Clinical Research
Cardiovascular Risk
Psychological Distress as a Risk Factor for Cardiovascular Events: Pathophysiological and Behavioral Mechanisms

https://doi.org/10.1016/j.jacc.2008.08.057Get rights and content
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Objectives

This study sought to estimate the extent to which behavioral and pathophysiological risk factors account for the association between psychological distress and incident cardiovascular events.

Background

The intermediate processes through which psychological distress increases the risk of cardiovascular disease (CVD) are incompletely understood. An understanding of these processes is important for treating psychological distress in an attempt to reduce CVD risk.

Methods

In a prospective study of 6,576 healthy men and women (ages 50.9 ± 13.1 years), we measured psychological distress (using the 12-item version of the General Health Questionnaire ≥4) and behavioral (smoking, alcohol, physical activity) and pathophysiological (C-reactive protein, fibrinogen, total and high-density lipoprotein cholesterol, obesity, hypertension) risk factors at baseline. The main outcome was CVD events (hospitalization for nonfatal myocardial infarction, coronary artery bypass, angioplasty, stroke, heart failure, and CVD-related mortality).

Results

Cigarette smoking, physical activity, alcohol intake, C-reactive protein, and hypertension were independently associated with psychological distress. There were 223 incident CVD events (63 fatal) over an average follow-up of 7.2 years. The risk of CVD increased in relation to presence of psychological distress in age- and sex-adjusted models (hazard ratio: 1.54, 95% confidence interval: 1.09 to 2.18, p = 0.013). In models that were adjusted for potential mediators, behavioral factors explained the largest proportion of variance (∼65%), whereas pathophysiological factors accounted for a modest amount (C-reactive protein ∼5.5%, hypertension, ∼13%).

Conclusions

The association between psychological distress and CVD risk is largely explained by behavioral processes. Therefore, treatment of psychological distress that aims to reduce CVD risk should primarily focus on health behavior change.

Key Words

stress
CVD
behavior
inflammation
hypertension

Abbreviations and Acronyms

CHD
coronary heart disease
CI
confidence interval
CRP
C-reactive protein
CV
coefficient of variation
CVD
cardiovascular disease
GHQ-12
12-item version of the General Health Questionnaire
HDL
high-density lipoprotein
HR
hazard ratio
MI
myocardial infarction
SHS
Scottish Health Survey

Cited by (0)

Drs. Hamer and Molloy receive grant funding from the British Heart Foundation, United Kingdom. Dr. Stamatakis receives grant funding from the National Institute for Health Research, United Kingdom. The Scottish Health Survey is funded by the Scottish Executive. The views expressed in this article are those of the authors and not necessarily of the funding bodies.