Association of Perceived Stress With Incident Heart Failure

Abstract

Background: The relationship between psychological stress and heart failure (HF) has not been well studied. We sought to assess the relationship between perceived stress and incident HF.

Methods: We used data from the national REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a large prospective biracial cohort study that enrolled community-dwellers aged 45 years and older between 2003 and 2007, with follow-up. We included participants free of suspected prevalent HF who completed the Cohen 4-item Perceived Stress Scale (PSS-4). Our outcome variables were incident HF event, HF with reduced ejection fraction events, and HF with preserved ejection fraction events. We estimated Cox proportional hazard models to determine if PSS-4 quartiles were independently associated with incident HF events, adjusting for sociodemographics, social support, unhealthy behaviors, comorbid conditions, and physiologic parameters. We also tested interactions by baseline statin use, given its anti-inflammatory properties.

Results: Among 25,785 participants with a mean age of 64 ± 9.3 years, 55% were female and 40% were Black. Over a median follow-up of 10.1 years, 1109 ± 4.3% experienced an incident HF event. In fully adjusted models, the PSS-4 was not associated with HF or HF with reduced ejection fraction. However, PSS-4 quartiles 2-4 (compared with the lowest quartile) were associated with incident HF with preserved ejection fraction (Q2 hazard ratio 1.37, 95% confidence interval 1.00-1.88; Q3 hazard ratio 1.42, 95% confidence interval 1.03-1.95; Q4 hazard ratio 1.41, 95% confidence interval 1.04-1.92). Notably, this association was attenuated among participants who took a statin at baseline (P for interaction = .07).

Conclusions: Elevated perceived stress was associated with incident HF with preserved ejection fraction but not HF with reduced ejection fraction.

Figure 1.

Exclusion cascade. REGARDS, REasons for Geographic And Racial Differences in Stroke.

Figure 2.

Forest plot for association of PSS-4 quartile and incident HF. The adjusted model includes age, sex, race, annual household income, educational attainment, geographic region of residence, marital status, social isolation, number of other adults living in the household, smoking status, alcohol use, exercise frequency, atrial fibrillation, history of coronary heart disease, dyslipidemia, diabetes mellitus, body mass index, systolic blood pressure, diastolic blood pressure, left ventricular hypertrophy, estimated glomerular filtration rate, urinary albumin to creatinine ratio, depressive symptoms, physical functioning, and statin use. CI, confidence interval; HF, heart failure; HR, hazard ratio; PSS, Perceived Stress Scale Score.

Figure 3.

Forest plot for Association of PSS-4 quartile with incident HFrEF and incident HFpEF square indicates point estimate for HFrEF and triangle indicates point estimate for HFpEF. The adjusted model includes age, sex, race, annual household income, educational attainment, geographic region of residence, marital status, social isolation, number of other adults living in the household, smoking status, alcohol use, exercise frequency, atrial fibrillation, history of coronary heart disease, dyslipidemia, diabetes mellitus, body mass index, systolic blood pressure, diastolic blood pressure, left ventricular hypertrophy, estimated glomerular filtration rate, urinary albumin to creatinine ratio, depressive symptoms, physical functioning, and statin use. CI, confidence interval; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HR, hazard ratio; PSS, Perceived Stress Scale Score.