Social Isolation, Loneliness and Cardiovascular Health: The Art of Listening!

Social isolation and loneliness are increasingly common for various reasons. The COVID-19 pandemic deteriorated the situation remarkably. Quarantine and social distancing are necessary measures to prevent the virus from spreading but also lead to elevated levels of loneliness and social isolation, which predispose to physical- and mental-health related repercussions. There is now substantial evidence available showing an inverse association between social isolation, loneliness, and coronary heart disease and stroke mortality.^{1, 2} However, despite the information on the risk of worse outcomes among individuals with cardiovascular disease in those who are also socially isolated or lonely, we lack information on interventions to alleviate social isolation and loneliness as a strategy for preserving or even improving cardiovascular and brain health.^{3, 4} Emerging evidence also indicates that important life events and transition periods such as job loss, income reduction due to furlough, death of a beloved one, or social stress due to life habit changes can acutely increase cardiovascular risk.² It is imperative to identify these time periods where individual distress is critically high and implement effective cardiovascular prevention strategies. Developing risk prediction tools via the collection of data on social isolation and loneliness in electronic health records may be one solution to identify these often under-recognized determinants of health.⁵ On the other hand, physical activity interventions (e.g., recreational activity) implemented within other complex programs (e.g., senior programs) or using technology approaches (e.g. computer use) appear as promising strategies to mitigate social isolation and loneliness.^{6, 7} In this context, one should not forget the strength and support that family members and family ties can provide. During COVID-19 lockdowns social contacts have largely been restricted to household members. For the outcome of all-cause mortality, it has been reported that support from family members may be more beneficial than support from friends.⁸ Current evidence also suggests that the absence of another person who may potentially assist with health-care seeking during acute events might explain the association between social isolation and fatal cardiovascular disease.⁹

The recently released American Heart Association Scientific Statement on the associations and mechanisms between social isolation and loneliness and cardiovascular and brain health by Dr. Cené and the writing group is based on a large systematic review and is particularly useful to a wide range of health care providers. The statement first summarizes current evidence on the association between social isolation and loneliness on cardiovascular health. Thereafter, it presents data on effective or promising intervention strategies to combat social isolation and loneliness and improve cardiovascular health with a focus on vulnerable populations, such as teens/young adults, under-represented groups, immigrants, or rural populations. Last, current gaps of knowledge are identified and key areas for future research are highlighted. Clearly, more methodologically rigorous research is still needed to understand how and by which mechanisms social isolation and loneliness impact cardiovascular and brain health in general and in times of crisis such as during war and civil unrest, natural disasters, and environmental changes. Identifying adequate interventions to reduce social isolation and loneliness may not only help to preserve and promote cardiovascular health but also advance health equity.

In the light of the COVID-19 pandemic the need to develop a more comprehensive view on the cardiovascular health consequences of social isolation and loneliness has become strikingly apparent. The AHA statement by Dr. Cené and colleagues provides an important contribution to this task. Following Dr. Bernard Lown’s famous book ‘The Lost Art of Healing’, the problem of social isolation and loneliness, should, however, also remind us about the loss of the fundamental human relationship between doctor and patient.¹⁰ The science of history taking and the art of listening are critical despite all medical advances as patients still crave a partnership with their physicians who are sensitive to their arching souls as to their malfunctioning anatomy.