BMJ 2002;324:1247 ( 25 May )

Papers

Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men

John Macleod, clinical research fellow, ^a George Davey Smith, professor of clinical epidemiology, ^b Pauline Heslop, research assistant, ^b Chris Metcalfe, research assistant, ^b Douglas Carroll, professor of applied psychology, ^c Carole Hart, research fellow. ^d

^a Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT, ^b Department of Social Medicine, University of Bristol, Canynge Hall, Bristol BS8 2PR, ^c School of Sport and Exercise Science, University of Birmingham, Birmingham B15 2TT, ^d Department of Public Health, University of Glasgow, Glasgow G12 8RZ

Correspondence to: J Macleod j.a.macleod{at}bham.ac.uk

Objectives: To examine the association between self perceived psychological stress and cardiovascular disease in a population where stress was not associated with social disadvantage.
Design: Prospective observational study with follow up of 21 years and repeat screening of half the cohort 5 years from baseline. Measures included perceived psychological stress, coronary risk factors, self reported angina, and ischaemia detected by electrocardiography.
Setting: 27 workplaces in Scotland.
Participants: 5606 men (mean age 48 years) at first screening and 2623 men at second screening with complete data on all measures
Main outcome measures: Prevalence of angina and ischaemia at baseline, odds ratio for incident angina and ischaemia at second screening, rate ratios for cause specific hospital admission, and hazard ratios for cause specific mortality.
Results: Both prevalence and incidence of angina increased with increasing perceived stress (fully adjusted odds ratio for incident angina, high versus low stress 2.66, 95% confidence interval 1.61 to 4.41; P for trend <0.001). Prevalence and incidence of ischaemia showed weak trends in the opposite direction. High stress was associated with a higher rate of admissions to hospital generally and for admissions related to cardiovascular disease and psychiatric disorders (fully adjusted rate ratios for any general hospital admission 1.13, 1.01 to 1.27, cardiovascular disease 1.20, 1.00 to 1.45, and psychiatric disorders 2.34, 1.41 to 3.91). High stress was not associated with increased admission for coronary heart disease (1.00, 0.76-1.32) and showed an inverse relation with all cause mortality, mortality from cardiovascular disease, and mortality from coronary heart disease, that was attenuated by adjustment for occupational class (fully adjusted hazard ratio for all cause mortality 0.94, 0.81 to 1.11, cardiovascular mortality 0.91, 0.78 to 1.06, and mortality from coronary heart disease 0.98, 0.75 to 1.27).
Conclusions: The relation between higher stress, angina, and some categories of hospital admissions probably resulted from the tendency of participants reporting higher stress to also report more symptoms. The lack of a corresponding relation with objective indices of heart disease suggests that these symptoms did not reflect physical disease. The data suggest that associations between psychosocial measures and disease outcomes reported from some other studies may be spurious.

What is already known on this topic Higher psychological stress has predicted coronary heart disease in several observational studies Exposure to stress and heart disease outcomes were often based on self report so that a general tendency to negative perceptions may have generated a spurious association between higher perceived stress and heart disease symptoms What this study adds Perceived stress was strongly related to subjective symptoms of heart disease, including those leading to hospital admission However, stress showed a weakly inverse relation to all objective indices of heart disease: socially advantaged men perceived themselves to be most stressed, and the "protective" effect of stress was probably attributable to residual confounding Suggestions that psychological stress is an important determinant of heart disease may be premature

---

© BMJ 2002
CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Personality, lifestyle, and risk of cardiovascular disease and cancer: follow-up of population based cohort

Til Stürmer, Petra Hasselbach, and Manfred Amelang
BMJ 2006 332: 1359. [Abstract] [Full Text] [PDF]

Psychological stress and cardiovascular disease

Matthew Hotopf, Paul J Rosch, and Carole Hart
BMJ 2002 325: 337. [Extract] [Full Text]

Link of stress to heart disease is artefactual
BMJ 2002 324: 0. [Full Text]

On things not being what they seem
BMJ 2002 324: 0. [Full Text] [PDF]

This article has been cited by other articles:

• Kristensen, P, Nordhagen, R, Wergeland, E, Bjerkedal, T (2008). Job adjustment and absence from work in mid-pregnancy in the Norwegian Mother and Child Cohort Study (MoBa). Occup. Environ. Med. 65: 560-566 [Abstract] [Full text]  
• Burazeri, G, Goda, A, Sulo, G, Stefa, J, Kark, J D (2008). Financial loss in pyramid savings schemes, downward social mobility and acute coronary syndrome in transitional Albania. J. Epidemiol. Community Health 62: 620-626 [Abstract] [Full text]  
• Netterstrom, B., Conrad, N., Bech, P., Fink, P., Olsen, O., Rugulies, R., Stansfeld, S. (2008). The Relation between Work-related Psychosocial Factors and the Development of Depression. Epidemiol Rev 0: mxn004v1-mxn004 [Abstract] [Full text]  
• Groffen, D. A. I., Bosma, H., van den Akker, M., Kempen, G. I. J. M., van Eijk, J. Th. M. (2008). Material deprivation and health-related dysfunction in older Dutch people: findings from the SMILE study. Eur J Public Health 18: 258-263 [Abstract] [Full text]  
• Gallacher, J. (2008). Commentary: Personality and health inequality: inconclusive evidence for an indirect hypothesis. Int J Epidemiol 37: 602-603 [Full text]  
• Smith, P M, Frank, J W, Mustard, C A, Bondy, S J (2008). Examining the relationships between job control and health status: a path analysis approach. J. Epidemiol. Community Health 62: 54-61 [Abstract] [Full text]  
• Smith, P., Frank, J., Bondy, S., Mustard, C. (2008). Do Changes in Job Control Predict Differences in Health Status? Results From a Longitudinal National Survey of Canadians. Psychosom. Med. 70: 85-91 [Abstract] [Full text]  
• Macleod, J. (2007). Cannabis use and psychosis: the origins and implications of an association. Adv. Psychiatr. Treat. 13: 400-411 [Abstract] [Full text]  
• Macleod, J., Metcalfe, C., Smith, G. D., Hart, C. (2007). Does consideration of either psychological or material disadvantage improve coronary risk prediction? Prospective observational study of Scottish men. J. Epidemiol. Community Health 61: 833-837 [Abstract] [Full text]  
• Thoresen, M. (2007). A Note on Correlated Errors in Exposure and Outcome in Logistic Regression. Am J Epidemiol 166: 465-471 [Abstract] [Full text]  
• Haheim, L. L., Tonstad, S., Hjermann, I., Leren, P., Holme, I. (2007). Predictiveness of body mass index for fatal coronary heart disease in men according to length of follow-up: A 21-year prospective cohort study. Scand J Public Health 35: 4-10 [Abstract]  
• Adamson, J. A, Ebrahim, S., Hunt, K. (2006). The psychosocial versus material hypothesis to explain observed inequality in disability among older adults: data from the West of Scotland Twenty-07 Study.. J. Epidemiol. Community Health 60: 974-980 [Abstract] [Full text]  
• Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and health. Int J Epidemiol 35: 888-901 [Abstract] [Full text]  
• Sturmer, T., Hasselbach, P., Amelang, M. (2006). Personality, lifestyle, and risk of cardiovascular disease and cancer: follow-up of population based cohort. BMJ 332: 1359- [Abstract] [Full text]  
• Rugulies, R., Bultmann, U., Aust, B., Burr, H. (2006). Psychosocial Work Environment and Incidence of Severe Depressive Symptoms: Prospective Findings from a 5-Year Follow-up of the Danish Work Environment Cohort Study. Am J Epidemiol 163: 877-887 [Abstract] [Full text]  
• Salamon, R, Verret, C, Jutand, M A, Begassat, M, Laoudj, F, Conso, F, Brochard, P (2006). Health consequences of the first Persian Gulf War on French troops. Int J Epidemiol 35: 479-487 [Abstract] [Full text]  
• Lallukka, T., Martikainen, P., Reunanen, A., Roos, E., Sarlio-Lahteenkorva, S., Lahelma, E. (2006). Associations between working conditions and angina pectoris symptoms among employed women.. Psychosom. Med. 68: 348-354 [Abstract] [Full text]  
• Macleod, J., Davey Smith, G. (2005). RE: "JOB STRESS AND BREAST CANCER RISK: THE NURSES' HEALTH STUDY". Am J Epidemiol 162: 1133-1134 [Full text]  
• Kivimaki, M., Ferrie, J. E., Brunner, E., Head, J., Shipley, M. J., Vahtera, J., Marmot, M. G. (2005). Justice at Work and Reduced Risk of Coronary Heart Disease Among Employees: The Whitehall II Study. Arch Intern Med 165: 2245-2251 [Abstract] [Full text]  
• Hintsanen, M., Kivimaki, M., Elovainio, M., Pulkki-Raback, L., Keskivaara, P., Juonala, M., Raitakari, O. T., Keltikangas-Jarvinen, L. (2005). Job Strain and Early Atherosclerosis: The Cardiovascular Risk in Young Finns Study. Psychosom. Med. 67: 740-747 [Abstract] [Full text]  
• Smith, G. D., Ben-Shlomo, Y., Beswick, A., Yarnell, J., Lightman, S., Elwood, P. (2005). Cortisol, Testosterone, and Coronary Heart Disease: Prospective Evidence From the Caerphilly Study. Circulation 112: 332-340 [Abstract] [Full text]  
• Metcalfe, C., Davey Smith, G., Sterne, J. A. C., Heslop, P., Macleod, J., Hart, C. L. (2005). Cause-specific hospital admission and mortality among working men: association with socioeconomic circumstances in childhood and adult life, and the mediating role of daily stress. Eur J Public Health 15: 238-244 [Abstract] [Full text]  
• Khang, Y.-H., Kim, H. R. (2005). Explaining socioeconomic inequality in mortality among South Koreans: an examination of multiple pathways in a nationally representative longitudinal study. Int J Epidemiol 34: 630-637 [Abstract] [Full text]  
• Steptoe, A, Whitehead, D L (2005). Depression, stress, and coronary heart disease: the need for more complex models. Heart 91: 419-420 [Abstract] [Full text]  
• Rasul, F, Stansfeld, S A, Hart, C L, Davey Smith, G (2005). Psychological distress, physical illness, and risk of coronary heart disease. J. Epidemiol. Community Health 59: 140-145 [Abstract] [Full text]  
• Hart, C. L, MacKinnon, P. L, Watt, G. C., Upton, M. N, McConnachie, A., Hole, D. J, Smith, G. D., Gillis, C. R, Hawthorne, V. M (2005). The Midspan studies. Int J Epidemiol 34: 28-34 [Full text]  
• Khatun, M., Ahlgren, C., Hammarstrom, A. (2004). The influence of factors identified in adolescence and early adulthood on social class inequities of musculoskeletal disorders at age 30: a prospective population-based cohort study. Int J Epidemiol 33: 1353-1360 [Abstract] [Full text]  
• Macleod, J., Davey Smith, G. (2004). RE: "DOES JOB STRAIN INCREASE THE RISK FOR CORONARY HEART DISEASE OR DEATH IN MEN AND WOMEN? THE FRAMINGHAM OFFSPRING STUDY". Am J Epidemiol 160: 1031-1032 [Full text]  
• Eaker, E. D., Sullivan, L. M., Kelly-Hayes, M., D'Agostino, R. B., Benjamin, E. J. (2004). THE AUTHORS REPLY. Am J Epidemiol 160: 1032-1032 [Full text]  
• Christenfeld, N. J. S., Sloan, R. P., Carroll, D., Greenland, S. (2004). Risk Factors, Confounding, and the Illusion of Statistical Control. Psychosom. Med. 66: 868-875 [Abstract] [Full text]  
• Adams, R J, Wilson, D H, Taylor, A W, Daly, A, Tursan d'Espaignet, E, Dal Grande, E, Ruffin, R E (2004). Psychological factors and asthma quality of life: a population based study. Thorax 59: 930-935 [Abstract] [Full text]  
• Muntaner, C., Eaton, W. W., Miech, R., O'Campo, P. (2004). Socioeconomic Position and Major Mental Disorders. Epidemiol Rev 26: 53-62 [Full text]  
• Christensen, U., Lund, R., Damsgaard, M. T., Holstein, B. E., Ditlevsen, S., Diderichsen, F., Due, P., Iversen, L., Lynch, J. (2004). Cynical Hostility, Socioeconomic Position, Health Behaviors, and Symptom Load: A Cross-Sectional Analysis in a Danish Population-Based Study. Psychosom. Med. 66: 572-577 [Abstract] [Full text]  
• Ohlin, B, Nilsson, P.M, Nilsson, J-A, Berglund, G (2004). Chronic psychosocial stress predicts long-term cardiovascular morbidity and mortality in middle-aged men. Eur Heart J 25: 867-873 [Abstract] [Full text]  
• Vahtera, J., Kivimaki, M., Pentti, J., Linna, A., Virtanen, M., Virtanen, P., Ferrie, J. E (2004). Organisational downsizing, sickness absence, and mortality: 10-town prospective cohort study. BMJ 328: 555- [Abstract] [Full text]  
• Hartvigsen, J, Lings, S, Leboeuf-Yde, C, Bakketeig, L (2004). Psychosocial factors at work in relation to low back pain and consequences of low back pain; a systematic, critical review of prospective cohort studies. Occup. Environ. Med. 61: e2-2 [Abstract] [Full text]  
• Macleod, J., Carroll, D. (2003). Commentary: What should we make of associations between vital exhaustion and heart disease?. Int J Epidemiol 32: 997-999 [Full text]  
• Lynch, J., Harper, S., Davey Smith, G. (2003). Commentary: Plugging leaks and repelling boarders--where to next for the SS Income Inequality?. Int J Epidemiol 32: 1029-1036 [Full text]  
• Singh-Manoux, A, Macleod, J, Davey Smith, G (2003). Psychosocial factors and public health. J. Epidemiol. Community Health 57: 553-556 [Full text]  
• Macleod, J, Davey Smith, G (2003). Psychosocial factors and public health: a suitable case for treatment?. J. Epidemiol. Community Health 57: 565-570 [Abstract] [Full text]  
• Macleod, J., Hickman, M., Smith, G. D. (2003). Early Exposure to Marijuana and Risk of Later Drug Use. JAMA 290: 329-330 [Full text]  
• van Amelsvoort, L G P M, Kant, I., Bultmann, U, Swaen, G M H (2003). Need for recovery after work and the subsequent risk of cardiovascular disease in a working population. Occup. Environ. Med. 60: i83-87 [Abstract] [Full text]  
• Davey Smith, G., Ebrahim, S. (2002). Data dredging, bias, or confounding. BMJ 325: 1437-1438 [Full text]  
• Carroll, D., Ebrahim, S., Tilling, K., Macleod, J., Davey Smith, G. (2002). Admissions for myocardial infarction and World Cup football: database survey. BMJ 325: 1439-1442 [Abstract] [Full text]  
• Macleod, J., Davey Smith, G. (2002). Commentary: Stress and the heart, 50 years of progress?. Int J Epidemiol 31: 1111-1113 [Full text]  
• Stansfeld, S. A (2002). Commentary: The problem with stress: minds, hearts and disease. Int J Epidemiol 31: 1113-1116 [Full text]  
• Sykes, D., Arveiler, D, Salters, C., Ferrieres, J, McCrum, E, Amouyel, P, Bingham, A, Montaye, M, Ruidavets, J-B, Haas, B, Ducimetiere, P, Evans, A. (2002). Psychosocial risk factors for heart disease in France and Northern Ireland: The Prospective Epidemiological Study of Myocardial Infarction (PRIME). Int J Epidemiol 31: 1227-1234 [Abstract] [Full text]  
• (2002). Is Stress a Risk Factor for Heart Disease: What's the Evidence?. JWatch Emergency Med. 2002: 4-4 [Full text]  
• Hotopf, M., Rosch, P. J, Hart, C. (2002). Psychological stress and cardiovascular disease. BMJ 325: 337-337 [Full text]  
• (2002). Psychological Stress Might Not Be So Important in CV Disease. Journal Watch Cardiology 2002: 5-5 [Full text]  
• (2002). Psychological Stress Might Not Be So Important in CV Disease. JWatch General 2002: 6-6 [Full text]  

Rapid Responses:

Read all Rapid Responses

Rose questionnaire is not what it seems

Matthew Hotopf
bmj.com, 24 May 2002 [Full text]

What about stress in women?

Clemency M C Pleming
bmj.com, 25 May 2002 [Full text]

The meaning of "stress" has changed since the 70's

David A Brown
bmj.com, 25 May 2002 [Full text]

The difficulty in demonstrating a relationship between 'Stress' and CHD

Serge Doublet
bmj.com, 28 May 2002 [Full text]

'Not everything that matters can be measured' (Albert Einstein)

Malcolm E Kendrick
bmj.com, 29 May 2002 [Full text]

More Heat Than Light

Paul J. Rosch
bmj.com, 30 May 2002 [Full text]

Type of reporting bias matters

Petter Kristensen
bmj.com, 4 Jun 2002 [Full text]

Hysterical men

Hege R. Eriksen, et al.
bmj.com, 5 Jun 2002 [Full text]

Outdated research tools are unhelpful

Siobhan M MacHale
bmj.com, 11 Jun 2002 [Full text]

Interpreting observational evidence in psychosocial epidemiology: authors' response

John Macleod, et al.
bmj.com, 12 Jun 2002 [Full text]

What is "stress"? Reporting bias and confused concepts.

Stein Knardahl
bmj.com, 1 Aug 2002 [Full text]

Re: What is "stress"? Reporting bias and confused concepts.

John Macleod, et al.
bmj.com, 5 Aug 2002 [Full text]

Stress and ill health

Neville D Lewis
bmj.com, 17 Feb 2005 [Full text]

A guide to good health

Neville D Lewis
bmj.com, 17 Feb 2005 [Full text]