Clinical Review Evidence based cardiology

Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies

BMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7196.1460 (Published 29 May 1999) Cite this as: BMJ 1999;318:1460
  1. Harry Hemingway, senior lecturer in epidemiology,
  2. Michael Marmot, professor of epidemiology and public health (h.hemingway@public-health.ucl.ac.uk)
  1. International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, London WC1E 6BT
  1. Correspondence to: Dr H Hemingway, Department of Research and Development, Kensington and Chelsea and Westminster Health Authority, London W2 6LX

    Do psychosocial factors cause coronary heart disease or affect survival among patients with coronary heart disease? Here we use an explicit methodological quality filter to review systematically the prospective cohort studies testing specific psychosocial hypotheses. This review of the epidemiological literature identifies the psychosocial factors that have been most rigorously tested. Only four psychosocial factors met the quality filter: type A/hostility, depression and anxiety, work characteristics, and social supports. The importance of other study designs—for example, ecological1 or nested case-control24 studies—is acknowledged. The review should be seen as complementary to existing reviews58 on single psychosocial factors and as a challenge to investigators in the field to ensure that the systematic review is made unbiased, kept up to date, and used to guide future hypothesis testing.

    Summary points

    In healthy populations, prospective cohort studies show a possible aetiological role for type A/hostility (6/14 studies), depression and anxiety (11/11 studies), psychosocial work characteristics (6/10 studies), social support (5/8 studies)

    In populations of patients with coronary heart disease, prospective studies show a prognostic role for depression and anxiety (6/6 studies), psychosocial work characteristics (1/2 studies), and social support (9/10 studies); none of five studies showed a prognostic role for type A/hostility

    Although this review can not discount the possibility of publication bias, prospective cohort studies provide strong evidence that psychosocial factors, particularly depression and social support, are independent aetiological and prognostic factors for coronary heart disease

    What is a psychosocial factor?

    A psychosocial factor may be defined as a measurement that potentially relates psychological phenomena to the social environment and to pathophysiological changes. The validity and reliability (precision) of the questionnaire based instruments used to measure psychosocial factors has been improved through the use of psychometric techniques. By avoiding the unhelpful general term of “stress,” recent work has developed theoretical models—for example, the …

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