July 3, 2024

Anger’s Impact on Cardiovascular Health in Young People

Results from a randomized study
Sadness, anxiety, and anger affect our endothelial health differently


Shimbo D, Cohen MT, McGoldrick M, et al. Translational research of the acute effects of negative emotions on vascular endothelial health: findings from a randomized controlled study. J Am Heart Assoc. 2024;13(9):e032698.

Study Objective

To assess the impacts of provoked emotions such as anger, anxiety, and sadness on endothelial health

Key Takeaway

Provoked anger adversely impacted endothelial health by impairing endothelium-dependent vasodilation, while anxiety and sadness did not have a statistically significant effect.


Single-blinded, parallel-arm, randomized study


Of 620 adults aged 18 years and older who were assessed for eligibility, 280 met the eligibility criteria and were randomized to the trial. The average age was approximately 26 years. 

Exclusion criteria included any chronic cardiovascular condition, dyslipidemia, diabetes, active smoking, any medication use including over-the-counter (OTC) or supplements, and any history of diagnosed psychosis, mood disorder, or personality disorder.


Participants were randomized to 1 of 4 groups. Each group received a task that elicited 1 emotion:

  1. Anger,
  2. Anxiety,
  3. Sadness, or
  4. Neutral.

On the day of the trial, participants were seated in a comfortable chair and instructed to relax for 30 minutes. Following this, blood pressure was taken, blood was drawn, endothelial-dependent vasodilation (EDV) was measured via finger probe, and visual analog scale (VAS) ratings of anger, anxiety, and sadness were assessed.

After these measurements, participants received an 8-minute negative-emotion-induction task according to their group. The same measurements were then repeated at 3, 40, 70, and 100 minutes after the task concluded.

Study Parameters Assessed

Investigators used the Visual Analog Scale, which gauges emotion based on facial expression, to determine the intensity of the emotions experienced following each task. They also monitored blood pressure and heart rate. They measured EDV via a finger probe using peripheral arterial tonometry to find a Reactive Hyperemia Index.

Investigators measured endothelial-cell (EC) injury by measuring circulating levels of microparticles released by ECs. They assessed the ability of ECs to repair themselves by measuring endothelial progenitor cells.

Primary Outcomes

 Primary outcomes included the following:

  • Reactive hyperemia index (RHI) scores
  • Endothelial-derived microparticle levels (specifically CD62E+ microparticles)
  • The presence of endothelial progenitor cells (specifically CD34+/CD133+/KDR+ cells)

These outcomes were based on the authors’ previous study that associated provoked anger with a decreased RHI score, increased levels of endothelial-derived microparticles, and decreased levels of endothelial progenitor cells.

Key Findings

In the anger group, investigators observed a statistically significant impairment of RHI scores in comparison to the neutral group, particularly at 40 minutes postintervention (0.20±0.67 and 0.50±0.60; P=0.007). They did not observe any changes in the RHI scores of the anxiety or sadness groups.

Investigators also did not find any changes in endothelial-derived microparticles or endothelial progenitor cells in any of the intervention groups.

Although it was not a primary outcome, the anger and anxiety groups showed an increase in blood pressure over time.


This study was funded by the National Institutes of Health and from the National Heart, Lung, and Blood Institute. The authors did not make any other disclosures.

Practice Implications & Limitations

Anxiety, depression, and anger have all been implicated as risk factors in the development of cardiovascular disease (CVD).1-3 This study is 1 of many that are helping to tease out the intricacies of these relationships. While there was no biochemical or cellular evidence of endothelial cell injury in any of the groups in this study, the anger group showed impairment of endothelial-dependent vasodilation (EDV): Impaired EDV is correlated with endothelial-cell dysfunction, which is implicated as a hallmark of CVD.4 Clinically, this study is interesting because it shows that for young, heathy people, anger is the emotion most likely to initiate physiological change that could lead to CVD in the long term. 

So what differentiates the results of this study from other studies that link any negative emotional state with CVD? First, this study looked specifically at endothelial vasodilation in young adults. The exclusion criteria in this study was quite restrictive; anyone with any chronic disease or taking any medication, including OTC drugs and supplements, were excluded. This restriction included people with high cholesterol and those taking a multivitamin. Because of these criteria, the mean age of participants in each group was 26 years. So the information we glean from this study is likely less relevant to a state that could initiate an imminent cardiac event; rather, it gives some indication of how events earlier in life can affect cardiovascular dysfunction. 

Other studies have also correlated anger with impaired EDV in young people. One study looked at self-assessed emotional health and its association with peripheral arterial tonometry in school-aged children (mean age 14 years). It showed that girls had higher scores overall for depression, anger, and anxiety and that in girls higher scores for anger were associated with impaired EDV.5 In contrast, other studies have shown no change in endothelial function in depressed patients, even though depression is a risk factor for CVD,6,7 and 1 study showed a similar effect with anxiety but only in elderly men, not young men.8

So why would anger have a greater impact on endothelial function than other emotions? Sympathetic stimulation during an episode of anger would likely decrease the production of acetylcholine by the parasympathetic nervous system. In the blood vessels, acetylcholine stimulates production of nitric oxide, which in turn initiates EDV.9 It would make sense then that activation of the sympathetic nervous system during times of anger or stress would cause impaired peripheral vasodilation. This effect has been shown to occur at up to 90 minutes following an event that initiates anger.10,11

In a similar vein, high levels of stress have been associated with an acute syndrome known as “takotsubo cardiomyopathy,” which resembles a myocardial infarction without coronary artery disease. This is thought to be a result of toxicity from high catecholamine exposure. Restricted EDV is also seen in this condition.12 Interestingly, most cases of this are experienced by postmenopausal women.

While this study shows that anger can have a significant impact on the cardiovascular health of young adults, it is also interesting to look at how anger can impact CVD over the lifespan. For older people, some studies have found the link between anger and CVD to be more nuanced. A series of prospective cohort studies in Japan looked at adults aged 40 to 79 and evaluated their overall expression of anger vs incidence of CVD. They found that participants who lived in rural vs urban areas, regularly participated in outdoor recreational activities, and remained working after retirement age did not show a correlation between anger expression and CVD.13-17 Conversely, urban-dwelling people, those who did not recreate outdoors, and people who stopped working at retirement age showed a significant association between anger expression and CVD. This indicates that environment and lifestyle can play a moderating role in how anger impacts cardiovascular health. 

Another moderating factor in the impact of anger on cardiovascular health is a person’s worldview. Dispositional optimism, for instance, decreases the cardiovascular impact of events that cause anger and sadness. One study showed that increases in systolic blood pressure and heart rate initiated by anger and sadness were lower in subjects who were more optimistic.18 Pessimism, on the other hand, has been shown to have a negative effect on systolic blood pressure reactivity.19 So an overall positive outlook can decrease the impact of any negative emotion on the cardiovascular system.

Overall, this study adds a useful detail as to how we can support the long-term cardiovascular health of our patients. For our younger patients, we can see that anger plays the most profound role in restricting endothelial vasodilation, which can increase their long-term risk of cardiovascular disease. We can counsel these patients to find strategies to manage and dispel anger in order to serve their long-term health. For our older patients, there is a more complex and nuanced relationship between any chronic negative emotion and CVD. However, the tools we know to help decrease stress, improve mood, and engage the parasympathetic nervous system are still useful ways to protect our patients’ cardiovascular health.

Conflict of Interest Disclosure

The author declares no conflict of interest.

Categorized Under


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