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Psychological stress and short-term hospitalisations or death in patients with heart failure
  1. Romano Endrighi1,2,
  2. Andrew J Waters1,
  3. Stephen S Gottlieb3,
  4. Kristie M Harris4,
  5. Andrew J Wawrzyniak5,
  6. Nadine S Bekkouche1,
  7. Yisheng Li6,
  8. Willem J Kop7,
  9. David S Krantz1
  1. 1Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  2. 2Division of Behavioral Science Research, Department of Health Policy and Health Services Research, Boston University, Boston, Massachusetts, USA
  3. 3University of Maryland School of Medicine, Baltimore, Maryland, USA
  4. 4Cardiopulmonary Behavioral Medicine Laboratory, The Ohio State University, Columbus, Ohio, USA
  5. 5Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, Florida, USA
  6. 6Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  7. 7Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
  1. Correspondence to Professor David S Krantz, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda MD 20814, USA; david.krantz{at}


Objective Standard predictors do not fully explain variations in the frequency and timing of heart failure (HF) adverse events (AEs). Psychological stress can trigger acute cardiovascular (CV) events, but it is not known whether stress can precipitate AEs in patients with HF. We investigated prospective associations of psychological stress with AEs in patients with HF.

Methods 144 patients with HF (77% male; 57.5±11.5, range 23–87 years, left ventricular ejection fraction ≤40%) were longitudinally evaluated for psychological stress (Perceived Stress Scale) and AEs (CV hospitalisations/death) at 2-week intervals for 3 months and at 9-month follow-up.

Results 42 patients (29.2%) had at least one CV hospitalisation and nine (6.3%) died. Patients reporting high average perceived stress across study measurements had a higher likelihood of AEs during the study period compared with those with lower stress (odds ratio=1.10, 95% confidence interval=1.04 to 1.17). In contrast to average levels, increases in stress did not predict AEs (p=0.96). Perceived stress was elevated after a CV hospitalisation (B=2.70, standard error (SE)=0.93, p=0.004) suggesting that CV hospitalisations increase stress. Subsequent analysis indicated that 24 of 38 (63%) patients showed a stress increase following hospitalisation. However, a prospective association between stress and AEs was present when accounting for prior hospitalisations (B=2.43, SE=1.23, p=0.05).

Conclusions Sustained levels of perceived stress are associated with increased risk of AEs, and increased distress following hospitalisation occurs in many, but not all, patients with HF. Patients with chronically high stress may be an important target group for HF interventions aimed at reducing hospitalisations.

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  • Contributors All authors listed have read and approved the submitted manuscript. In addition, each author has made a significant contribution to the manuscript and meet the authorship criteria of ICMJE: having made substantial contributions to the conception, design, acquisition, analysis or interpretation of data; drafting for important content; final approval of the version published and agreement to be accountable for the work. In addition, RE, AJW and DSK had full access to all data in the study and take responsibility for the integrity of the data and accuracy of data analysis. Detailed contributions of each of the authors are unchanged from what was provided with the initial submission of the manuscript.

  • Funding This work was supported by National Heart Lung and Blood Institute grant RO1-HL085730. The opinions and assertions expressed herein are those of the authors and are not to be construed as representing the views of Uniformed Services University or the US government.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval University of Maryland School of Medicine and Uniformed Services University of the Health Sciences.

  • Provenance and peer review Not commissioned; externally peer reviewed.