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Stress-related disorders linked to higher CVD risk

Stephen Padilla
15 Apr 2019

A robust association exists between stress-related disorders and an increased subsequent risk of cardiovascular disease (CVD), particularly during the months after diagnosis of a stress-related disorder, according to a population-based, sibling-controlled study in Sweden.

“This association applies equally to men and women and is independent of familial factors, history of somatic or psychiatric diseases, and psychiatric comorbidities,” researchers said.

The respective crude incidence rate of any CVD during up to 27 years of follow-up was 10.5, 8.4 and 6.9 per 1,000 person-years among exposed patients, their unaffected full siblings and the matched unexposed individuals. [BMJ 2019;365:l1255]

Hazard ratio (HR) for any CVD in sibling-based comparisons was 1.64 (95 percent CI, 1.45–1.84), with heart failure showing the highest specific HR (6.95; 1.88–25.68), during the first year following diagnosis of any stress-related disorder. The HRs, however, dropped beyond 1 year (overall HR, 1.29; 1.24–1.34), ranging from 1.12 (1.04–1.21) for arrhythmia to 2.02 (1.45–2.82) for artery thrombosis/embolus.

Stress-related disorders had a stronger association with early onset CVDs (HR for attained age <50 years, 1.40; 1.32–1.49) than later onset ones (HR for attained age ≥50 years, 1.24; 1.18–1.30; pdifference=0.002). The presence of psychiatric comorbidity did not modify such associations, except for fatal CVDs.

Results were similar in analyses within the population-matched cohort (HR for any CVD during the first year of follow-up, 1.71; 1.59–1.83; HR for CVD beyond 1 year of follow-up, 1.36; 1.33–1.39).

“These findings call for enhanced clinical awareness and, if verified, monitoring or early intervention among patients with recently diagnosed stress-related disorders,” researchers said.

These results are consistent with those from previous prospective studies, which suggest a possible role of stress-related disorders in the pathogenesis of CVD. [J Am Heart Assoc 2013;2:e000431; J Am Coll Cardiol 2013;62:970-978; Prev Med 2011;53:370-376; Psychosom Med 2008;70:668-676; Arch Gen Psychiatry 2007;64:109-116; Health Psychol 2009;28:125-130; Circulation 2015;132:251-259]

Based on clinical observations, severe emotional or physical stress could trigger immediate cardiovascular consequences, such as heart attack and sudden cardiac arrest, even in apparently healthy people. [JAMA 2007;298:324-329; Heart 2004;90:e52]

“Our results consolidate these reported associations by showing that a clinically confirmed stress related disorder (requiring a preceding occurrence of a trauma or significant life stressor) is also associated with these acute cardiovascular events,” researchers said.

The present study included 136,637 patients in the Swedish National Patient Register with stress-related disorders, including post-traumatic stress disorder, acute stress reaction, adjustment disorder and other stress reactions, from 1987 to 2013; 171,314 unaffected full siblings of these patients; and 1,366,370 matched unexposed people from the general population.

Outcome measures were primary diagnosis of incident CVD—any or specific subtypes (ie, ischaemic heart disease, cerebrovascular disease, emboli/thrombosis, hypertensive disease, heart failure, arrhythmia/conduction disorder, and fatal CVD)—and 16 individual diagnoses of CVD. The investigators derived HRs for CVD from Cox models after controlling for confounders.

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