• Chronic coronary disease
• Epidemiology

Psychological distress is increasingly being recognised as a risk factor for cardiovascular disease. In the past, psychological distress has been investigated as a contributor to the development of coronary heart disease (CHD), as a trigger for acute coronary events or as a prognostic factor following acute events, usually acute myocardial infarction.1 In the INTERHEART (Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries) study, individuals who reported psychological distress (at home, at work or both) and those who were under financial stress or had stressful life events were at increased risk of an acute myocardial infarction with an effect size (for severe stress) comparable to that of arterial hypertension or abdominal obesity.2 A recent individual participant pooled analysis of 10 prospective cohort studies with 68 222 participants living in England and free of CHD (at entry) showed a dose–response association between psychological distress and the risk of overall and cardiovascular mortality.3 In a cohort of 4204 patients with acute myocardial infarction, moderate-to-high psychological stress was associated with higher 2-year mortality compared with those having low levels of stress and the association persisted after adjustment for a wide range of potential confounders.4 The increased risk associated with stress was evident despite the fact that patients with increased perceived stress had less cardiovascular risk, potentially suggesting that psychological distress per se contributes to the poor prognosis.4

Despite epidemiological and other lines of evidence linking psychological distress with the risk of coronary events or mortality, many aspects of the association between psychological distress and these outcomes remain poorly investigated. Psychological distress is multifactorial and reaction to exposure and consequently perceived stress differs widely across the individuals. The assessment of psychological distress and CHD or outcome is commonly based on self-reporting whose accuracy depends on recall bias …