Fast track — ArticlesAssociation of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): case-control study
Introduction
Popular opinion holds that stress is an important risk factor for coronary heart disease. However, compared with other major risk factors, psychosocial variables such as stress are difficult to define objectively, and stress consists of several different (and inter-related) elements. Therefore, measurement of stress is complex and difficult. Despite this drawback, several constructs within the broad conceptual framework of stress are increasingly regarded as being causally related to coronary heart disease.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15
The concept of stress encompasses several factors, from external stressors such as job stress,5, 8, 10, 13 adverse life events7 and financial problems, to potential reactions to stress such as depression,1, 2, 3 vital exhaustion,15 anxiety,12, 14 psychological distress,11 and sleeping difficulties. The same construct might not be applicable in different countries and ethnic groups, because cultural influences can vary. Perceived mental stress, measured by response to a single-item question, was associated with increased mortality from coronary disease in a large study of Japanese men and women.9 Apart from this study,9 previous investigations have been done in mainly North American or European populations. Thus, limited data are available about psychological variables and coronary heart disease in other countries and ethnic groups. The aim of the INTERHEART study, undertaken in a large number of patients with a first acute myocardial infarction and controls matched for age and sex, was to investigate the associations of several psychosocial stressors with the risk of acute myocardial infarction globally, and in different populations characterised by age, sex, geographic region, and ethnic origin.
Section snippets
Study Population
12461 incident cases of acute myocardial infarction from 262 centres in 52 countries representing all geographic regions, and 14637 age-matched, sex-matched, and site-matched controls free of clinical heart disease, took part in the study.16, 17 Centres attempted to recruit consecutive patients. Recruitment was from February, 1999, until March, 2003. Patients admitted to the coronary care unit or equivalent cardiology ward of participating centres were screened to identify incident cases of
Results
The mean age of cases was 58·2 years (SD 12·2) and of controls 57·1 years (12·1); 24·2% (2686) of cases and 26·5% (3619) of controls were women. Figure 1 outlines the distribution of cases and controls by region and ethnic origin and provides the odds ratios associated with high general stress. We defined high general stress as several periods of or permanent stress, at work, home, or both. Figure 2 shows corresponding data for depressive mood, which we defined as feeling sad, blue, or
Discussion
Our study shows that several elements reflecting psychosocial stress are associated with increased risk of acute myocardial infarction. These factors include those that are subjective and perceived by the patients, such as stress, defined as tension or anxiety due to external influences. Some of these measures—eg, locus of control or depression—are not generally perceived by lay people to be stressors. Further, discrete external events (eg, major life events), which are less subjective and less
References (38)
- et al.
Self-perceived psychological stress and incidence of coronary artery disease in middle-aged men
Am J Cardiol
(1991) - et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study
Lancet
(2004) - et al.
INTERHEART: a global study of risk factors for acute myocardial infarction
Am Heart J
(2001) - et al.
Socioeconomic factors, material inequalities, and perceived control in self-rated health: cross-sectional data from seven post-communist countries
Soc Sci Med
(2000) Depression as a predictor for coronary heart disease: a review and meta-analysis
Am J Prev Med
(2002)- et al.
Effects of mental stress on coronary epicardial vasomotion and flow velocity in coronary artery disease: relationship with hemodynamic stress responses
J Am Coll Cardiol
(2001) - et al.
Childhood social circumstances and psychosocial and behavioural factors as determinants of plasma fibrinogen
Lancet
(1996) - et al.
Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of US adults
Epidemiology
(1993) - et al.
Symptoms of depression, acute myocardial infarction, and total mortality in a community sample
Circulation
(1996) - et al.
Depression as an antecedent to heart disease among women and men in the NHANES I study
Arch Intern Med
(2000)
Evidence based cardiology: psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies
BMJ
Relation of type A behavior pattern and job-related psychosocial factors to nonfatal myocardial infarction: a case-control study of Japanese male workers and women
Psychosom Med
The relationship between job strain and coronary heart disease: evidence from an English sample of the working male population
Psychol Med
Myocardial infarction in parents who lost a child: a nationwide prospective cohort study in Denmark
Circulation
Chronic work stress and marital dissolution increase risk of posttrial mortality in men from the Multiple Risk Factor Intervention Trial
Arch Intern Med
Perceived mental stress and mortality from cardiovascular disease among Japanese men and women: the Japan Collaborative Cohort Study for Evaluation of Cancer Risk Sponsored by Monbusho (JACC Study)
Circulation
Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees
BMJ
Psychological distress as a risk factor for coronary heart disease in the Whitehall II Study
Int J Epidemiol
Psychological characteristics in patients with myocardial infarction: a case-control study
Cardiovasc Risk Factors
Cited by (1833)
Correlation of allostatic load and perceived stress with clinical features in first-episode schizophrenia
2024, Journal of Psychiatric ResearchFinancial strain is associated with poorer cardiovascular health: The multi-ethnic study of atherosclerosis
2024, American Journal of Preventive CardiologyChronic Stress and Cardiovascular Events: Findings From the CARDIA Study
2024, American Journal of Preventive MedicineLifestyle effects on aging and CVD: A spotlight on the nutrient-sensing network
2023, Ageing Research Reviews