Adverse childhood events and heart disease

With the St. Valentine’s Day tradition of hearts, February is designated National Heart Month by the NIH’s National Heart Lung and Blood Institute. Contemporary celebration of St. Valentine’s Day is mostly focused on notions of romantic love. But St. Valentine the martyrs (there were several in history) were killed by Roman authorities for their crimes of protecting (that is showing love for) persecuted Christians in the 4rd Century AD. The symbolism of Heart Health Month and love is proving to be more than just symbolic. It is physiologic, especially when love is absent in childhood.

We all hope that children grow up in loving, supportive, and nurturing families. But what are the consequences of that loving environment being titrated with a toxic environment of physical, psychological, and sexual abuse, neglect, household dysfunction, domestic violence, parental mental health disorders or substance abuse, parental absence due to separation, imprisonment, or death, foster care, homelessness, food insecurity? The evidence is mounting that these adverse childhood experiences (ACEs) can have a marked effect on long-term health consequences, including heart disease.

ACEs are common. A study by Kaiser Permanente1Centers for Disease Control and Prevention, Kaiser Permanente. The ACE Study Survey Data [Unpublished Data]. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2016. captured just how frequently children encounter adverse experiences. The original Kaiser study illuminated “the relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood…”2 Felitti V, et.al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14(4) The KP ACEs study identified a number of psychosocial challenges that contribute to adverse childhood experiences.Chart of KP Aces stud

Screening for ACEs in clinical practice in both adult and pediatric patients may be appropriate in a number of clinical circumstances such as chronic pain, other chronic conditions like fibromyalgia, GI disorders, lung disease, cancer, and heart disease.  Various screening tools are available3Center for Health Care Strategies, Inc.  https://www.traumainformedcare.chcs.org/wp-content/uploads/2019/02/TA-Tool-Screening-for-ACEs-and-Trauma_020619.pdf, but they all rely on a trusting and supportive clinical relationship between the patient and their clinician. One example of an ACEs screening tool is below. A higher score reflects greater potential for health effects of adverse childhood experiences. An ACEs screening tool may not be necessary in all cases, but including a broad question in obtaining the psychosocial history can be useful and lead to further inquiry. Dialog such as, “Do you think that you were you under stress as a child?” or “Did anything happen to you as a child that you would not want for your own children?”4Clarke D. Stress Check-up. http://www.stressillness.com/blog/?p=1549


For each “yes” answer, add 1. The total number at the end is your cumulative number of ACEs.

Before your 18th birthday:

  1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
  2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
  3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
  4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
  5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
  6. Were your parents ever separated or divorced?
  7. Was your mother or stepmother:
    Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
  8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
  9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
  10. Did a household member go to prison?

ACEs often are associated with risk factors for cardiovascular disease such as smoking, drug abuse, obesity, lack of physical exercise, all of which are associated with heart disease. The complexity of these psychophysiological and behavioral factors was recognized by the seminal Kaiser study in 1998. The authors observed,

Multiple ACEs indicate a disordered social environment and stressful exposures that can negatively affect the developing brain as well as emotional and social well-being. The chain of events begins with childhood exposure to abuse, neglect, and household dysfunction, which lead to the development of unpleasant affective states, depression and anger/hostility, as a result of long-term effect of physiological response to stress. Attempts to cope with these stresses may also lead to the adoption of risk behaviors, such as smoking, overeating, and physical inactivity.

However, ACEs by themselves independently contribute to the risk of heart disease and amplify risk in the presense of the other risk factors. The link between heart disease and pathophysiologial effects of ACEs is being explored. A recent longitudinal study proposal noted, “the potential effect of ACEs on CVD is more significant than previously thought. Yet, how ACEs amplify the risk for later CVD remains unclear. Lifestyle risk factors only partially account for this connection, instead directing attention to the interaction between psychosocial factors and physiological mechanisms such as inflammation.”5Wade TJ, O’Leary DD, Dempster KS, et al. Adverse childhood experiences (ACEs) and cardiovascular development from childhood to early adulthood: study protocol of the Niagara Longitudinal Heart Study. BMJ Open. 2019;9(7):e030339. Published 2019 Jul 16. doi:10.1136/bmjopen-2019-030339

So in this Heart Health Month, we can all benefit from remembering the power of love to create health.