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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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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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