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Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees

BMJ 2002; 325 doi: (Published 19 October 2002) Cite this as: BMJ 2002;325:857
  1. Mika Kivimäki, acting professor (mika.kivimaki{at},
  2. Päivi Leino-Arjas, senior researchera,
  3. Ritva Luukkonen, statisticiana,
  4. Hilkka Riihimäi, professora,
  5. Jussi Vahtera, senior researchera,
  6. Juhani Kirjonen, emeritus professorb
  1. aDepartment of Psychology, University of Helsinki, PO Box 13, FIN-00014, Finland
  2. bDepartment of Physical Education, University of Jyväskylä, Jyväskylä, Finland
  1. Correspondence to M Kivimäki
  • Accepted 23 May 2002


Objective: To examine the association between work stress, according to the job strain model and the effort-reward imbalance model, and the risk of death from cardiovascular disease.

Design: Prospective cohort study. Baseline examination in 1973 determined cases of cardiovascular disease, behavioural and biological risks, and stressful characteristics of work. Biological risks were measured at 5 year and 10 year follow up.

Setting: Staff of a company in the metal industry in Finland.

Participants: 812 employees (545 men, 267 women) who were free from cardiovascular diseases at baseline.

Main outcome measure: Cardiovascular mortality 1973-2001 from the national mortality register.

Results: Mean length of follow up was 25.6 years. After adjustment for age and sex, employees with high job strain, a combination of high demands at work and low job control, had a 2.2-fold (95% confidence interval 1.2 to 4.2) cardiovascular mortality risk compared with their colleagues with low job strain. The corresponding risk ratio for employees with effort-reward imbalance (low salary, lack of social approval, and few career opportunities relative to efforts required at work) was 2.4 (1.3 to 4.4). These ratios remained significant after additional adjustment for occupational group and biological and behavioural risks at baseline. High job strain was associated with increased serum total cholesterol at the 5 year follow up. Effort-reward imbalance predicted increased body mass index at the 10 year follow up.

Conclusions: High job strain and effort-reward imbalance seem to increase the risk of cardiovascular mortality. The evidence from industrial employees suggests that attention should be paid to the prevention of work stress.


  • Funding Grants from the Academy of Finland (project number 70139) and the Ministry of Education, Finland (188/722/2000). MK and JV were supported by the Academy of Finland (project numbers 44968 and 77560).

  • Competing interests None declared.

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