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Stress and cardiovascular disease

Abstract

The physiological reaction to psychological stress, involving the hypothalamic–pituitary–adrenocortical and sympatho–adrenomedullary axes, is well characterized, but its link to cardiovascular disease risk is not well understood. Epidemiological data show that chronic stress predicts the occurrence of coronary heart disease (CHD). Employees who experience work-related stress and individuals who are socially isolated or lonely have an increased risk of a first CHD event. In addition, short-term emotional stress can act as a trigger of cardiac events among individuals with advanced atherosclerosis. A stress-specific coronary syndrome, known as transient left ventricular apical ballooning cardiomyopathy or stress (Takotsubo) cardiomyopathy, also exists. Among patients with CHD, acute psychological stress has been shown to induce transient myocardial ischemia and long-term stress can increase the risk of recurrent CHD events and mortality. Applications of the 'stress concept' (the understanding of stress as a risk factor and the use of stress management) in the clinical settings have been relatively limited, although the importance of stress management is highlighted in European guidelines for cardiovascular disease prevention.

Key Points

  • Psychological stress contributes to cardiovascular disease at several stages, including the long-term development of coronary heart disease and acute triggering of cardiac events

  • Disturbances of inflammatory, hemostatic, and autonomic processes are likely to be the mechanisms by which short-term psychological stress triggers acute myocardial infarction

  • Chronic stress at work and in private life is associated with a 40–50% increase in the occurrence of coronary heart disease in prospective observational studies

  • Indicators of elevated long-term stress, such as social isolation and work-related stress, are associated with poor prognosis among patients with established coronary heart disease

  • Stress-management interventions improve the quality of life of patients with advanced coronary heart disease, but effects on disease prognosis have been inconsistent

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Figure 1
Figure 2: The physiological stress response.
Figure 3: Risk of acute MI associated with exposure to multiple risk factors among 29,972 individuals across 52 countries in the INTERHEART study.9
Figure 4: Left ventriculography of a patient with stress cardiomyopathy.
Figure 5: The effects of stress on platelet activation and BP.

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References

  1. Hjemdahl, P., Rosengren, A. & Steptoe, A. (eds) Stress and Cardiovascular Disease (Springer-Verlag, New York, 2011).

    Google Scholar 

  2. Milczarek, M., Schneider, E. & González, E. R. European Agency for Safety and Health at Work. European Risk Observatory Report. OSH in Figures: Stress at Work—Facts and Figures [online], (2009).

    Google Scholar 

  3. Cannon, W. B. Bodily Changes in Pain, Hunger, Fear and Rage (Routledge & Kegan Paul, London, 1915).

    Google Scholar 

  4. McEwen, B. S. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol. Rev. 87, 873–904 (2007).

    Article  PubMed  Google Scholar 

  5. Lazarus, R. S. Stress and Emotion: A New Synthesis (Springer Publishing Company, Inc., New York, 1999).

    Google Scholar 

  6. Wu, T., Snieder, H. & de Geus, E. Genetic influences on cardiovascular stress reactivity. Neurosci. Biobehav. Rev. 35, 58–68 (2010).

    Article  PubMed  Google Scholar 

  7. Brotman, D. J., Golden, S. H. & Wittstein, I. S. The cardiovascular toll of stress. Lancet 370, 1089–1100 (2007).

    Article  PubMed  Google Scholar 

  8. Ulrich-Lai, Y. M. & Herman, J. P. Neural regulation of endocrine and autonomic stress responses. Nat. Rev. Neurosci. 10, 397–409 (2009).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Yusuf, S. et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet 364, 937–952 (2004).

    Article  PubMed  Google Scholar 

  10. Karasek, R. A. & Theorell, T. Healthy Work: Stress, Productivity, and the Reconstruction of Working Life (Basic Books, New York, 1990).

    Google Scholar 

  11. Siegrist, J. Adverse health effects of high-effort/low-reward conditions. J. Occup. Health Psychol. 1, 27–41 (1996).

    Article  CAS  PubMed  Google Scholar 

  12. Kivimäki, M. et al. Justice at work and reduced risk of coronary heart disease among employees: the Whitehall II Study. Arch. Intern. Med. 165, 2245–2251 (2005).

    Article  PubMed  Google Scholar 

  13. Belkic, K. L., Landsbergis, P. A., Schnall, P. L. & Baker, D. Is job strain a major source of cardiovascular disease risk? Scand. J. Work Environ. Health 30, 85–128 (2004).

    Article  PubMed  Google Scholar 

  14. Kivimäki, M. et al. Work stress in the etiology of coronary heart disease—a meta-analysis. Scand. J. Work Environ. Health 32, 431–442 (2006).

    Article  PubMed  Google Scholar 

  15. Hemingway, H. & Marmot, M. Evidence based cardiology: psychosocial factors in the etiology and prognosis of coronary heart disease. Systematic review of prospective cohort studies. BMJ 318, 1460–1467 (1999).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Backe, E. M., Seidler, A., Latza, U., Rossnagel, K. & Schumann, B. The role of psychosocial stress at work for the development of cardiovascular diseases: a systematic review. Int. Arch. Occup. Environ. Health 85, 67–79 (2012).

    Article  PubMed  Google Scholar 

  17. Eller, N. H. et al. Work-related psychosocial factors and the development of ischemic heart disease: a systematic review. Cardiol. Rev. 17, 83–97 (2009).

    Article  PubMed  Google Scholar 

  18. Reed, D. M., LaCroix, A. Z., Karasek, R. A., Miller, D. & MacLean, C. A. Occupational strain and the incidence of coronary heart disease. Am. J. Epidemiol. 129, 495–502 (1989).

    Article  CAS  PubMed  Google Scholar 

  19. Johnson, J. V. & Hall, E. M. Job strain, work place social support, and cardiovascular disease: a cross-sectional study of a random sample of the Swedish working population. Am. J. Public Health 78, 1336–1342 (1988).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Alterman, T., Shekelle, R. B., Vernon, S. W. & Burau, K. D. Decision latitude, psychologic demand, job strain, and coronary heart disease in the Western Electric Study. Am. J. Epidemiol. 139, 620–627 (1994).

    Article  CAS  PubMed  Google Scholar 

  21. Kivimäki, M. et al. Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. BMJ 325, 857 (2002).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Lee, S., Colditz, G., Berkman, L. & Kawachi, I. A prospective study of job strain and coronary heart disease in US women. Int. J. Epidemiol. 31, 1147–1153 (2002).

    Article  PubMed  Google Scholar 

  23. Kuper, H. & Marmot, M. Job strain, job demands, decision latitude, and risk of coronary heart disease within the Whitehall II study. J. Epidemiol. Community Health 57, 147–153 (2003).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. De Bacquer, D. et al. Perceived job stress and incidence of coronary events: 3-year follow-up of the Belgian Job Stress Project cohort. Am. J. Epidemiol. 161, 434–441 (2005).

    Article  PubMed  Google Scholar 

  25. Netterstrøm, B., Kristensen, T. S. & Sjøl, A. Psychological job demands increase the risk of ischaemic heart disease: a 14-year cohort study of employed Danish men. Eur. J. Cardiovasc. Prev. Rehabil. 13, 414–420 (2006).

    Article  PubMed  Google Scholar 

  26. Uchiyama, S., Kurasawa, T., Sekizawa, T. & Nakatsuka, H. Job strain and risk of cardiovascular events in treated hypertensive Japanese workers: hypertension follow-up group study. J. Occup. Health 47, 102–111 (2005).

    Article  PubMed  Google Scholar 

  27. Steenland, K., Johnson, J. & Nowlin, S. A follow-up study of job strain and heart disease among males in the NHANES1 population. Am. J. Ind. Med. 31, 256–260 (1997).

    Article  CAS  PubMed  Google Scholar 

  28. Eaker, E. D., Sullivan, L. M., Kelly-Hayes, M., D'Agostino, R. B. Sr & Benjamin, E. J. Does job strain increase the risk for coronary heart disease or death in men and women? The Framingham Offspring Study. Am. J. Epidemiol. 159, 950–958 (2004).

    Article  PubMed  Google Scholar 

  29. Kornitzer, M. et al. Job stress and major coronary events: results from the Job Stress, Absenteeism and Coronary Heart Disease in Europe study. Eur. J. Cardiovasc. Prev. Rehabil. 13, 695–704 (2006).

    Article  PubMed  Google Scholar 

  30. Kuper, H., Adami, H. O., Theorell, T. & Weiderpass, E. Psychosocial determinants of coronary heart disease in middle-aged women: a prospective study in Sweden. Am. J. Epidemiol. 164, 349–357 (2006).

    Article  PubMed  Google Scholar 

  31. Tsutsumi, A., Kayaba, K., Hirokawa, K. & Ishikawa, S. Psychosocial job characteristics and risk of mortality in a Japanese community-based working population: the Jichi Medical School Cohort Study. Soc. Sci. Med. 63, 1276–1288 (2006).

    Article  PubMed  Google Scholar 

  32. Andre-Petersson, L., Engstrom, G., Hedblad, B., Janzon, L. & Rosvall, M. Social support at work and the risk of myocardial infarction and stroke in women and men. Soc. Sci. Med. 64, 830–841 (2007).

    Article  PubMed  Google Scholar 

  33. Kivimaki, M., Theorell, T., Westerlund, H., Vahtera, J. & Alfredsson, L. Job strain and ischaemic disease: does the inclusion of older employees in the cohort dilute the association? The WOLF Stockholm Study. J. Epidemiol. Community Health 62, 372–374 (2008).

    Article  CAS  PubMed  Google Scholar 

  34. Bonde, J. P. et al. Job strain and ischemic heart disease: a prospective study using a new approach for exposure assessment. J. Occup. Environ. Med. 51, 732–738 (2009).

    Article  PubMed  Google Scholar 

  35. Netterstrøm, B., Kristensen, T. S., Jensen, G. & Schnor, P. Is the demand–control model still a usefull tool to assess work-related psychosocial risk for ischemic heart disease? Results from 14 year follow up in the Copenhagen City Heart study. Int. J. Occup. Med. Environ. Health 23, 217–224 (2010).

    Article  PubMed  Google Scholar 

  36. Orth-Gomér, K. et al. Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. JAMA 284, 3008–3014 (2000).

    Article  PubMed  Google Scholar 

  37. Parkes, C. M., Benjamin, B. & Fitzgerald, R. G. Broken heart: a statistical study of increased mortality among widowers. BMJ 1, 740–743 (1969).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Li, J., Hansen, D., Mortensen, P. B. & Olsen, J. Myocardial infarction in parents who lost a child: a nationwide prospective cohort study in Denmark. Circulation 106, 1634–1639 (2002).

    Article  PubMed  Google Scholar 

  39. Lee, S., Colditz, G. A., Berkman, L. F. & Kawachi, I. Caregiving and risk of coronary heart disease in U. S. women: a prospective study. Am. J. Prev. Med. 24, 113–119 (2003).

    Article  PubMed  Google Scholar 

  40. McPherson, M. & Smith-Lovin, L. Social isolation in America: Changes in core discussion networks over two decades. Am. Sociol. Rev. 71, 353–375 (2006).

    Article  Google Scholar 

  41. Griffin, J. Mental Health Foundation. The lonely society? [online], (2010).

    Google Scholar 

  42. Holt-Lunstad, J., Smith, T. B. & Layton, J. B. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 7, e1000316 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Patterson, A. C. & Veenstra, G. Loneliness and risk of mortality: a longitudinal investigation in Alameda County, California. Soc. Sci. Med. 71, 181–186 (2010).

    Article  PubMed  Google Scholar 

  44. Thurston, R. C. & Kubzansky, L. D. Women, loneliness, and incident coronary heart disease. Psychosom. Med. 71, 836–842, (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  45. Olsen, R. B., Olsen, J., Gunner-Svensson, F. & Waldstrøm, B. Social networks and longevity. A 14 year follow-up study among elderly in Denmark. Soc. Sci. Med. 33, 1189–1195 (1991).

    Article  CAS  PubMed  Google Scholar 

  46. Heffner, K. L., Waring, M. E., Roberts, M. B., Eaton, C. B. & Gramling, R. Social isolation, C-reactive protein, and coronary heart disease mortality among community-dwelling adults. Soc. Sci. Med. 72, 1482–1488, (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  47. Orth-Gomér, K., Rosengren, A. & Wilhelmsen, L. Lack of social support and incidence of coronary heart disease in middle-aged Swedish men. Psychosom. Med. 55, 37–43 (1993).

    Article  PubMed  Google Scholar 

  48. Kaplan, G. A. et al. Social connections and mortality from all causes and from cardiovascular disease: prospective evidence from eastern Finland. Am. J. Epidemiol. 128, 370–380 (1988).

    Article  CAS  PubMed  Google Scholar 

  49. Marmot, M. G. et al. Health inequalities among British civil servants: the Whitehall II study. Lancet 337, 1387–1393 (1991).

    Article  CAS  PubMed  Google Scholar 

  50. Kivimäki, M. et al. Why is evidence on job strain and coronary heart disease mixed? An illustration of measurement challenges in the Whitehall II study. Psychosom. Med. 68, 398–401 (2006).

    Article  PubMed  Google Scholar 

  51. Chandola, T., Brunner, E. & Marmot, M. Chronic stress at work and the metabolic syndrome: prospective study. BMJ 332, 521–525 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  52. Chandola, T. et al. Work stress and coronary heart disease: what are the mechanisms? Eur. Heart J. 29, 640–648 (2008).

    Article  PubMed  Google Scholar 

  53. Markovitz, J. H., Matthews, K. A., Whooley, M., Lewis, C. E. & Greenlund, K. J. Increases in job strain are associated with incident hypertension in the CARDIA Study. Ann. Behav. Med. 28, 4–9 (2004).

    Article  PubMed  Google Scholar 

  54. Grippo, A. J., Lamb, D. G., Carter, C. S. & Porges, S. W. Social isolation disrupts autonomic regulation of the heart and influences negative affective behaviors. Biol. Psychiatry 62, 1162–1170 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  55. Adam, E. K., Hawkley, L. C., Kudielka, B. M. & Cacioppo, J. T. Day-to-day dynamics of experience—cortisol associations in a population-based sample of older adults. Proc. Natl Acad. Sci. USA 103, 17058–17063 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Grant, N., Hamer, M. & Steptoe, A. Social isolation and stress-related cardiovascular, lipid, and cortisol responses. Ann. Behav. Med. 37, 29–37 (2009).

    Article  PubMed  Google Scholar 

  57. Cacioppo, J. T. et al. Loneliness and health: potential mechanisms. Psychosom. Med. 64, 407–417 (2002).

    Article  PubMed  Google Scholar 

  58. Netterstrøm, B. et al. The relation between work-related psychosocial factors and the development of depression. Epidemiol. Rev. 30, 118–132 (2008).

    Article  PubMed  Google Scholar 

  59. Bonde, J. P. Psychosocial factors at work and risk of depression: a systematic review of the epidemiological evidence. Occup. Environ. Med. 65, 438–445 (2008).

    Article  CAS  PubMed  Google Scholar 

  60. Virtanen, M. et al. Overcrowding in hospital wards as a predictor of antidepressant treatment among hospital staff. Am. J. Psychiatry 165, 1482–1486 (2008).

    Article  PubMed  Google Scholar 

  61. Kivimäki, M. et al. Psychosocial work environment as a risk factor for absence with a psychiatric diagnosis: an instrumental-variables analysis. Am. J. Epidemiol. 172, 167–172 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  62. Nieuwenhuijsen, K., Bruinvels, D. & Frings-Dresen, M. Psychosocial work environment and stress-related disorders, a systematic review. Occup. Med. (Lond.) 60, 277–286 (2010).

    Article  CAS  Google Scholar 

  63. Kuper, H. et al. Evaluating the causal relevance of diverse risk markers: horizontal systematic review. BMJ 339, b4265 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  64. Epel, E. S. et al. Accelerated telomere shortening in response to life stress. Proc. Natl Acad. Sci. USA 101, 17312–17315 (2004).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Brouilette, S. W. et al. Telomere length, risk of coronary heart disease, and statin treatment in the West of Scotland Primary Prevention Study: a nested case–control study. Lancet 369, 107–114 (2007).

    Article  CAS  PubMed  Google Scholar 

  66. Hintsanen, M. et al. Job strain and early atherosclerosis: the Cardiovascular Risk in Young Finns study. Psychosom. Med. 67, 740–747 (2005).

    Article  PubMed  Google Scholar 

  67. Kivimäki, M. et al. Early risk factors, job strain, and atherosclerosis among men in their 30s: the Cardiovascular Risk in Young Finns Study. Am. J. Public Health 97, 450–452 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Nordstrøm, C. K. et al. Work-related stress and early atherosclerosis. Epidemiology 12, 180–185 (2001).

    Article  PubMed  Google Scholar 

  69. Rosvall, M. et al. Work-related psychosocial factors and carotid atherosclerosis. Int. J. Epidemiol. 31, 1169–1178 (2002).

    Article  CAS  PubMed  Google Scholar 

  70. Muntaner, C. et al. Work organization and atherosclerosis: findings from the ARIC study. Atherosclerosis Risk in Communities. Am. J. Prev. Med. 14, 9–18 (1998).

    Article  CAS  PubMed  Google Scholar 

  71. Lynch, J. Krause, N., Kaplan, G. A., Salonen, R. & Salonen, J. T. Workplace demands, economic reward and progression of carotid atherosclerosis. Circulation 96, 302–307 (1997).

    Article  CAS  PubMed  Google Scholar 

  72. Xu, W. et al. Job stress and carotid intima–media thickness in Chinese workers. J. Occup. Health 52, 257–262 (2010).

    Article  PubMed  Google Scholar 

  73. Cohen, S., Doyle, W. J., Skoner, D. P., Rabin, B. S. & Gwaltney, J. M. Jr. Social ties and susceptibility to the common cold. JAMA 277, 1940–1944 (1997).

    Article  CAS  PubMed  Google Scholar 

  74. Kiecolt-Glaser, J. K. et al. Hostile marital interactions, proinflammatory cytokine production, and wound healing. Arch. Gen. Psychiatry 62, 1377–1384 (2005).

    Article  PubMed  Google Scholar 

  75. The Interleukin-6 Receptor Mendelian Randomisation Analysis Consortium. The interleukin-6 receptor as a target for prevention of coronary heart disease: a Mendelian randomisation analysis. Lancet, in press.

  76. Kivimäki, M. et al. Work stress, weight gain and weight loss: evidence for bidirectional effects of job strain on body mass index in the Whitehall II study. Int. J. Obes. (Lond.) 30, 982–987 (2006).

    Article  Google Scholar 

  77. Wardle, J., Chida, Y., Gibson, E. L., Whitaker, K. L. & Steptoe, A. Stress and adiposity: a meta-analysis of longitudinal studies. Obesity (Silver Spring) 19, 771–778 (2011).

    Article  Google Scholar 

  78. Nyberg, S. T. et al. Job strain in relation to body mass index: pooled analysis of 160,000 adults from 13 cohort studies. J. Intern. Med. http://dx.doi.org/10.1111/j.1365-2796.2011.02482.x.

  79. Kouvonen, A., Kivimäki, M., Virtanen, M., Pentti, J. & Vahtera, J. Work stress, smoking status, and smoking intensity: an observational study of 46,190 employees. J. Epidemiol. Community Health 59, 63–69 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  80. Rod, N. H., Grønbaek, M., Schnohr, P., Prescott, E. & Kristensen, T. S. Perceived stress as a risk factor for changes in health behavior and cardiac risk profile: a longitudinal study. J. Intern. Med. 266, 467–475 (2009).

    Article  PubMed  Google Scholar 

  81. Virtanen, M. et al. Long working hours and sleep disturbances: the Whitehall II prospective cohort study. Sleep 32, 737–745 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  82. Cappuccio, F. P., Cooper, D., D'Elia, L., Strazzullo, P. & Miller, M. A. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur. Heart J. 32, 1484–1492 (2011).

    Article  PubMed  Google Scholar 

  83. Chandola, T., Ferrie, J. E., Perski, A., Akbaraly, T. & Marmot, M. G. The effect of short sleep duration on coronary heart disease risk is greatest among those with sleep disturbance: a prospective study from the Whitehall II cohort. Sleep 33, 739–744 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  84. Hawkley, L. C., Thisted, R. A. & Cacioppo, J. T. Loneliness predicts reduced physical activity: cross-sectional & longitudinal analyses. Health Psychol. 28, 354–363 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  85. Lauder, W., Mummery, K., Jones, M. & Caperchione, C. A comparison of health behaviors in lonely and non-lonely populations. Psychol. Health Med. 11, 233–245 (2006).

    Article  PubMed  Google Scholar 

  86. Chida, Y. & Steptoe, A. Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: A meta-analysis of prospective evidence. Hypertension 55, 1026–1032 (2010).

    Article  CAS  PubMed  Google Scholar 

  87. Hamer, M., O'Donnell, K., Lahiri, A. & Steptoe, A. Salivary cortisol responses to mental stress are associated with coronary artery calcification in healthy men and women. Eur. Heart J. 31, 424–429 (2010).

    Article  CAS  PubMed  Google Scholar 

  88. Sheps, D. S. et al. Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: results from the Psychophysiological Investigations of Myocardial Ischemia study. Circulation 105, 1780–1784 (2002).

    Article  PubMed  Google Scholar 

  89. Babyak, M. A. et al. Prognosis after change in left ventricular ejection fraction during mental stress testing in patients with stable coronary artery disease. Am. J. Cardiol. 105, 25–28 (2010).

    Article  PubMed  Google Scholar 

  90. Macleod, J. et al. Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men. BMJ 324, 1247–1251 (2002).

    Article  PubMed  PubMed Central  Google Scholar 

  91. Distel, M. A. et al. Familial resemblance for loneliness. Behav. Genet. 40, 480–494 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  92. Wilson, P. W. et al. Prediction of coronary heart disease using risk factor categories. Circulation 97, 1837–1847 (1998).

    Article  CAS  PubMed  Google Scholar 

  93. Kivimäki, M. et al. Using additional information on working hours to predict coronary heart disease: a cohort study. Ann. Intern. Med. 154, 457–463 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  94. Graham, I. et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur. Heart J. 28, 2375–2414 (2007).

    Article  PubMed  Google Scholar 

  95. Pearson, T. A. et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 106, 388–391 (2002).

    Article  PubMed  Google Scholar 

  96. Kloner, R. A. Natural and unnatural triggers of myocardial infarction. Prog. Cardiovasc. Dis. 48, 285–300 (2006).

    Article  PubMed  Google Scholar 

  97. Steptoe, A. & Brydon, L. Emotional triggering of cardiac events. Neurosci. Biobehav. Rev. 33, 63–70 (2009).

    Article  PubMed  Google Scholar 

  98. Mittleman, M. A. & Mostofsky, E. Physical, psychological and chemical triggers of acute cardiovascular events: preventive strategies. Circulation 124, 346–354 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  99. Thompson, P. D. et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 115, 2358–2368 (2007).

    Article  PubMed  Google Scholar 

  100. Warren-Gash, C., Smeeth, L. & Hayward, A. C. Influenza as a trigger for acute myocardial infarction or death from cardiovascular disease: a systematic review. Lancet Infect. Dis. 9, 601–610 (2009).

    Article  PubMed  Google Scholar 

  101. Trichopoulos, D., Katsouyanni, K., Zavitsanos, X., Tzonou, A. & Dalla-Vorgia, P. Psychological stress and fatal heart attack: the Athens (1981). earthquake natural experiment. Lancet 1, 441–444 (1983).

    Article  CAS  PubMed  Google Scholar 

  102. Brown, D. L. Disparate effects of the 1989 Loma Prieta and 1994 Northridge earthquakes on hospital admissions for acute myocardial infarction: importance of superimposition of triggers. Am. Heart J. 137, 830–836 (1999).

    Article  CAS  PubMed  Google Scholar 

  103. Leor, J. & Kloner, R. A. The Northridge earthquake as a trigger for acute myocardial infarction. Am. J. Cardiol. 77, 1230–1232 (1996).

    Article  CAS  PubMed  Google Scholar 

  104. Bhaskaran, K. et al. Effects of ambient temperature on the incidence of myocardial infarction. Heart 95, 1760–1769 (2009).

    Article  CAS  PubMed  Google Scholar 

  105. Ruidavets, J. B. et al. Triggering of acute coronary syndromes after a chemical plant explosion. Heart 92, 257–258 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  106. Feng, J., Lenihan, D. J., Johnson, M. M., Karri, V. & Reddy, C. V. Cardiac sequelae in Brooklyn after the September 11 terrorist attacks. Clin. Cardiol. 29, 13–17 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  107. Kark, J. D., Goldman, S. & Epstein, L. Iraqi missile attacks on Israel. The association of mortality with a life-threatening stressor. JAMA 273, 1208–1210 (1995).

    Article  CAS  PubMed  Google Scholar 

  108. Kloner, R. A., McDonald, S., Leeka, J. & Poole, W. K. Comparison of total and cardiovascular death rates in the same city during a losing versus winning super bowl championship. Am. J. Cardiol. 103, 1647–1650 (2009).

    Article  PubMed  Google Scholar 

  109. Carroll, D., Ebrahim, S., Tilling, K., Macleod, J. & Smith, G. D. Admissions for myocardial infarction and World Cup football: database survey. BMJ 325, 1439–1442 (2002).

    Article  PubMed  PubMed Central  Google Scholar 

  110. Witte, D. R., Bots, M. L., Hoes, A. W. & Grobbee, D. E. Cardiovascular mortality in Dutch men during 1996 European football championship: longitudinal population study. BMJ 321, 1552–1554 (2000).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  111. Wilbert-Lampen, U. et al. Cardiovascular events during World Cup soccer. N. Engl. J. Med. 358, 475–483 (2008).

    Article  CAS  PubMed  Google Scholar 

  112. Dahabreh, I. J. & Paulus, J. K. Association of episodic physical and sexual activity with triggering of acute cardiac events: systematic review and meta-analysis. JAMA 305, 1225–1233 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  113. Tofler, G. H. et al. Analysis of possible triggers of acute myocardial infarction (the MILIS study). Am. J. Cardiol. 66, 22–27 (1990).

    Article  CAS  PubMed  Google Scholar 

  114. Mittleman, M. A. et al. Triggering of acute myocardial infarction onset by episodes of anger. Circulation 92, 1720–1725 (1995).

    Article  CAS  PubMed  Google Scholar 

  115. Lipovetzky, N. et al. Emotional events and anger at the workplace as triggers for a first event of the acute coronary syndrome: a case-crossover study. Isr. Med. Assoc. J. 9, 310–315 (2007).

    PubMed  Google Scholar 

  116. Möller, J. et al. Do episodes of anger trigger myocardial infarction? A case–crossover analysis in the Stockholm Heart Epidemiology Program (SHEEP). Psychosom. Med. 61, 842–849 (1999).

    Article  PubMed  Google Scholar 

  117. Strike, P. C., Perkins-Porras, L., Whitehead, D. L., McEwan, J. & Steptoe, A. Triggering of acute coronary syndromes by physical exertion and anger: clinical and sociodemographic characteristics. Heart 92, 1035–1040 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  118. Möller, J., Theorell, T., de Faire, U., Ahlbom, A. & Hallqvist, J. Work related stressful life events and the risk of myocardial infarction. Case–control and case–crossover analyses within the Stockholm heart epidemiology program (SHEEP). J. Epidemiol. Community Health 59, 23–30 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  119. Steptoe, A., Strike, P. C., Perkins-Porras, L., McEwan, J. R. & Whitehead, D. L. Acute depressed mood as a trigger of acute coronary syndromes. Biol. Psychiatry 60, 837–842 (2006).

    Article  PubMed  Google Scholar 

  120. Steptoe, A. et al. Emotional triggering and low socio-economic status as determinants of depression following acute coronary syndrome. Psychol. Med. 41, 1857–1866 (2011).

    Article  CAS  PubMed  Google Scholar 

  121. Mostofsky, E. et al. Risk of acute myocardial infarction after the death of a significant person in one's life: The Determinants of Myocardial Infarction Onset Study. Circulation 125, 491–496 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  122. Wittstein, I. S. et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N. Engl. J. Med. 352, 539–548 (2005).

    Article  CAS  PubMed  Google Scholar 

  123. Sharkey, S. W. et al. Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J. Am. Coll. Cardiol. 55, 333–341 (2010).

    Article  PubMed  Google Scholar 

  124. Naghavi, M. et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part II. Circulation 108, 1772–1778 (2003).

    Article  PubMed  Google Scholar 

  125. Goldberg, A. D. et al. Ischemic, hemodynamic, and neurohormonal responses to mental and exercise stress. Experience from the Psychophysiological Investigations of Myocardial Ischemia Study (PIMI). Circulation 94, 2402–2409 (1996).

    Article  CAS  PubMed  Google Scholar 

  126. Strike, P. C. & Steptoe, A. Systematic review of mental stress-induced myocardial ischaemia. Eur. Heart J. 24, 690–703 (2003).

    Article  CAS  PubMed  Google Scholar 

  127. Yeung, A. C. et al. The effect of atherosclerosis on the vasomotor response of coronary arteries to mental stress. N. Engl. J. Med. 325, 1551–1556 (1991).

    Article  CAS  PubMed  Google Scholar 

  128. Kop, W. J. et al. Changes in heart rate and heart rate variability before ambulatory ischemic events (1). J. Am. Coll. Cardiol. 38, 742–749 (2001).

    Article  CAS  PubMed  Google Scholar 

  129. Steinberg, J. S. et al. Increased incidence of life-threatening ventricular arrhythmias in implantable defibrillator patients after the World Trade Center attack. J. Am. Coll. Cardiol. 44, 1261–1264 (2004).

    Article  PubMed  Google Scholar 

  130. Strike, P. C. et al. Pathophysiological processes underlying emotional triggering of acute cardiac events. Proc. Natl Acad. Sci. USA 103, 4322–4327 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  131. Tofler, G. H. & Muller, J. E. Triggering of acute cardiovascular disease and potential preventive strategies. Circulation 114, 1863–1872 (2006).

    Article  PubMed  Google Scholar 

  132. Nawrot, T. S., Perez, L., Kunzli, N., Munters, E. & Nemery, B. Public health importance of triggers of myocardial infarction: a comparative risk assessment. Lancet 377, 732–740 (2011).

    Article  PubMed  Google Scholar 

  133. Meijer, A. et al. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis of 25 years of research. Gen. Hosp. Psychiatry 33, 203–216 (2011).

    Article  PubMed  Google Scholar 

  134. Lett, H. S. et al. Social support and coronary heart disease: epidemiologic evidence and implications for treatment. Psychosom. Med. 67, 869–878 (2005).

    Article  PubMed  Google Scholar 

  135. Ruberman, W., Weinblatt, E., Goldberg, J. D. & Chaudhary, B. S. Psychosocial influences on mortality after myocardial infarction. N. Engl. J. Med. 311, 552–559 (1984).

    Article  CAS  PubMed  Google Scholar 

  136. Theorell, T., Perski, A., Orth-Gomér, K., Hamsten, A. & de Faire, U. The effects of the strain of returning to work on the risk of cardiac death after a first myocardial infarction before the age of 45. Int. J. Cardiol. 30, 61–67 (1991).

    Article  CAS  PubMed  Google Scholar 

  137. Aboa-Eboule, C. et al. Job strain and risk of acute recurrent coronary heart disease events. JAMA 298, 1652–1660 (2007).

    Article  CAS  PubMed  Google Scholar 

  138. Aboa-Eboulé, C. et al. Effort-reward imbalance at work and recurrent coronary heart disease events: a 4-year prospective study of post-myocardial infarction patients. Psychosom. Med. 73, 436–447 (2011).

    Article  PubMed  Google Scholar 

  139. László, K. D., Ahnve, S., Hallqvist, J., Ahlbom, A. & Janszky, I. Job strain predicts recurrent events after a first acute myocardial infarction: the Stockholm Heart Epidemiology Program. J. Intern. Med. 267, 599–611 (2010).

    Article  CAS  PubMed  Google Scholar 

  140. Georgiades, A., Janszky, I., Blom, M., László, K. D. & Ahnve, S. Financial strain predicts recurrent events among women with coronary artery disease. Int. J. Cardiol. 135, 175–183 (2009).

    Article  PubMed  Google Scholar 

  141. Barth, J., Schneider, S. & von Kanel, R. Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis. Psychosom. Med. 72, 229–238 (2010).

    Article  PubMed  Google Scholar 

  142. Leineweber, C. et al. Covert coping with unfair treatment at work and risk of incident myocardial infarction and cardiac death among men: prospective cohort study. J. Epidemiol. Community Health 65, 420–425 (2011).

    Article  CAS  PubMed  Google Scholar 

  143. O'Donnell, K., Badrick, E., Kumari, M. & Steptoe, A. Psychological coping styles and cortisol over the day in healthy older adults. Psychoneuroendocrinology 33, 601–611 (2008).

    Article  CAS  PubMed  Google Scholar 

  144. Linden, W., Phillips, M. J. & Leclerc, J. Psychological treatment of cardiac patients: a meta-analysis. Eur. Heart J. 28, 2972–2984 (2007).

    Article  PubMed  Google Scholar 

  145. Whalley, B. et al. Psychological interventions for coronary heart disease. Cochrane Database of Systematic Reviews, Issue 8. Art. No.: CD002902. http://dx.doi.org/10.1002/14651858.CD002902.pub3 (2011).

  146. van Dixhoorn, J. & White, A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. Eur. J. Cardiovasc. Prev. Rehabil. 12, 193–202 (2005).

    Article  PubMed  Google Scholar 

  147. Jones, D. A. & West, R. R. Psychological rehabilitation after myocardial infarction: multicenter randomised controlled trial. BMJ 313, 1517–1521 (1996).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  148. Orth-Gomér, K. et al. Stress reduction prolongs life in women with coronary disease: the Stockholm Women's Intervention Trial for Coronary Heart Disease (SWITCHD). Circ. Cardiovasc. Qual. Outcomes 2, 25–32 (2009).

    Article  PubMed  Google Scholar 

  149. Gulliksson, M. et al. Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Arch. Intern. Med. 171, 134–140 (2011).

    Article  PubMed  Google Scholar 

  150. Blumenthal, J. A. et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial. JAMA 293, 1626–1634 (2005).

    Article  CAS  PubMed  Google Scholar 

  151. Bishop, G. D. et al. Effects of a psychosocial skills training workshop on psychophysiological and psychosocial risk in patients undergoing coronary artery bypass grafting. Am. Heart J. 150, 602–609 (2005).

    Article  PubMed  Google Scholar 

  152. Stewart, L. A. & Parmar, M. K. Meta-analysis of the literature or of individual patient data: is there a difference? Lancet 341, 418–422 (1993).

    Article  CAS  PubMed  Google Scholar 

  153. Medical Research Council. Using natural experiments to evaluate population health interventions: guidance for producers and users of evidence [online], (2011).

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Acknowledgements

M. Kivimäki is supported by the Medical Research Council, UK.

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Steptoe, A., Kivimäki, M. Stress and cardiovascular disease. Nat Rev Cardiol 9, 360–370 (2012). https://doi.org/10.1038/nrcardio.2012.45

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