in samenwerking met de Universiteit Maastricht

Many patients feel tired, distressed or even depressed after an infarction or stroke. Epidemiological studies investigating the precursors of myocardial infarction have shown that these feelings had already existed before the occurrence in the majority of patients. This prodromal state was labeled by Appels as Vital Exhaustion, a state characterized by unusual fatigue, loss of energy, increased irritability and feelings of demoralization.(1) This state reflects a breakdown of the adaptation to stress. Prevention of cardiovascular disease, including myocardial infarction and stroke, is an important task for physicians, including general practitioners. Primarily, prevention requires the identification of risk factors. Generally recognized risk factors for myocardial infarction include older age, male gender, positive family history, smoking habits, hypertension, hypercholesterolemia and diabetes mellitus. In the case of stroke, the factor most generally recognized as the principal risk factor is hypertension. Other risk factors are MI, especially in the first month after the event; diabetes mellitus and smoking. This observation induced us to test whether an assessment of vital exhaustion could contribute to the identification of subjects at increased risk of myocardial infarction and first stroke in general practice. This test was performed in the context of the so-called Mierlo Project.(2)
  1. 1. Appels A. Psychological prodromata of myocardial infarction and sudden death. Psychother Psychosom 1980; 34(2-3):187-95
  2. 2. Schuitemaker GE. The Mierlo Project. Risk factors for cardiovascular diseases in a primary care population: their interrelationships, clinical outcomes and responses to intervention. Dissertation, Maastricht University, 2004.


Assessment of vital exhaustion and identification of subjects at increased risk of myocardial infarction in general practice
Vital exhaustion, a state characterized by unusual fatigue, loss of energy, increased irritability, and feelings of demoralization, is one of the cardiovascular risk factors. The authors investigated whether vital exhaustion contributes to the identification of subjects at increased risk of myocardial infarction in general practice. In this prospective cohort study, vital exhaustion was assessed with the Maastricht Interview on Vital Exhaustion. Other cardiovascular risk factors established were age, gender, systolic and diastolic blood pressure, total cholesterol, body mass index, smoking habits, cardiovascular disease, and diabetes mellitus. A Cox regression analysis was used. The subjects were adults (41-66 years) in an average Dutch village population. Outcome measures were fatal and nonfatal myocardial infarction. At the univariate level, vital exhaustion doubled the risk of myocardial infarction. The effect of exhaustion was confounded by gender; women had higher exhaustion scores and a lower incidence of myocardial infarction. With control for gender, age, systolic blood pressure, total cholesterol, smoking habits, self-reported cardiovascular disease, and diabetes mellitus, vital exhaustion almost tripled the risk of myocardial infarction. Assessment of vital exhaustion contributes to the identification of subjects at increased risk of myocardial infarction in general practice.

Schuitemaker GE, Dinant GJ, Pol GA, Appels A. Assessment of vital exhaustion and identification of subjects at increased risk of myocardial infarction in general practice. Psychosomatics 2004 Sep-Oct; 45(5):414-8

Vital exhaustion as a risk indicator for first stroke
Fatigue is a common condition after stroke. An unresolved question is whether the fatigue is a consequence of the stroke or is one of the precursors. The authors' objective was to investigate whether vital exhaustion is a precursor of first stroke while controlling for other cardiovascular risk factors. The design was a prospective cohort study. Vital exhaustion was diagnosed with the Maastricht Interview Vital Exhaustion scale. The authors controlled for age, gender, diabetes mellitus, systolic and diastolic blood pressure, total cholesterol, body mass index, and smoking habits as possible confounders. Data were analyzed with Cox regression analysis. The subjects were adults ages 41-66 in an average Dutch village population. Outcome measures included first stroke. Vital exhaustion increased the risk of stroke by 13% per vital exhaustion point on the Maastricht Interview Vital Exhaustion scale. This value remained statistically significant after control for other risk factors. Total cholesterol, diastolic blood pressure, systolic blood pressure, diabetes mellitus, and smoking also increased the risk of stroke significantly. A state of exhaustion is one of the risk indicators for stroke. This means that the fatigue so often seen after stroke was already experienced by many patients before the occurrence of the stroke.

Schuitemaker GE, Dinant GJ, Van Der Pol GA, Verhelst AF, Appels A. Vital exhaustion as a risk indicator for first stroke. Psychosomatics 2004 Mar-Apr; 45(2):114-8

Vital exhaustion as a risk factor for ischaemic heart disease and all-cause mortality in a community sample. A prospective study of 4084 men and 5479 women in the Copenhagen City Heart Study
BACKGROUND: Vital exhaustion, a psychological measure characterized by fatigue and depressive symptoms, has been suggested to be an independent risk factor for ischaemic heart disease (IHD) but the generality of the phenomenon remains in question. The aim of this study is to describe prevalence of these symptoms in a community sample and determine whether they prospectively predict increased risk of IHD and all-cause mortality in men and women. METHODS: The study base was 4084 men and 5479 women aged 20-98 free of IHD examined in 1991-1993 in the Copenhagen City Heart Study. Events were ascertained through record linkage until 1998 for IHD and September 2000 for all-cause mortality. There were 483 first hospital admissions and deaths caused by IHD and 1559 deaths from all causes during follow-up.
RESULTS: The 17 items on the vital exhaustion questionnaire were frequently endorsed with prevalence ranging from 6 to 47 per cent, higher in women. All but 4 of the 17 items were significantly associated with IHD with significant relative risks (RR) ranging between 1.36 (95% CI: 1.08, 1.72) and 2.10 (95% CI: 1.63, 2.71). Associations with all-cause mortality were also observed, but were weaker. RR of both IHD and all-cause mortality increased with increasing item sum score and were similar in men and women. For IHD, RR reached a maximum of 2.57 (95% CI: 1.65, 4.00) for subjects endorsing >9 items. The similar RR for all-cause mortality was 2.50 (95% CI: 2.09, 2.99). Multivariate adjustment for biological, behavioural, and socioeconomic risk factors did not substantially affect the association for IHD but attenuated the association with all-cause mortality.
CONCLUSIONS: Measures of fatigue and depression were common symptoms in this population sample and convey increased risk of IHD and of all-cause mortality. We propose this knowledge begin to be implemented in risk assessment in clinical practice.

Prescott E, Holst C, Gronbaek M, Schnohr P, Jensen G, Barefoot J. Vital exhaustion as a risk factor for ischaemic heart disease and all-cause mortality in a community sample. A prospective study of 4084 men and 5479 women in the Copenhagen City Heart Study. Int J Epidemiol. 2003 Dec; 32(6):990-7

Independent relation of vital exhaustion and inflammation to fibrinolysis in apparently healthy subjects
OBJECTIVE--Vital exhaustion (VE) and a hypercoagulable state both have been associated with coronary artery disease (CAD). Candidate mechanisms by which VE predicts CAD events are impaired fibrinolysis and inflammatory changes, the latter also affecting hemostasis. We investigated whether VE and inflammation would independently relate to hemostasis. DESIGN--Study participants were 217 (mean age+/-SD, 40+/-9 years) apparently healthy men and women working at an airplane manufacturing plant in Germany who completed the Shortened 9-item VE Maastricht Questionnaire. All subjects had a set of classic cardiovascular risk factors assessed, and plasma levels of fibrin D-dimer, type I plasminogen activator inhibitor (PAI-1) antigen, C-reactive protein (CRP), and tumor necrosis factor (TNF)-alpha were measured. RESULTS--PAI-1 correlated with VE (r=0.18, p=0.009), CRP (r=0.20, p=0.004), and TNF-alpha (r=0.18, p=0.009); D-dimer correlated with CRP (r=0.16, p=0.018). In linear regression analyses, VE and TNF-alpha independently explained 2 and 1%, respectively, of the variance in PAI-1. CONCLUSION--Our study corroborates previous findings on impaired fibrinolysis in VE. The findings suggest that VE and inflammation may impair fibrinolysis by different pathways, and independently of traditional cardiovascular risk factors.

von Kanel R, Frey K, Fischer J. Independent relation of vital exhaustion and inflammation to fibrinolysis in apparently healthy subjects. Scand Cardiovasc J. 2004 Mar; 38(1):28-32

Synergism between smoking and vital exhaustion in the risk of ischemic stroke: evidence from the ARIC study
Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL 33612, USA. sschwartz@hsc.usf.edu

PURPOSE: To examine the synergism between vital exhaustion and cigarette smoking in producing ischemic stroke. Vital exhaustion (VE), a state characterized by unusual fatigue, irritability, and feelings of demoralization, is measured by the Maastricht questionnaire (MQ), a 21-item inventory of symptoms. METHODS: The Atherosclerosis Risk in Communities (ARIC) Study is an ongoing cohort study, initiated in 1987. The MQ was administered at the second follow-up visit (1990-1992), and participants were subsequently followed for an average of 6.27 years. Four US communities (Minneapolis, Minnesota; Washington County, Maryland; Forsyth County, North Carolina; and Jackson, Mississippi). 13,066 participants aged 48 to 67 years at baseline (Visit 2) with no history of stroke. Validated hospitalized ischemic stroke. RESULTS: During the follow-up period, there were 202 incident ischemic strokes. After multivariate adjustment, current smoking, and high VE were independent risk factors for incident stroke: (smoking vs. non-smoking HR=1.76, p < 0.01; high VE vs. low VE HR=1.94, p < 0.01). For persons with both VE and smoking vs. persons with neither, HR=2.71 (p < 0.001). The proportion of stroke disease burden due to VE and smoking that could be attributed to their interaction was 81 to 93 percent. CONCLUSIONS: The combination of cigarette smoking and VE is synergistic in the production of stroke.

Schwartz SW, Carlucci C, Chambless LE, Rosamond WD. Synergism between smoking and vital exhaustion in the risk of ischemic stroke: evidence from the ARIC study. Ann Epidemiol. 2004 Jul;14(6): 416-24.