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. 2020 Jun 1;3(6):e208741.
doi: 10.1001/jamanetworkopen.2020.8741.

Association of Perceived Stress Levels With Long-term Mortality in Patients With Peripheral Artery Disease

Ali O Malik  1   2 , Poghni Peri-Okonny  1   2 , Kensey Gosch  2 , Merrill Thomas  1 , Carlos Mena  3 , William R Hiatt  4 , Philip G Jones  1   2 , Jeremy B Provance  1 , Clementine Labrosciano  5 , Qurat-Ul-Ain Jelani  3 , John A Spertus  1   2 , Kim G Smolderen  6
Affiliations

Association of Perceived Stress Levels With Long-term Mortality in Patients With Peripheral Artery Disease

Ali O Malik et al. JAMA Netw Open. .

Abstract

Importance: Identifying modifiable risk factors, such as stress, that could inform the design of peripheral artery disease (PAD) management strategies is critical for reducing the risk of mortality. Few studies have examined the association of self-perceived stress with outcomes in patients with PAD.

Objective: To examine the association of high levels of self-perceived stress with mortality in patients with PAD.

Design, setting, and participants: This cohort study analyzed data from the registry of the Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study, a multicenter study that enrolled patients with new or worsening symptoms of PAD who presented to 16 subspecialty clinics across the US, the Netherlands, and Australia from June 2, 2011, to December 3, 2015. However, the present study included only patients in the US sites because assessments of mortality for patients in the Netherlands and Australia were not available. Data analysis was conducted from July 2019 to March 2020.

Exposure: Self-perceived stress was quantified using the 4-item Perceived Stress Scale (PSS-4), with a score range of 0 to 16. A score of 6 or higher indicated high stress in this cohort. Missing scores were imputed using multiple imputation by chained equations with predictive mean matching. Stress was assessed at baseline and at 3-, 6-, and 12-month follow-up. Patients who reported high levels of stress at 2 or more follow-up assessments were categorized as having chronic stress.

Main outcomes and measures: All-cause mortality was the primary study outcome. Such data for the subsequent 4 years after the 12-month follow-up were obtained from the National Death Index.

Results: The final cohort included 765 patients, with a mean (SD) age of 68.4 (9.7) years. Of these patients, 57.8% were men and 71.6% were white individuals. High stress levels were reported in 65% of patients at baseline and in 20% at the 12-month follow-up. In an adjusted Cox proportional hazards regression model accounting for demographics, comorbidities, disease severity, treatment type, and socioeconomic status, exposure to chronic stress during the 12 months of follow-up was independently associated with increased risk of all-cause mortality in the subsequent 4 years (hazard ratio, 2.12; 95% CI, 1.14-3.94; P = .02).

Conclusions and relevance: In thie cohort study of patients with PAD, higher stress levels in the year after diagnosis appeared to be associated with greater long-term mortality risk, even after adjustment for confounding factors. These findings suggest that, given that stress is a modifiable risk factor for which evidence-based management strategies exist, a holistic approach that includes assessment of chronic stress has the potential to improve survival in patients with PAD.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Malik reported receiving grants from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) during the conduct of the study. Dr Mena reported receiving consulting fees from Boston Scientific, Bard, Cardinal Health, Cook, and Medtronic outside the submitted work. Dr Hiatt reported receiving grants from the NIH, Bayer, and Janssen during the conduct of the study as well as grants from Bayer, Janssen, and Amgen outside the submitted work. Dr Spertus reported receiving personal fees from AstraZeneca, Novartis, Janssen, Merck, Bayer, United Healthcare, Blue Cross Blue Shield of Kansas City, Myokaria, and Amgen outside the submitted work; holding the copyright to the Peripheral Artery Questionnaire, licensed and with royalties paid; and having equity interest in Health Outcomes Sciences. Dr Smolderen reported receiving support through unrestricted research grants from Abbott Vascular, Boston Scientific, and Terumo; receiving grants from the Patient-Centered Outcomes Research Institute (PCORI) and Gore during the conduct of the study; and being a consultant for Optum Labs. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. STROBE Diagram of Analytical Cohort
PORTRAIT indicates Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories; PSS-4, 4-item Perceived Stress Scale.
Figure 2.
Figure 2.. Association of Chronic Self-Perceived Stress and Mortality
Age-adjusted survival curves in patients with chronic stress vs those without (P = .008).
See this image and copyright information in PMC

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