The Association Between Emotional Upset and Cardiac Arrhythmia During Daily Life Robert A. Carels, Holly Cacciapaglia, Carlos I. Pe ´rez-Benı ´tez, and Olivia Douglass Bowling Green State University Samantha Christie St. Charles Mercy Hospital William H. O’Brien Bowling Green State University Ventricular arrhythmia exhibits considerable within-subject variability that cannot be attributed to clinical status alone. This investigation examined the extent to which cardiac arrhythmia was associated with psychological and physical factors assessed during the hour preceding arrhythmic or nonarrhythmic activity. Approximately twice hourly, 46 patients randomly completed a diary assessing mood and physical symptoms during 24-hr electrocardiographic monitoring. Greater negative emotion was asso- ciated with increased arrhythmia. Additionally, greater negative emotion was significantly associated with increased arrhythmia among participants in a low left ventricular ejection fraction group (LVEF). However, this relationship between negative emotion and arrhythmia was not observed among higher LVEF participants. These findings contribute to a larger body of evidence suggesting that negative moods may exacerbate cardiac conditions. Cardiac arrhythmia occurs frequently in patients with conges- tive heart failure (CHF; Birgersdotter-Green, Rosenqvist, & Ry- den, 1991; Deedwania, 1994; Francis, 1986) and is a significant predictor of future cardiac events after the control of accepted risk factors, such as age, gender, New York Heart Association func- tional class, 6-min walk, previous myocardial infarction, and dia- betes (Bigger et al., 1984; Capone et al., 1991; Doval et al., 1996; Galinier et al., 1998; Gradman et al., 1989; Hofman et al., 1988; Khoshnevis & Massumi, 1999; Kostis et al., 1987; Mukharji et al., 1984; Multicenter Postinfarction Research Group, 1983). Ambu- latory electrographic (ECG) studies of congestive heart failure patients have indicated that ventricular arrhythmia during daily life exhibits considerable within-subject variability in both frequency and duration that cannot be attributed to clinical status alone (i.e., deterioration of left ventricular function; Packer, 1985). These findings raise the possibility that variations in mental stress may contribute to arrhythmic activity. Several researchers have demonstrated that cardiac arrhythmia can be triggered by stressful events (Follick et al., 1988; Lown, 1987; Lown, Verrier, & Corbalan, 1973; Matta, Lawler, & Lown, 1976; Moser & Dracup, 1996; Packer, Gottlieb, & Kessler, 1986; Ruberman, Weinblatt, Goldberg, & Chaudhary, 1984; Sigler, 1967; Taggart, Carruthers, & Somerville, 1973; Taggart, Gibbons, & Somerville, 1973). For example, Lown, Verrier, and Corbalan’s (1973) important early research with animals revealed that when psychological stressors are applied to animals with coronary oc- clusion, sustained and potentially lethal ventricular arrhythmias were often provoked. Further, patients that experienced a greater frequency and severity of ventricular ectopy in response to labo- ratory stress were more likely to experience ventricular arrhyth- mias or sudden cardiac death (Lown & DeSilva, 1978). Finally, several small naturalistic studies suggest that premature ventricular contractions (PVCs) increase during events presumed to be psy- chologically stressful, such as public speaking, driving, and inter- viewing (Sigler, 1967; Taggart, Carruthers, & Somerville, 1973; Taggart, Gibbons, & Somerville, 1973). Ambulatory ECG studies examining myocardial ischemic epi- sodes (i.e., prolonged S-T segment depression presumed to indi- cate a decreased supply of oxygenated blood to the heart) have also yielded data suggesting that mental stress and emotional upset may be associated with ischemic events. For example, ischemic epi- sodes are more intense and prolonged during periods of intense mental activities and anger (Gabbay et al., 1996) and after negative moods are experienced (Gullette et al., 1997), and they are greater during increased levels of mental activity (Barry et al., 1988). The research examining mental stress and myocardial ischemia has yielded several positive findings. The issues of whether high levels of mental stress are associated with the frequency of cardiac arrhythmia and whether disease severity moderates this relation- ship have not been extensively evaluated. To address this question, the present study examined the impact of mood and physical symptoms on cardiac arrhythmia during 24-hr ECG monitoring using ecological momentary assessment (EMA) techniques (Shiff- man & Stone, 1998; Stone & Shiffman, 1994). EMA reflects repeated, real-time (momentary) assessment in the participants’ Robert A. Carels, Holly Cacciapaglia, Carlos I. Pe ´rez-Benı ´tez, Olivia Douglass, and William H. O’Brien, Department of Psychology, Bowling Green State University; Samantha Christie, Heart Failure Clinic, St. Charles Mercy Hospital, Oregon, Ohio. Correspondence concerning this article should be addressed to Robert A. Carels, Department of Psychology, Bowling Green State University, Bowling Green, Ohio 43403. E-mail: rcarels@bgnet.bgsu.edu Journal of Consulting and Clinical Psychology Copyright 2003 by the American Psychological Association, Inc. 2003, Vol. 71, No. 3, 613– 618 0022-006X/03/$12.00 DOI: 10.1037/0022-006X.71.3.613 613