Adults who reported loneliness were more likely to develop degenerative valvular heart disease (VHD), aortic valve stenosis, and mitral valve regurgitation, a new study suggested.

Degenerative VHD is usually attributed to aging and changes in the valve, but psychosocial factors are not usually considered a factor, said Zhaowei Zhu, MD, PhD, associate professor in the Department of Cardiovascular Medicine at The Second Xiangya Hospital, Central South University in Changsha, China.

“In recent years, loneliness and social isolation have been linked to several cardiovascular outcomes, but there has been very little research on whether they also matter for valvular disease,” Zhu told Medscape Medical News. “We thought this was an important gap, especially because degenerative valvular heart disease is common in older adults and may reflect more than aging alone.”

The paper was published on April 15 in the Journal of the American Heart Association.

Loneliness and Degenerative VHD

Using data from the UK Biobank, Zhu and colleagues performed a prospective cohort study of 462,917 adults with VHD who were asked about loneliness and social isolation and then tracked for degenerative VHD over a median of 13.9 years. The median age was 58 years; 95% were White, and 45% were men.

Researchers measured loneliness by asking adults if they often felt lonely and whether they could confide in someone close to them. They defined social isolation by how many people were living in the household, how often the adult visited family and friends, and if they attended certain events once or more per week.

Researchers also examined the genetic risk for degenerative VHD and aortic valve stenosis by evaluating polygenic risk scores and family history of cardiovascular disease derived from UK Biobank blood samples and questionnaire data.

There were 11,003 degenerative VHD cases during the study period, which also included 4280 aortic valve stenosis and 4693 mitral valve regurgitation cases. Most participants had a loneliness scale score of 0 (72%), while a minority of participants reported a score of 1 (23%) or 2 (5%). Those with higher loneliness scores were more likely to be men with a lower education level, higher levels of smoking, and poor diets and sleep patterns, the researchers said.

Zhu and colleagues identified a significant association between the highest loneliness scores and development of degenerative VHD (hazard ratio [HR], 1.19; P < .001) as well as aortic valve stenosis (HR, 1.21; P < .001) and mitral valve regurgitation (HR, 1.23; P < .001). In contrast, researchers noted no significant association between social isolation and degenerative VHD, aortic valve stenosis, or mitral valve regurgitation.

When assessing genetic risk background in relation to degenerative VHD, Zhu and colleagues found polygenic risk scores and family history of cardiovascular disease were both significantly associated with degenerative VHD, aortic valve stenosis, and mitral valve regurgitation (P < .001 for all). However, loneliness remained a significant risk factor when accounting for genetic and familial risk for cardiovascular disease, they said (P < .001).

Tracking Loneliness in Clinical Practice

Zhu said social disconnection could potentially be included as part of risk assessment and long-term health management for degenerative VHD.

“During clinic visits, clinicians can use brief questions or structured screening questionnaires to identify whether a patient may be experiencing loneliness, social isolation, or limited social support,” he said.

Tracking loneliness and social disconnection “should not stop at a single outpatient visit,” Zhu said. 

“Ideally, it should also be entered into family physician or primary care follow-up systems so it can be tracked over time and managed together with traditional cardiovascular risk factors,” he said. “That kind of follow-up would make it easier to turn psychosocial risk screening into practical, long-term care.”

However, Zhu noted that his group’s findings found an association, rather than a direct causation, between loneliness and degenerative VHD. Social disconnection is also associated with other risk factors related to lifestyle, mental health, and a patient’s health status, he added. The study results should be evaluated in different populations and independent cohorts, Zhu said.

Zhu said he would like to see more research on whether improving social connection and psychological support can reduce the risk for degenerative VHD.

“Combining social and behavioral factors with genetic risk and traditional risk factors may help improve risk stratification,” he said.

‘Social Prescribing’

Crystal Cené, MD, MPH, chief administrative officer and associate chief medical officer for health equity at University of California, San Diego Health, said the study “contributes to a robust body of research” showing the adverse effects of lack of social connectedness on heart health.

“Clinicians should take away from this study the importance of recognizing and responding to loneliness in their patients, particularly those with existing heart disease,” said Cené, who was not involved in the study. “Loneliness is not just an emotion and something a person should ‘get over’ or deal with. It not only affects a person’s mental health; it also takes a toll on our physical health, as this study demonstrates.” 

The strengths of the study were in its large sample size, long follow-up period, and the questions it asked about loneliness and social isolation, Cené said. However, the study was limited by its observational design and by the fact that loneliness was only measured once, she added.

Cené also pointed out that the study lacked diversity. “Levels of social connectedness may be different and have different health implications in more racial and ethnically diverse populations,” she said.

Cené also drew a distinction between social isolation and loneliness — problems that impacted society before the “loneliness epidemic” in the wake of the COVID pandemic and that have persisted today.

Social isolation involves having few or infrequent social connections, while loneliness is the perception of isolation regardless of the number of social connections. This phenomenon can be seen in situations where people, particularly younger adults, have a lot of online connections but are still lonely.

“A person can be socially isolated but not be lonely. Conversely, a person can be lonely even when you are surrounded by others, because those connections aren’t fulfilling or meaningful,” she said.

Cené said physicians should consider “social prescribing” — asking their patients to engage in more social activities with family, friends, and neighbors — when counseling patients on loneliness. “Just like we prescribe medications, we should prescribe ‘social engagement’ because social connection improves overall health, mental, and physical health,” she added.

Clinicians may be uniquely suited to identify social isolation and loneliness in their patients because many people who are socially isolated or lonely have frequent encounters with the healthcare system, Cené noted.

“It is critical that clinicians ask and talk to patients about their social connections, recognizing that failure to do so could unwittingly place our patients at risk of worse cardiovascular health, even death,” she said.

The study was supported by the National Natural Science Foundation of China. No authors reported having relevant financial relationships. Cené reported having no relevant financial relationships.

Jeff Craven is an independent journalist living in Wilmington, Delaware.