Psychosocial stress and atherosclerosis: family and work stress accelerate progression of coronary disease in women. The Stockholm Female Coronary Angiography Study

The neuropathology of intimate partner violence

Lifelong brain health consequences of traumatic brain injury (TBI) include the risk of neurodegenerative disease. Up to one-third of women experience intimate partner violence (IPV) in their lifetime, often with TBI, yet remarkably little is known about the range of autopsy neuropathologies encountered in IPV. We report a prospectively accrued case series from a single institution, the New York City Office of Chief Medical Examiner, evaluated in partnership with the Brain Injury Research Center of Mount Sinai, using a multimodal protocol comprising clinical history review, ex vivo imaging in a small subset, and comprehensive neuropathological assessment by established consensus protocols. Fourteen brains were obtained over 2 years from women with documented IPV (aged 3rd-8th decade; median, 4th) and complex histories including prior TBI in 6, nonfatal strangulation in 4, cerebrovascular, neurological, and/or psychiatric conditions in 13, and epilepsy in 7. At autopsy, all had TBI stigmata (old and/or recent). In addition, white matter regions vulnerable to diffuse axonal injury showed perivascular and parenchymal iron deposition and microgliosis in some subjects. Six cases had evidence of cerebrovascular disease (lacunes and/or chronic infarcts). Regarding neurodegenerative disease pathologies, Alzheimer disease neuropathologic change was present in a single case (8th decade), with no chronic traumatic encephalopathy neuropathologic change (CTE-NC) identified in any. Findings from this initial series then prompted similar exploration in an expanded case series of 70 archival IPV cases (aged 2nd-9th decade; median, 4th) accrued from multiple international institutions. In this secondary case series, we again found evidence of vascular and white matter pathologies. However, only limited neurodegenerative proteinopathies were encountered in the oldest subjects, none meeting consensus criteria for CTE-NC. These observations from this descriptive exploratory study reinforce a need to consider broad co-morbid and neuropathological substrates contributing to brain health outcomes in the context of IPV, some of which may be potentially modifiable.

Behavioral factors predict all-cause mortality in female coronary patients and healthy controls over 26 years - a prospective secondary analysis of the Stockholm Female Coronary Risk Study

OBJECTIVE

The prognosis of coronary artery disease (CAD) is related to its severity and cardiovascular risk factors in both sexes. In women, social isolation, marital stress, sedentary lifestyle and depression predicted CAD progression and outcome within 3 to 5 years. We hypothesised that these behavioral factors would still be associated with all-cause mortality in female patients after 26 years.

METHODS

We examined 292 patients with CAD and 300 healthy controls (mean age of 56 ± 7 y) within the Fem-Cor-Risk-Study at baseline. Their cardiac, behavioral, and psychosocial risk profiles, exercise, smoking, and dietary habits were assessed using standardized procedures. Physiological characteristics included a full lipid profile, the coagulation cascade and autonomic dysfunction (heart rate variability, HRV). A new exploratory analysis using machine-learning algorithms compared the effects of social and behavioral mechanisms with standard risk factors. Results: All-cause mortality records were completed in 286 (97.9%) patients and 299 (99.7%) healthy women. During a median follow-up of 26 years, 158 (55.2%) patients and 101 (33.9%) matched healthy controls died. The annualized mortality rate was 2.1% and 1.3%, respectively. After controlling for all available confounders, behavioral predictors of survival in patients were social integration (HR 0.99, 95% CI 0.99-1.0) and physical activity (HR 0.54, 95% CI 0.37-0.79). Smoking acted as a predictor of all-cause mortality (HR 1.56, 95% CI 1.03-2.36). Among healthy women, moderate physical activity (HR 0.42, 95% CI 0.24-0.74) and complete HRV recordings (≥50%) were found to be significant predictors of survival.

CONCLUSIONS

CAD patients with adequate social integration, who do not smoke and are physically active, have a favorable long-term prognosis. The exact survival times confirm that behavioral risk factors are associated with all-cause mortality in female CAD patients and healthy controls.

The Burden of Living With Cutaneous Lupus Erythematosus

Cutaneous lupus erythematosus (CLE) is a group of heterogeneous autoimmune disorders primarily affecting the skin. Patients with these conditions are mostly young women when they become sick and often suffer from recurrent skin symptoms or longstanding changes in their physical appearance. CLE disorders lead to different levels of morbidity and can impact profoundly patients' quality of life, particularly in the psychological and social health domains. This review provides a summary of recent research investigating the psychosocial burden of living with CLE and the intersect amongst the disease characteristics, patient factors, and social determinants of health. Furthermore, this review provides insight into patient care and research needs that remain unmet to improve the quality of life of patients living with CLE.

Association of Perceived Stress and Physical Activity Level with Severity of Coronary Artery Disease in Gaza Strip, Palestine: A Cross-Sectional Study

Background

The association between life-event stressors and low physical activity linked to the severity of coronary artery disease (CAD) is poorly understood. Therefore, this study aimed to determine the perceived stress status and physical activity level associated with the severity of CAD.

Methods

The study was conducted among 423 patients with newly discovered CAD (both sexes, aged 35–65 years) confirmed by coronary angiography results. CAD severity was classified according to the Gensini score as severe or non-severe. The fasting blood glucose and lipid profiles were also investigated. Anthropometric and brachial blood pressure measurements were obtained. A structured questionnaire including participants’ characteristics, the Perceived Stress Scale (PSS-14), and the International Physical Activity Questionnaire were used via face-to-face interviews. Multivariable binary logistic regression was used to assess the predictors of CAD severity using IBM SPSS ver. 24.0 (IBM Corp., Armonk, NY, USA).

Results

Most participants were classified as having severe CAD (63.8%). Adjusting for age, sex, smoking status, systolic blood pressure, body mass index, and history of hypertension, the severity of CAD increased by 9% for a onescore increase in the PSS (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.01–1.14; P=0.030). Moreover, sufficiently active (600–1,500 metabolic equivalents [METs]/wk) patients had lower odds of severe CAD (OR, 0.43; 95% CI, 0.23–0.72; P=0.027) than those with insufficient activity. However, no significant association was found between physical activity (≥1,500 METs/wk) and CAD severity.

Conclusion

The odds of CAD severity significantly increased with increasing perceived stress score but decreased with sufficient physical activity.

Potential Factors That Contribute to Post-COVID-19 Fatigue in Women

Mortality of acute coronavirus disease (COVID-19) is higher in men than in women. On the contrary, women experience more long-term consequences of the disease, such as fatigue. In this perspective article, we proposed a model of the potential factors that might contribute to the higher incidence of post-COVID-19 fatigue in women. Specifically, psycho-physiological factors are features that might increase central factors (e.g., inflammation) and result in greater perceptions of fatigue. Furthermore, pre-existing conditions likely play a prominent role. This model offers a framework for researchers and clinicians, and future research is required to validate our proposed model and elucidate all mechanisms of the increased incidence and prevalence of post-COVID-19 fatigue in women.

Intimate Relationships and Coronary Heart Disease: Implications for Risk, Prevention, and Patient Management

Purpose of Review

Research and clinical services addressing psychosocial aspects of coronary heart disease (CHD) typically emphasize individuals, focusing less on the context of intimate relationships such as marriage and similar partnerships. This review describes current evidence regarding the role of intimate relationships in the development, course, and management of CHD.

Recent Findings

Having an intimate partner is associated with reduced risk of incident CHD and a better prognosis among patients, but strain (e.g., conflict) and disruption (i.e., separation, divorce) in these relationships are associated with increased risk and poor outcomes. These associations likely reflect mechanisms involving health behavior and the physiological effects of emotion and stress. Importantly, many other well-established psychosocial risk and protective factors (e.g., low SES, job stress, depression, and optimism) are strongly related to the quality of intimate relationships, and these associations likely contribute to the effects of those other psychosocial factors. For better or worse, intimate partners can also affect the outcome of efforts to alter health behaviors (physical activity, diet, smoking, and medication adherence) central in the prevention and management CHD. Intimate partners also influence—and are influenced by—stressful aspects of acute coronary crises and longer-term patient adjustment and management.

Summary

Evidence on each of these roles of intimate relationships in CHD is considerable, but direct demonstrations of the value of couple assessments and interventions are limited, although preliminary research is promising. Research needed to close this gap must also address issues of diversity, disparities, and inequity that have strong parallels in CHD and intimate relationships.

Severity of psychological distress over five years differs as a function of sex and presence of coronary artery disease

BACKGROUND

Psychological distress is more prevalent and severe among patients with coronary artery disease (CAD) compared to healthy individuals. Little is known regarding its time course, and whether these differences extend to individuals with non-cardiovascular (CV) illnesses. This study examined the presence, severity, and time course of psychological distress in men and women with CAD and those of similarly aged individuals suffering from non-CV conditions.

METHODS

1229 individuals (61% men; mean_age = 60.4 ± 7.0 years) with stable CAD or non-CV illnesses reported on social support, hostility, stress, anxiety and depression at baseline as well as 4.8 ± 0.8 years later. Analyses involved mixed (Sex*CAD status*Time) repeated measures analyses (controlling for relevant covariates), as well as Chi-square and McNemar analyses.

RESULTS

Women with CAD reported more symptoms of depression compared to other participants at both evaluations (p's < 0.01), and reported more symptoms of anxiety and stress compared to others at T1 (p's < 0.05). At T2, perceived stress remained significantly greater among women with CAD compared to men (p's < 0.01), though differences in anxiety were no longer significant. Men reported more hostility than women (p = 0.001). CAD women fell within the clinical range for depression (p < 0.001), anxiety (p = 0.001), and stress (p = 0.030) more frequently compared to others at T1, and for depression (p = 0.009) and stress (p = 0.002) at T2.

CONCLUSIONS

The evolution of patient distress differed as a function of the measure examined, their sex, and/or CV status. While psychological distress was prevalent among these patients with diverse health conditions, women with CAD were particularly and chronically vulnerable.

Chronic stress exposure in men and women, and implications for the course of fatigue after percutaneous coronary intervention; the THORESCI study

BACKGROUND

Fatigue is a prevalent symptom in patients with coronary heart disease (CHD). Individual differences in chronic stress may affect the experience and persistence of fatigue, and this may vary between the sexes. Therefore, we studied the effect of chronic stress on the course of fatigue over a 2-year period after percutaneous coronary intervention (PCI), and examined the moderating effects of sex.

METHODS

1682 patients (78% men, age = 67.1 ± 10.6) were recruited and filled out multiple self-report questionnaires at baseline, one, 12, and 24 months post-PCI, including questions on demographics, fatigue (HCS). Multiple chronic stressors were assessed at baseline: work stress (ERI16), marital stress (MMQ-6), early life events (Life Events Questionnaire) and social stress. Latent class factor analysis (LatentGOLD) was used to construct a comprehensive chronic stress index. Linear mixed modeling examined the predictive quality of predictors and covariates.

RESULTS

Fatigue was found to substantially decrease over the first month post-PCI, then stabilized at a moderate level. Chronic stress impacted both the level and course of fatigue by increasing its level and delaying recovery. Overall and across time, women reported more fatigue than men. The level and course effects of chronic stress and sex were independent of demographic, health behavioral, and medical covariates.

CONCLUSIONS

Individual differences in chronic stress impact both the level and course of fatigue post-PCI, with women being affected most. Future research could further explain the mechanisms underlying the observed relationships. Developing and testing interventions focusing on exercise and stress-reduction could be used to alleviate fatigue.

Mind-Body Connection: Cardiovascular Sequelae of Psychiatric Illness

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Mental health disorders are associated with the onset and progression of cardiac disease. The adverse sequelae of this association include worsened quality of life, adverse cardiovascular outcomes, and heightened mortality. The increased prevalence of CVD is partly explained by increased rates of traditional cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking, but mental illness is an independent risk factor for CVD and mortality. Given the association between mental health disorders and poor cardiovascular health, it is vital to have an early and accurate identification and treatment of these disorders. Our review article shares the current literature on the adverse cardiovascular events associated with psychiatric disorders. We present a review on depression, anxiety, bipolar disorder, schizophrenia, type A and D personality disorders, obsessive-compulsive disorder, and stress.

Harnessing Life's Slings and Arrows: The Science and Opportunities for Mindfulness Meditation During a Global Pandemic and Beyond

ABSTRACT

We are at a difficult time in history with societal increases in stress, loneliness, and psychopathology, along with high rates of obesity, sedentary lifestyles, and chronic pain. Mindfulness interventions offer promise to address these societal issues. However, in order to make best use of the opportunities revealed by our current challenges, we must: (1) tackle these issues head-on with inclusive, innovative, and creative experimental designs and interventions, and (2) collectively adhere to rigorous, high quality methods so as to provide an evidence-based integration of mindfulness interventions into mainstream medicine and public health.We find there are several areas for which important advances are happening, including sampling socially diverse populations, examining mechanisms of action, pain management, and health behaviors. Furthermore, rigorous methods, including measurement, causal inference from control groups, delivery and scalability of mindfulness interventions, and effect modifiers to determine who mindfulness programs work best for are also gaining traction. This special issue on Mindfulness: Biobehavioral Mechanisms and Health Outcomes attends to many of these issues, several of which are highlighted in this editorial perspective.

Occupational Health and Safety, Organisational Commitment, and Turnover Intention in the Spanish IT Consultancy Sector

Background: The purpose of this study is to analyse the impact that occupational health and safety policies have on employees’ work and organisational commitment and, in turn, on their intention to leave the company. Methods: For this study, we designed a questionnaire with a five-level Likert scale and distributed it among professionals from different companies in the IT consultancy sector in Spain. The data collected from 458 completed questionnaires were analysed using the partial least squares structural equation modelling (PLS-SEM) technique using the SmartPLS software. Results: From the analysis of the data, it was concluded that there is indeed a positive relationship between occupational health and safety policies and employees’ work and organisational commitment, as well as a negative relationship between these policies and the intention to leave the company. Similarly, there is a negative relationship between employees’ work and organisational commitment and their turnover intention. Conclusions: Although, due to the activity of professionals in the sector, occupational health and safety has not been an area of priority, it was concluded from this study that an improvement in these areas would have a beneficial effect on the commitment of workers to the company, thus helping to reduce the high levels of turnover in the sector. Future lines of research, as well as their practical application and the limitations of the study, are indicated at the end of the paper.

Associations of Job Strain, Stressful Life Events, and Social Strain With Coronary Heart Disease in the Women's Health Initiative Observational Study

Background

The association between psychosocial stress and coronary heart disease (CHD) may be stronger in women than men and may differ across types of stressors. In this study, we assessed associations of psychosocial stressors, including job strain, stressful life events, and social strain with the incidence of CHD in women.

Methods and Results

We used longitudinal data from 80 825 WHI‐OS (Women's Health Initiative Observational Study) participants with a mean age of 63.4 years (7.3 years) at baseline. Job strain was assessed through linkage of Standard Occupational Classification codes to the Occupational Information Network. Stressful life events and social strain were assessed via validated self‐reported questionnaires. Cox proportional hazard models were used to evaluate associations of each stressor with CHD separately and jointly. A total of 3841 (4.8%) women developed CHD during an average of 14.7 years of follow‐up. After adjustment for age, other stressors, job tenure, and socioeconomic factors, high stressful life events score was associated with a 12% increased CHD risk, and high social strain was associated with a 9% increased CHD risk. Job strain was not independently associated with CHD risk, but we observed a statistically significant interaction between job strain and social strain (P=0.04), such that among women with high social strain, passive job strain was associated with a 21% increased CHD risk.

Conclusions

High stressful life events and social strain were each associated with higher CHD risk. Job strain and social strain work synergistically to increase CHD risk.

The role of cardiac rehabilitation in vocational reintegration Belgian working group of cardiovascular prevention and rehabilitation position paper

Cardiovascular disease is one of the main causes of morbidity and sick leave in Belgium, imposing a great socio-economic burden on the contemporary healthcare system and society. Cardiac rehabilitation is an evidence-based treatment strategy that not only improves the cardiac patients' health state but also holds promise so as to facilitate vocational reintegration in the society. This position paper was developed and endorsed by the Belgian Working Group of Cardiovascular Prevention and Rehabilitation. It provides an overview of the currently available Belgian data with regard to the role of cardiac rehabilitation in return to work after an initial cardiac event. It identifies the relevant barriers and facilitators of vocational integration of cardiac patients and summarises the contemporary Belgian legal and medical framework in this regard. Cardiac rehabilitation remains a primordial component of the post-acute event management of the cardiac patient, facilitating vocational reintegrating and thereby decreasing the pressure on social security. Despite the availability of a relevant legislative framework, there is a need for well-defined algorithms to assess readiness for return to work that can be used in daily clinical practice.

Short-TErm Psychotherapy IN Acute Myocardial Infarction (STEP-IN-AMI) Trial: Final Results

PURPOSE

The purpose of this research was to assess whether short-term psychotherapy enhances long-term clinical outcomes in patients with a recent acute myocardial infarction (AMI).

METHODS

Patients ≤70 years old were randomized within 1 week of their AMI to short-term ontopsychological psychotherapy plus routine medical therapy vs routine medical therapy only. The primary composite outcome was defined as the combined incidence of new cardiovascular events (re-infarction, death, stroke, revascularization, life-threatening ventricular arrhythmias, and the recurrence of clinically significant angina) and clinically significant new comorbidities. Secondary outcome measures were: rates for individual components of the primary composite outcome; the rate of re-hospitalization for cardiovascular problems; and New York Heart Association functional class.

RESULTS

Ninety-four patients were analyzed, translating into 425 patient-years. The 2 treatment groups were similar across baseline characteristics. At 5-year follow-up, psychotherapy patients had a lower incidence of primary outcome, relative to controls (77/223 vs 98/202 patient-years, respectively; P = .035; absolute risk reduction = 19%, number needed to treat = 8); this benefit was attributable to the lower incidence of new comorbidities and clinically significant angina in the psychotherapy group. Gains in the primary outcome, relative to controls, among psychotherapy patients occurred in the first year and subsequently remained stable over the following 4 years.

CONCLUSIONS

Adding short-term ontopsychological psychotherapy to routine secondary prevention of myocardial infarction improves clinical outcomes overall up to 5 years post AMI. Studying time trends may aid in better targeting of psychological interventions during follow-up. Larger studies remain necessary to confirm these results.

TRIAL REGISTRATION

www.ClinicalTrial.gov NCT00769366.

Psychosocial Risk Factors and Ischemic Heart Disease: A New Perspective

BACKGROUND

Cardiovascular disease is the most common cause of morbidity and mortality worldwide, with ischemic heart disease (IHD) accounting for roughly 50% of these events in industrialized nations. In recent years, the relative importance of IHD in less industrialized countries is also rising at an alarming and steadily-increasing rate.

OBJECTIVES

Many experimental, observational and epidemiological studies have demonstrated the importance of psychosocial risk factors in the development and clinical manifestations of IHD. They act both indirectly, associated with an unhealthy lifestyle; and directly, through the activation of inflammatory cascades and the sympathetic nervous system. They also cluster with biological risk factors to increase the incidence and clinical manifestations of IHD. From these assumptions, there emerges the potential that an integrated approach that incorporates psychological therapy in various forms might reduce IHD patients' symptoms and maladaptive behaviors, and thereby enhance their prognosis.

METHODS

To date, three psychotherapeutic approaches have been utilized within cardiac psychology practice: (1) cognitive-behavioral psychotherapy; (2) psychodynamic psychotherapy; and (3) ontopsychological psychotherapy. The current article briefly describes these three approaches and how their use might enhance the care of IHD patients.

RESULTS

A range of psychological characteristics influence the development, course and management of cardiac patients' IHD. Among others, these include patients' emotions, attitudes, behaviors, relationships, and stressors. State-of- the-art literature suggests that psychological interventions should be considered in much the same way as medical interventions, in terms of their relevance to both patient management and outcomes.

CONCLUSION

For this reason, it is essential that professional psychological and psychotherapeutic support be rendered available to cardiology patients, as a means to enhance both the effectiveness and efficiency of care.

Gender differences in psychosocial outcomes of psychotherapy trial in patients with depression and coronary artery disease

INTRODUCTION

The biological and psychosocial risk profile differs between women and men with coronary artery disease (CAD). Depressive symptoms and Vital Exhaustion (VE) predict an unfavourable course of CAD. The secondary analysis of the SPIRR-CAD trial offered the possibility to examine gender as exposure variable of the clinical and psychological situation at baseline and in a variety of psychosocial measures as outcomes.

METHODS

In this trial, 450 men (78.9%) and 120 women (21.1%) with CAD (age ≤ 75 y), with mild to moderate depression (scoring ≥8 on the HADS), were randomized to usual care with or without a stepwise psychotherapy intervention. Beside clinical measures exhaustion and other indicators of depressive symptoms were collected at baseline and 18-month follow up.

RESULTS

Men had more signs and symptoms of heart disease at baseline, whereas women had higher psychosocial burden (e.g. negative affect). Women were more likely to live alone, had lower educational levels and employment rates and higher levels of depression and exhaustion. The psychotherapy intervention differed as a function of gender: In women, VE decreased from 29.4 ± 8.1 to 22.1 ± 11.7 in the intervention group (IG) and from 29.2 ± 8.2 to 25.1 ± 11.3 in the control group (CG). In men VE decreased from 23.3 + -10.8 to 21.2 ± 9.7 in the IG and from 23.6 ± 10.7 to 19.3 ± 11.3 in the CG (time x intervention x gender; F = 4.97; p = .026).

DISCUSSION

Women had a higher psychosocial burden than men. VE compared to other rating instruments of depressive symptoms suggested a stronger response to the intervention in women. VE may help to understand gender differences in psychotherapeutic treatment studies of CAD.

ISRCTN

76240576; clinicaltrials.gov.

Psychosocial Workplace Factors and Healthcare Utilization: A Study of Two Employers

Background: While a large literature links psychosocial workplace factors with health and health behaviors, there is very little work connecting psychosocial workplace factors to healthcare utilization.

Methods: Survey data were collected from two different employers using computer-assisted telephone interviewing as a part of the Work-Family Health Network (2008-2013): one in the information technology (IT) service industry and one that is responsible for a network of long-term care (LTC) facilities. Participants were surveyed four times at six month intervals. Responses in each wave were used to predict utilization in the following wave. Four utilization measures were outcomes: having at least one emergency room (ER)/Urgent care, having at least one other healthcare visit, number of ER/urgent care visits, and number of other healthcare visits. Population-averaged models using all four waves controlled for health and other factors associated with utilization.

Results: Having above median job demands was positively related to the odds of at least one healthcare visit, odds ratio [OR] 1.37 (P<.01), and the number of healthcare visits, incidence rate ratio (IRR) 1.36 (P<.05), in the LTC sample. Work-to-family conflict was positively associated with the odds of at least one ER/urgent care visit in the LTC sample, OR 1.15 (P<.05), at least one healthcare visit in the IT sample, OR 1.35 (P<.01), and with more visits in the IT sample, IRR 1.35 (P<.01). Greater schedule control was associated with reductions in the number of ER/urgent care visits, IRR 0.71 (P<.05), in the IT sample.

Conclusion: Controlling for other factors, some psychosocial workplace factors were associated with future healthcare utilization. Additional research is needed.

Associations between Job Strain and Arterial Stiffness: A Large Survey among Enterprise Employees from Thailand

As an intermediate endpoint to cardiovascular disease, arterial stiffness has received much attention recently. So far, the research on work stress and arterial stiffness is still sparse and inconsistent, and no investigations on work stress and cardiovascular health among the Thai working population have been reported. Therefore, we conducted an epidemiological study among 2141 Thai enterprise employees (858 men and 1283 women) who were free from any diagnosed cardiovascular disease. Work stress was measured using Karasek’s Job Demand–Control model for job strain (a combination of high demand and low control). Arterial stiffness was evaluated by a non-invasive approach using pulse-wave analysis based on a finger photoplethysmogram. Multivariable linear regression was applied to examine associations between job strain and arterial stiffness. In men, job strain was significantly associated with arterial stiffness (β  =  0.078, 95% confidence interval  =  0.026 to 0.130), after accounting for sociodemographic, behavioral, dietary and biomedical factors. However, the association in women was not significant. As the first study in Thailand on work stress and cardiovascular risk, we found that job strain might be an important risk factor for cardiovascular disease among Thai working men. Further studies with longitudinal design are warranted.

The predictive value of positive affect and Type D personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease

BACKGROUND

Patients with non-obstructive coronary artery disease (NOCAD) continue to experience disabling symptoms. Positive affect (PA) has shown a cardioprotective potential. Type D personality has previously been shown to have a deleterious effect on adverse outcomes in diverse cardiac populations. Little is known about the predictive value of PA and Type D personality for long-term outcomes in NOCAD patients. The aim was to investigate the effect of PA and Type D personality on clinical outcomes.

METHODS

547 patients (mean age 61 years±9, 48% male) who underwent a coronary angiography or CT-scan between January 2009 and February 2013 answered questionnaires concerning PA (GMS) and Type D personality (DS14). Cox proportional hazards analyses were performed.

RESULTS

When analyzed dichotomously, PA was a significant predictor of need for repeat cardiac testing (HR=0.64, 95% CI: 0.41-0.99), but not emergency department (ED) admissions (HR=0.83, 95% CI: 0.52-1.32) after adjustment for age, sex, education, diagnosis by group, BMI and hypertension. Analyzed continuously, the predictive value of PA was non-significant for both repeat testing (HR=0.85, 95% CI: 0.69-1.06) and ED admissions (HR=0.98, 95% CI: 0.77-1.23). Type D personality, both continuously and dichotomously, was not significantly associated with the outcomes. Findings were also examined for men and women separately.

CONCLUSION

Although Type D personality was not predictive of adverse events in this sample, PA is an interesting and important variable to take into account in NOCAD patients. Research on psychosocial factors in NOCAD patients should consider the importance of choices of endpoint, given the heterogeneity of NOCAD patients.

Sex Differences in Clinical Characteristics, Psychosocial Factors, and Outcomes Among Patients With Stable Coronary Heart Disease: Insights from the STABILITY (Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy) Trial

Background

Greater understanding of differences between men and women with coronary heart disease is needed.

Methods and Results

In this post hoc analysis of the STABILITY (Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy) trial, we described psychosocial factors, treatments, and outcomes of men versus women with stable coronary heart disease and explored the association of sex with psychosocial characteristics and cardiovascular risk. Cox proportional hazards models were used to assess the relationship between sex and outcomes. Interactions among sex, psychosocial factors, and the composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke were tested. Of 15 828 patients, 2967 (19%) were women. Among women, 21.2% felt often or always stressed at home (versus 9.8% of men), and 19.2% felt often or always sad or depressed (versus 10.1% of men; all P<0.0001). The median duration of follow‐up was 3.7 years (25th–75th percentiles: 3.5–3.8 years). Use of evidence‐based medications for coronary heart disease at baseline and 24 months was similar between sexes, as were event rates for all outcomes analyzed. In the multivariable model including psychosocial measures, female sex was associated with lower cardiovascular risk. There was a statistically significant interaction (P=0.03) such that the lower risk in women varied by depressive symptom frequency, whereby women who were more depressed had a risk similar to men.

Conclusions

Female sex was independently associated with better long‐term clinical outcomes, although this was modified by frequency of depressive symptoms. This suggests that emotional state may be an important target for improving outcomes in patients with coronary heart disease, specifically in women.

Clinical Trial Registration

STABILITY ClinicalTrials.gov number (NCT00799903).

Work-related psychosocial stress and the risk of type 2 diabetes in later life

OBJECTIVES

Although work-related psychosocial stress and type 2 diabetes mellitus (T2DM) have been investigated, the association between lifelong work stress and T2DM in later life remains unclear. This study examined whether high work stress increased the risk of T2DM risk in later life, accounting also for other sources of stress outside work, such as burden from household chores.

METHODS

From the population-based prospective study SNAC-K, 2719 diabetes-free participants aged ≥60 years were identified and followed up for 6 years. T2DM was ascertained by glycated haemoglobin level, self-report, hypoglycaemic medication use and clinical records. Levels of job control and demands over the whole working life were assessed by a validated matrix. Household chores load was assessed by hours spent on such chores. Multivariate logistic regression models were used to estimate the association between job strain and T2DM.

RESULTS

During the 6-year follow-up, 154 incident cases of T2DM were identified. High job strain was associated with T2DM occurrence amongst the 60-year-old cohort (OR = 3.14, 95% CI: 1.27-7.77), and only amongst women (OR = 6.18, 95% CI: 1.22-31.26), but not in men. When taking into account household chores load, a more pronounced risk of T2DM was associated with high job strain in combination with heavy household chores load in women aged 60 years at baseline (OR = 9.45, 95% CI: 1.17-76.53).

CONCLUSION

Work-related psychosocial stress may increase the risk of T2DM only amongst women in their early 60s. The risk can be amplified by high household chores load.

Gender differences in the relationships between psychosocial factors and hypertension

Gender differences in the epidemiology, pathophysiology, clinical manifestations and outcomes of cardiovascular disease are well established but there is still a lack of awareness of this both in the general population and among healthcare providers. In addition to the traditionally recognized cardiovascular risk factors, more recently psychosocial risk factors such as stress, mood disorders, low socioeconomic status and sleep disorders have been linked to cardiovascular diseases and hypertension. Psychosocial factors may have different cardiovascular consequences in men and women; thus further efforts are required to explore pathophysiological mechanisms, to obtain gender-specific data from clinical trials and to translate this knowledge into everyday clinical practice.

Nontraditional Cardiac Rehabilitation in Korean Patients with Coronary Artery Disease

PURPOSE

This pilot investigation sought to compare outcomes including depression, anxiety, stress, mindful awareness, and exercise capacity between exercise-focused cardiac rehabilitation (ECR) and meditation-focused cardiac rehabilitation (MCR) programs for patients with coronary artery disease (CAD) who had percutaneous coronary intervention (PCI).

DESIGN

A nonrandomized pretest-posttest design was employed.

METHODS

Two different interventions (ECR vs. MCR) were implemented with participants of each group for 12 weeks. Questionnaires assessing depression, anxiety, stress, and mindful awareness and measures of peak VO2 were completed before and after the 12-week interventions.

FINDINGS

Thirteen patients completed the cardiac rehabilitation (CR) programs. Meditation-focused cardiac rehabilitation was associated with significantly greater reductions in depression as compared to ECR; there were no significant differences between the two groups on other outcomes.

CONCLUSIONS

The MCR program has similar effects to improve the physical and psychological outcomes, compared with the ECR program.

CLINICAL RELEVANCE

There is potential for patients with CAD to participate in and benefit from nontraditional CR programs, and such CR could play a role in secondary prevention of CAD.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Single nucleotide polymorphism rs3774261 in the AdipoQ gene is associated with the risk of coronary heart disease (CHD) in Northeast Han Chinese population: a case-control study

Background

Coronary Heart Disease (CHD) is one of the leading causes of death in the world with a projected global 82 million DALYs by 2020. Genetic and environmental factors contribute to CHD development. Here, the authors investigate the association between CHD risk and three Single Nucleotide Polymorphisms (SNPs) in the AdipoQ gene (rs3774261, rs1063537 and rs2082940); and the interaction of this association with environmental factors, in Northeast Han Chinese population.

Methods

Using a case–control study design, 1514 participants (754 cases and 760 controls) were investigated. Three variants in the AdipoQ gene (rs3774261, rs1063537 and rs2082940) were selected and genotyped. The online SNPstats program and SPSS 21.0 software were used for data analyses.

Results

The authors found that the rs3774261G allele is associated with the risk of CHD but that the rs2082940T allele protects against CHD. No significant association was found between rs1063537 and CHD risk. The study also found significant interactions between triglyceride levels and the SNPs studied (P < 0.0001 for rs3774261, P = 0.014 for rs1063537, and P = 0.031 for rs2082940).

Conclusions

Variations in AdipoQ gene can protect against CHD (as with rs2082940T) or associated with CHD risk (as with rs3774261G) in Northeast Han Chinese – findings that will help shed light on the reported conflicting roles of AdipoQ in cardiovascular diseases. Serum triglycerides levels also interact in the AdipoQ – CHD association, thus further highlighting the roles environmental factors play in the genetic aspect of diseases.

Perceived stress status and sympathetic nervous system activation in young male patients with coronary artery disease in China

BACKGROUND AND PURPOSE

Young Chinese male adults have faced increasing psychological stress. Whether this is associated with the increased risk of coronary artery disease (CAD) in young Chinese males remains unclear. This study aimed to evaluate the correlation and underlying mechanisms of perceived stress and CAD in young male patients.

METHODS

A total of 178 male patients diagnosed as young CAD (aged ≤ 55 years) by coronary angiography (CAG) were enrolled, and 181 age-matched non-CAD individuals were set as control group. Traditional cardiovascular risk factors and levels of epinephrine and norepinephrine were measured, and perceived stress status was accessed by Perceived Stress Scale (PSS).

RESULTS

The PSS score was correlated with levels of epinephrine (r=0.45), norepinephrine (r=0.41), high-sensitivity C-reactive protein (hs-CRP) (r=0.38, p<0.01), and current smoking (r=0.32) (all p<0.05). Multivariate logistic regression analysis showed that smoking (OR, 3.12; 95%CI, 1.23-7.91), triglycerides (OR, 1.42; 95%CI, 1.04-1.94), hs-CRP (OR, 3.57; 95%CI, 1.65-7.72), and PSS score (OR, 1.81; 95%CI, 1.23-2.66) were independently correlated with CAD in young patients. The association between PSS score and risk of CAD become insignificant (OR, 1.43; 95%CI, 0.96-2.13) when further adjusted for the levels of epinephrine and norepinephrine.

CONCLUSIONS

After adjustment for multiple cardiovascular risk factors, high perceived stress was an independent risk factor for CAD in young Chinese male patients. Abnormal activation of the sympathetic nervous system may play an important role linking perceived stress with the risk of CAD.

TLR4/NF-κB signaling contributes to chronic unpredictable mild stress-induced atherosclerosis in ApoE-/- mice

Objective

Chronic stress is an important risk factor for atherosclerotic diseases. Our previous studies have shown that chronic unpredictable mild stress (CUMS) accelerates atherosclerosis and up-regulates TLR4/NF-κB expression in apoE^-/- mice. However, TLR4/NF-κB signaling whether directly contributes to the development of atherosclerosis in CUMS mice is unclear. We hypothesized that the interference of TLR4/NF-κB can ameliorate CUMS-induced inflammation and atherosclerosis in apoE^-/- mice.

Methods

ApoE^-/- mice were exposed to 12 weeks CUMS. Ad-siRNA TLR4 was given by tail vein injection (10 μl/mouse, every 5 days), and PDTC (an inhibitor of NF-κB) was given by intraperitoneal injection (60 mg/kg, once a day). Plasma corticosterone concentrations were determined by solid-phase ¹²⁵I radioimmunoassay. Atherosclerosis lesions in aortic sinuses were evaluated and quantified by IMAGEPRO PLUS. Western blotting was used to detect the expression of TLR4, NF-κB, and IL-1β in aortas of the mice. Plasma lipid profiles, IL-1β, TNF-α, and MCP-1 were measured by ELISA.

Results

Our results indicated that CUMS apoE^-/- mice treatment with siRNA TLR4 significantly decreased atherosclerosis and down-regulated TLR4, NF-κB, and inflammatory cytokines. PDTC also remarkably reduced atherosclerosis and the levels of IL-1β, TNF-α and MCP-1 in plasma. However, Treatment with siRNA TLR4 or PDTC had no effect on plasma corticosterone levels, and lipid profiles.

Conclusions

TLR4/NF-κB pathway may participate in CUMS-induced atherosclerosis through activation of proinflammatory cytokines in apoE^-/- mice. Our data may provide a new potential therapeutic target for prevention of CUMS -induced atherosclerosis.

Global Coronary Artery Plaque Area is Associated with Myocardial Hypoperfusion in Women with Non-ST Elevation Myocardial Infarction

BACKGROUND

Women with non-ST elevation myocardial infarction (NSTEMI) have similar extent of myocardial ischemia but less obstructive coronary artery disease (CAD) than their male counterparts. We tested the impact of global coronary artery plaque area and artery tortuosity on myocardial perfusion in NSTEMI patients.

METHODS

Coronary artery plaque area was determined by quantitative angiography in 108 patients (32% women) with NSTEMI. Myocardial perfusion was assessed by contrast echocardiography in the 17 individual left ventricular segments. Artery tortuosity was defined as ≥3 curves >45° in a main coronary artery.

RESULTS

Age, prevalence of hypertension, and diabetes did not differ between sexes (all nonsignificant). Women had lower prevalence of ≥50% coronary artery stenosis (74% vs. 91%, p<0.05), while global coronary plaque area (35±22 vs. 43±21mm(2)) and the number of segments with hypoperfusion (6.9±3.7 vs. 7.2±3.4) did not differ between sexes (both p>0.07). In multivariate analysis, larger coronary artery plaque area was associated with a 35% higher risk for having severe myocardial hypoperfusion (odds ratio 1.35 [95% confidence interval 1.01-1.80], p<0.05) in the total study population, while no association between artery tortuosity and myocardial ischemia was found. Similar results were obtained in separate analysis among women and men.

CONCLUSION

In women and men with NSTEMI, the global coronary artery plaque area was an important determinant of the severity of myocardial hypoperfusion at rest independent of presence of significant coronary stenoses. These findings may expand current understanding of NSTEMI in patients with nonobstructive CAD.

The Effect of Exercise and Distraction on Blood Pressure Recovery Following an Anger-Provoking Stressor in Normotensive Young Adults

Ruminating about a prior anger provoking event is found to elevate blood pressure (BP) and delay BP recovery. Delayed BP recovery may be associated with increased risk of hypertension. Interventions that improve BP recovery may be beneficial for cardiovascular health. The purposes of this study were to evaluate the influence of rumination and anger on BP reactivity and recovery, to compare the effect of an exercise intervention or distraction intervention on BP recovery and to explore if exercise improved BP recovery by distracting participants from stressor-related rumination and anger. Healthy, normotensive participants (n = 79, mean age 22.2 ± 4.0 years) underwent an anger-recall interview stressor task, 3 min of exercise (walking), distraction (reading) or no-intervention (quiet sitting) and a 15 min recovery period. State anger reactivity was associated with Δ diastolic (D) BP reactivity and approached significance with Δ systolic (S) BP reactivity. Trait rumination was associated with greater SBP during recovery. Δ SBP recovery did not differ between the exercise, distraction and no-intervention groups. Although there were no differences in Δ DBP recovery between the exercise and no-intervention groups, distraction improved Δ DBP recovery compared to the exercise intervention but not the no-intervention. The proportion of anger-related thoughts (state rumination) in the exercise group did not differ from the distraction or no-intervention groups. However, a smaller proportion of participants in the distraction intervention reported an anger-related thought during recovery compared to the no-intervention group with 76% of their thoughts relating to the provided distraction. Overall, post-stressor exercise was not found to improve BP recovery while reading was effective at distracting individuals from angry thoughts (state rumination) but had no effect on BP compared to no-intervention.

Epigenetics and social context: implications for disparity in cardiovascular disease

BACKGROUND

Although it is well established that African Americans (AA) experience greater social stressors than non-Hispanic Whites (NHW), the extent to which early life adversity and cumulative social stressors such as perceived discrimination, neighborhood violence, subjective social status, and socioeconomic status contribute to disparity in coronary heart disease (CHD) and stroke between AA and NHW are not well understood.

PURPOSE

The purpose of this paper is to propose a conceptual model based upon McEwen's Allostatic Load Model suggesting how the relationships among social context, early life adversity, psychological stress, inflammation, adaptation, and epigenetic signature may contribute to the development of CHD and ischemic stroke. We hypothesize that social context and prior life adversity are associated with genome-wide as well as gene-specific epigenetic modifications that confer a proinflammatory epigenetic signature that mediates an enhanced proinflammatory state. Exposure to early life adversity, coupled with an increased allostatic load places individuals at greater risk for inflammatory based diseases, such as CHD and ischemic stroke.

RESULTS

Based on a review of the literature, we propose a novel model in which social context and psychological stress, particularly during early life, engenders a proinflammatory epigenetic signature, which drives a heightened inflammatory state that increases risk for CHD and stroke. In the proposed model, a proinflammatory epigenetic signature and adaptation serve as mediator variables.

CONCLUSIONS

Understanding the extent to which epigenetic signature bridges the psycho-social environment with inflammation and risk for CHD may yield novel biomarkers that can be used to assess risk, development, and progression of CHD/stroke. Epigenetic biomarkers may be used to inform preventive and treatment strategies that can be targeted to those most vulnerable, or to those with early signs of CHD, such as endothelial dysfunction. Furthermore, epigenetic approaches, including lifestyle modification and stress reduction programs, such as mindfulness-based stress reduction, offer promise to reduce health inequity linked to social disadvantage, as emerging evidence demonstrates that adverse epigenetic marks can be reversed.

[Gender-specific aspects of coronary heart disease]

The total number of deaths from cardiovascular diseases (CVD) is greater for women than for men, although the mean age at manifestation of CVD is about 10 years older. However, the annual number of cases treated for CVD in acute hospital settings in men exceeds that of women by 50 %. Remarkable gender differences exist in terms of morphological and physiological conditions (e.g. mean coronary vessel diameter; ability to adapt to protective exercise-induced myocardial hypertrophy), as well as of the frequency and clinical significance of somatic risk factors (e.g. smoking). Female body weight increases after menopause and the body shape assumes a more android fat distribution. Women report higher levels of unspecific and affective symptoms. They suffer more from anxiety and depression than men; however, the secondary impact on CVD onset may be less pronounced. The post-acute CVD course is more complicated in women, mainly because they are older and suffer more from multi-morbidity. Whilst male CVD patients aim for a rapid recovery, physical fitness and an increased life expectancy, female patients seek relief from everyday challenges, the maintenance of their independence and emotional support.

Daily marital interaction quality and carotid artery intima-medial thickness in healthy middle-aged adults

OBJECTIVE

To examine the association between marital interaction quality during daily life and subclinical cardiovascular disease (CVD). Studies have shown that marital status and quality of marriage are associated with cardiovascular health. However, little is known about the role of marital interaction quality during daily life in contributing to these effects.

METHODS

The sample consisted of 281 healthy, employed middle-aged adults who were married or living with a partner in a marital-like relationship (mean age = 42.0 years, 88% white, 52% men). Marital interaction quality was assessed using hourly real-time ecological momentary assessments for 4 days, with participants rating their current or recent partner interactions on positive and negative characteristics (e.g., agreeableness and conflict). Carotid artery intima-medial thickness (IMT) was assessed using ultrasound imaging.

RESULTS

Adjusting for demographics, positive marital interaction was inversely associated with IMT (b = -0.02, F(1,275) = 9.18, p = .002), and negative marital interaction was positively associated with IMT (b = 0.02 F(1,275) = 10.29, p = .001). These associations were not accounted for by behavioral and biological CVD risk factors and were consistent across age, sex, race, and education. The associations were also independent of marital interaction frequency, nonmarital social interaction quality, and personality factors. Global reports of marital quality, in contrast, were not associated with IMT.

CONCLUSIONS

Marital quality as measured during real-time interactions between partners was associated with subclinical CVD in healthy middle-aged adults. This study supports the use of real-time social interaction assessment for characterizing links between social relationships and cardiovascular health.

Work stress is associated with diabetes and prediabetes: cross-sectional results from the MIPH Industrial Cohort Studies

BACKGROUND

Diabetes is rapidly rising globally, and the relation of psychosocial stress in workplace to diabetes and prediabetes is not well investigated.

PURPOSE

The aim of the study was to examine the association of work stress with diabetes and prediabetes in a sample of German industrial workers.

METHOD

In this cross-sectional survey of an occupational cohort (n = 2,674, 77 % male), work stress was measured by the Effort-Reward Imbalance (ERI) Questionnaire. Diabetic status, i.e., diabetes and prediabetes, were diagnosed by glycated hemoglobin A1c criterion or fasting plasma glucose criterion supplemented by self-reports.

RESULTS

The overall prevalence rates of diabetes and prediabetes were 3.5 and 42.2 %, respectively. Using ordinal logistic regression with adjustment for potential confounding factors, high ERI at work was associated with diabetes-related ordinal variable (odds ratio [OR], 1.27; 95 % confidence interval [95 % CI], 1.02-1.58) and prediabetes-related ordinal variable (OR, 1.26; 95 % CI, 1.01-1.58) in men, whereas the associations in women were somewhat less pronounced and did not reach statistical significance.

CONCLUSION

The findings indicate that work stress in terms of ERI is associated with diabetes and prediabetes in German industrial male workers. If supported by prospective evidence, results point to a new approach towards primary prevention of diabetes.

Elevated corticosterone in the dorsal hindbrain increases plasma norepinephrine and neuropeptide Y, and recruits a vasopressin response to stress

Repeated stress and chronically elevated glucocorticoids cause exaggerated cardiovascular responses to novel stress, elevations in baseline blood pressure, and increased risk for cardiovascular disease. We hypothesized that elevated corticosterone (Cort) within the dorsal hindbrain (DHB) would: 1) enhance arterial pressure and neuroendocrine responses to novel and repeated restraint stress, 2) increase c-Fos expression in regions of the brain involved in sympathetic stimulation during stress, and 3) recruit a vasopressin-mediated blood pressure response to acute stress. Small pellets made of 10% Cort were implanted on the surface of the DHB in male Sprague-Dawley rats. Blood pressure was measured by radiotelemetry. Cort concentration was increased in the DHB in Cort-treated compared with Sham-treated rats (60 ± 15 vs. 14 ± 2 ng Cort/g of tissue, P < 0.05). DHB Cort significantly increased the integrated arterial pressure response to 60 min of restraint stress on days 6, 13, and 14 following pellet implantation (e.g., 731 ± 170 vs. 1,204 ± 68 mmHg/60 min in Sham- vs. Cort-treated rats, day 6, P < 0.05). Cort also increased baseline blood pressure by day 15 (99 ± 2 vs. 108 ± 3 mmHg for Sham- vs. Cort-treated rats, P < 0.05) and elevated baseline plasma norepinephrine and neuropeptide Y concentrations. Cort significantly enhanced stress-induced c-Fos expression in vasopressin-expressing neurons in the paraventricular nucleus of the hypothalamus, and blockade of peripheral vasopressin V1 receptors attenuated the effect of DHB Cort to enhance the blood pressure response to restraint. These data indicate that glucocorticoids act within the DHB to produce some of the adverse cardiovascular consequences of chronic stress, in part, by a peripheral vasopressin-dependent mechanism.

Proficiency in positive vs. negative emotion identification and subjective well-being among long-term married elderly couples

Evidence is accruing that positive emotions play a crucial role in shaping a healthy interpersonal climate. Inspired by this research, the current investigation sought to shed light on the link between proficiency in identifying positive vs. negative emotions and a close partner's well-being. To this end, we conducted two studies with neurologically intact elderly married couples (Study 1) and an age-matched clinical sample, comprising married couples in which one spouse had been diagnosed with Parkinson's Disease (Study 2), which tends to hinder emotional expressivity. To assess proficiency in identifying emotions from whole body postures, we had participants in both studies complete a pointlight walker task, featuring four actors (two male, two female) expressing one positive (i.e., happiness) and three negative (i.e., sadness, anger, fear) basic emotions. Participants also filled out measures of subjective well-being. Among Study 1's neurologically intact spouses, greater expertise in identifying positive (but not negative) emotions was linked to greater partner life satisfaction (but not hedonic balance). Spouses of PD patients exhibited increased proficiency in identifying positive emotions relative to controls, possibly reflective of compensatory mechanisms. Complementarily, relative to controls, spouses of PD patients exhibited reduced proficiency in identifying negative emotions and a tendency to underestimate their intensity. Importantly, all of these effects attenuated with longer years from PD onset. Finally, there was evidence that it was increased partner expertise in identifying negative (rather than positive) emotional states that predicted greater life satisfaction levels among the PD patients and their spouses. Our results thus suggest that positive vs. negative emotions may play distinct roles in close relationship dynamics as a function of neurological status and disability trajectory.

Examining the effectiveness of psychological strategies on physiologic markers: evidence-based suggestions for holistic care of the athlete

CONTEXT

Current holistic rehabilitation blends both physical and psychological techniques. However, validation of the usefulness of psychological strategies is limited in the literature.

OBJECTIVE

To quantify the effects of psychological strategies on both physiologic (salivary cortisol) and subjective assessments of stress.

DESIGN

Randomized controlled clinical trial.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 97 college-aged students (age = 20.65 ± 4.38 years), most with little to no experience with psychological strategies.

INTERVENTION(S)

A 15-minute script via an iPod led the participant through visual imagery (cognitive relaxation) or deep breathing exercises (somatic relaxation) cues. The control group listened to 15 minutes of ambient nature sounds.

MAIN OUTCOME MEASURE(S)

Two samples (pretest, posttest) of salivary cortisol were analyzed using an enzyme immunoassay kit; the average was used for statistical analysis. Descriptive statistics and correlations were conducted to examine group differences in time of day, salivary cortisol, sex, Stress-O-Meter values, and Perceived Stress Scale scores.

RESULTS

Salivary cortisol levels were lower in the treatment group than the control group (F2,97 = 15.62, P < .001). Females had higher scores on both the pretest Stress-O-Meter (5.15 ± 1.796) and the Perceived Stress Scale (18.31 ± 5.833) than males (4.25 ± 1.741 and 15.272 ± 5.390, respectively).

CONCLUSIONS

Both cognitive and somatic relaxation strategies reduced cortisol levels. Participants who received verbal guidance achieved a larger cortisol reduction. However, the change in cortisol level was uncorrelated with the change in report of acute stress; females reported higher levels of stress. Clinical implications include attention to sex when assessing stress and providing coping skills during the rehabilitation process.

Marital quality and health: a meta-analytic review

This meta-analysis reviewed 126 published empirical articles over the past 50 years describing associations between marital relationship quality and physical health in more than 72,000 individuals. Health outcomes included clinical endpoints (objective assessments of function, disease severity, and mortality; subjective health assessments) and surrogate endpoints (biological markers that substitute for clinical endpoints, such as blood pressure). Biological mediators included cardiovascular reactivity and hypothalamic-pituitary-adrenal axis activity. Greater marital quality was related to better health, with mean effect sizes from r = .07 to .21, including lower risk of mortality (r = .11) and lower cardiovascular reactivity during marital conflict (r = -.13), but not daily cortisol slopes or cortisol reactivity during conflict. The small effect sizes were similar in magnitude to previously found associations between health behaviors (e.g., diet) and health outcomes. Effect sizes for a small subset of clinical outcomes were susceptible to publication bias. In some studies, effect sizes remained significant after accounting for confounds such as age and socioeconomic status. Studies with a higher proportion of women in the sample demonstrated larger effect sizes, but we found little evidence for gender differences in studies that explicitly tested gender moderation, with the exception of surrogate endpoint studies. Our conclusions are limited by small numbers of studies for specific health outcomes, unexplained heterogeneity, and designs that limit causal inferences. These findings highlight the need to explicitly test affective, health behavior, and biological mechanisms in future research, and focus on moderating factors that may alter the relationship between marital quality and health.

Psychological stress, vascular inflammation, and atherogenesis: potential roles of circulating cytokines

Cardiovascular disease is a major cause of morbidity and mortality worldwide. Epidemiological studies have clearly demonstrated that chronic psychosocial stress increases the risk of atherosclerotic cardiovascular disease and this may involve multiple mediators and regulating pathways, whereas the precise mechanisms underlying the effects of stress on development of atherosclerosis are not completely understood. In this mini review, we summarize current information from various animal studies suggesting that stress may promote atherogenesis by stimulating vascular inflammation via elevating the level of circulating proinflammatory cytokines (such as tumor necrosis factor α and interleukin 6). Although circulating cytokines can serve as reliable biomarkers of systemic inflammation, in light of the emerging evidence, we propose that these molecules may also have a causal role in mediating stress-triggered vascular inflammatory reaction and atherogenesis. Further studies are warranted to clarify whether targeting circulating cytokines may be an effective approach to reduce the detrimental effects of chronic stress.

Gender differences in the association between socioeconomic status and subclinical atherosclerosis

OBJECTIVES

This study explored the pattern of associations between socioeconomic status (SES) and atherosclerosis progression (as indicated by carotid intima media thickness, CIMT) across gender.

DESIGN

Cross-sectional analysis of a sample of 5474 older persons (mean age 73 years) recruited between 1999 and 2001 in the 3C study (France). We fitted linear regression models including neighborhood SES, individual SES and cardiovascular risk factors.

RESULTS

CIMT was on average 24 µm higher in men (95% CI: 17 to 31). Neighborhood SES was inversely associated with CIMT in women only (highest versus lowest tertiles: -12.2 µm, 95%CI -22 to -2.4). This association persisted when individual SES and risk factors were accounted for. High individual education was associated with lower CIMT in men (-21.4 µm 95%CI -37.5 to -5.3) whereas high professional status was linked to lower CIMT among women (-15.7 µm 95%CI: -29.2 to -2.2). Adjustment for cardiovascular risk factors resulted in a slightly more pronounced reduction of the individual SES-CIMT association observed in men than in women.

CONCLUSION

In this sample, neighborhood and individual SES displayed different patterns of associations with subclinical atherosclerosis across gender. This suggests that the causal pathways leading to SES variations in atherosclerosis may differ among men and women.

Lessons learned from a study of a complementary therapy for self-managing hypertension and stress in women

This report evaluates a Hawaiian-based, self-management intervention for reducing blood pressure (BP) and stress in women. It highlights lessons learned when using nonpharmacologic, complementary and alternative medicine (CAM) therapies. Specific participant characteristics and preferences should be considered for optimizing health outcomes in CAM research in nursing practice.

Effects of acute and chronic stress on the L-arginine nitric oxide pathway in black and white South Africans: the sympathetic activity and ambulatory blood pressure in Africans study

OBJECTIVE

This study investigated the impact of stress on effectors of the L-arginine/nitric oxide (NO) system including the endogenous inhibitor asymmetric dimethylarginine (ADMA).

METHODS

Black (n = 168) and white (n = 206) South African teachers were exposed to a mental and a physical stressor for 1 minute, respectively. Serum samples for determination of l-arginine, NO metabolites, ADMA, and symmetric dimethylarginine (SDMA) were obtained at rest and during stress exposure. Perception of task stressfulness was assessed on a 7-point Likert scale, and psychological distress was estimated by the General Health Questionnaire.

RESULTS

Black South Africans exhibited higher resting levels of NO metabolites (adjusted mean [standard error of the mean] = 11.3 [1.3] versus 3.9 [1.1] μmol/l, p < .001) but lower circulating ADMA (0.62 [0.02] versus 0.70 [0.02] μmol/l, p = .004) and SDMA (0.41 [0.01] versus 0.53 [0.01] μmol/l, p < .001) than did white South Africans. Ethnicity-by-psychological distress interaction was observed for resting levels of ADMA (p = .002), SDMA (p = .038), and L-arginine (p = .048). Ethnic differences in responses to experimental stress were evident for NO metabolites (blacks versus whites: 5.94 [1.55] versus -0.74 [1.25] μmol/l, p = .004) and SDMA (blacks versus whites: -0.02 [0.01] versus 0.02 [0.01] μmol/l, p = .004). Ethnicity-by-psychological distress interaction for stress responses was found for l-arginine/ADMA ratio (p = .027).

CONCLUSIONS

The l-arginine/NO system is affected by psychosocial distress with higher susceptibility in black South Africans. This interaction may contribute to the higher cardiovascular disease risk in black South Africans.

Perceived mental stress in women associated with psychosomatic symptoms, but not mortality: observations from the Population Study of Women in Gothenburg, Sweden

Purpose

To investigate possible association between mental stress and psychosomatic symptoms, socioeconomic status, lifestyle, as well as incident mortality in a middle-aged female population followed over 37 years.

Methods

A prospective observational study initiated in 1968–1969, including 1462 women aged 60, 54, 50, 46, and 38 years, with follow-ups in 1974–1975, 1980–1981, and 2000–2001, was performed. Measures included self-reported mental stress as well as psychosomatic symptoms and smoking, physical activity, total cholesterol, S-triglycerides, body mass index, waist–hip ratio, blood pressure, socioeconomic status and mortality.

Results

Smoking, not being single, and not working outside home were strongly associated with reported mental stress at baseline. Women who reported high mental stress in 1968–1969 were more likely to report presence of abdominal symptoms (odds ratio [OR] = 1.85, 95% confidence interval [CI]: 1.39–2.46), headache/migraine (OR = 2.04, 95% CI: 1.53–2.72), frequent infections (OR = 1.75, 95% CI: 1.14–2.70), and musculoskeletal symptoms (OR = 1.70, 95% CI: 1.30–2.23) than women who did not report mental stress. Women without these symptoms at baseline 1968–1969, but with perceived mental stress were more likely to subsequently report incident abdominal symptoms (OR = 2.15, 95% CI: 1.39–3.34), headache/migraine (OR = 2.27, 95% CI: 1.48–3.48) and frequent infections (OR = 2.21, 95% CI: 1.12–4.36) in 1974–1975 than women without mental stress in 1968–1969. There was no association between perceived mental stress at baseline and mortality over 37 years of follow-up.

Conclusion

Women reporting mental stress had a higher frequency of psychosomatic symptoms than women who did not report these symptoms. Not working outside home and smoking rather than low socioeconomic status per se was associated with higher stress levels. Perception of high mental stress was not associated with increased mortality.