Perceived stress in myocardial infarction: long-term mortality and health status outcomes

Abstract

Objectives: This study sought to determine the association of chronic stress with long-term adverse outcomes after acute myocardial infarction (AMI).

Background: Chronic stress has been shown to be associated with the development of cardiovascular disease and, in the case of particular types of stress such as job and marital strain, with recurrent adverse events after AMI. Little is known, however, about the association of chronic stress with mortality and adverse health status outcomes in a general AMI population.

Methods: In a cohort of 4,204 AMI patients from 24 U.S. hospitals completing the Perceived Stress Scale-4 (sum scores ranging from 0 to 16) during hospitalization, moderate/high stress over the previous month was defined as scores in the top 2 quintiles (scores of 6 to 16). Detailed data on sociodemographics, psychosocial status, and clinical characteristics were collected at baseline. Outcomes included patients' 1-year health status, assessed with the Seattle Angina Questionnaire, Short Form-12, and EuroQol Visual Analog Scale, and 2-year mortality.

Results: AMI patients with moderate/high stress had increased 2-year mortality compared with those having low levels of stress (12.9% vs. 8.6%; p < 0.001). This association persisted after adjusting for sociodemographics, clinical factors (including depressive symptoms), revascularization status, and GRACE (Global Registry of Acute Coronary Events) discharge risk scores (hazard ratio: 1.42: 95% confidence interval: 1.15 to 1.76). Furthermore, moderate/high stress was independently associated with poor 1-year health status, including a greater likelihood of angina, worse disease-specific and generic health status, and worse perceived health (p < 0.01 for all).

Conclusions: Moderate/high perceived stress at the time of an AMI is associated with adverse long-term outcomes, even after adjustment for important confounding factors. Future studies need to examine whether stress mediates observed racial and socioeconomic disparities and whether novel interventions targeting chronic stress and coping skills can improve post-AMI outcomes.

Figure 1. Kaplan-Meier survival curves for moderate/high vs. low perceived stress levels

Two-year survival after acute myocardial infarction in patients with moderate/high perceived stress levels (stress scores 6-16) versus low stress levels (stress scores 0-5).

Figure 2. Association between moderate/high vs. low perceived stress levels and long-term outcomes

Multivariable-adjusted hazard/odds ratios of the association between moderate/high perceived stress levels (stress scores 6-16) versus low stress levels (stress scores 0-5) and mortality and health status outcomes. Models were adjusted for age, sex, race, marital status, self-reported avoidance of care due to costs, hypertension, prior bypass surgery, diabetes, chronic lung disease, chronic heart failure, history of stroke or transient ischemic attack, body mass index, anemia, depressive symptoms, ST-elevations on admission, left ventricular function, GRACE score(22), in-hospital bypass surgery, in-hospital percutaneous coronary intervention, and the % of quality of care indicators received.