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High psychosocial stress independently associated with increased risk of CVD and death

10th January 2022

High psychosocial stress among people from low-, medium- and high income countries is significantly associated with both CVD and mortality

High psychosocial stress levels has been found to be significantly associated with an increased risk of cardiovascular disease (CVD) and all-cause mortality among those from low, middle and high income countries. This was the conclusion of a study by researchers from the School of Public Health and Community Medicine, University of Gothenburg, Sweden.

Cardiovascular diseases are known to be the leading cause of death across the world, resulting in the loss of around 17.9 million lives each year. The role of high psychosocial stress due to pressures at work in the development of CVD appear to be significant among men but not women, although given that self-reported stress is entirely subjective, it can be difficult to draw any firm conclusions over such associations. In fact, while psychosocial stress appears to be independently associated with CVD, this is highly dependent on the degree and duration of stress as well as the individual response to a particular stressor.

Evidence for the association between high psychosocial stress and the development of CVD and mortality from low and middle income countries is limited and for the present study, the researchers turned to data from the Prospective Urban Rural Epidemiology (PURE) study which was designed to examine the relationship of societal influences on human lifestyle behaviours, cardiovascular risk factors, and incidence of chronic noncommunicable diseases. The study includes individuals aged 35 to 70 years in 27 countries across 5 continents.

The researchers developed a composite measure of stress based on an assessment of psychological, life event and financial stress. Psychological stress was assessed based on questions related to stress at work and home, in which stress was defined as feeling irritable or filled with anxiety or having sleep difficulties as a result of conditions at home or work.

Life events stress was assessed in terms of major adverse events such as loss of income, death of a spouse etc and financial stress was dichotomised as little/none, moderate or high/severe. The composite stress score ranged from 0 (none), 1 (low stress), 2 (moderate stress) and 3 (high stress).

In regression analysis, the researchers adjusted for several covariates including age, sex, country income, marital status, education etc. The outcomes of interest were major CVD events (e.g., stroke, myocardial infarction, heart failure) and all-cause mortality.


A total of 118, 706 participants with a mean age of 50.4 years (58.8% women) without prior CVD were included and followed by for a median of 10.2 years.

Among the cohort, 7.3% were deemed to have high psychosocial stress, 18.4% moderate stress, 29.4% low stress and 44.8% no stress.

During the period of follow-up, there were 7428 deaths and 5934 major CVD events and compared to those reporting no stress and after adjustment for covariates, the risk of both outcomes of interest increased with higher stress levels.

For example, the risk of death increased from 9% (adjusted hazard ratio, aHR = 1.09, 95% CI 1.03 – 1.16) among those with low stress to 17% (aHR = 1.17, 95% CI 1.06 – 1.29) for those with high psychosocial stress. In addition, high psychosocial stress, but not either low or moderate, was also significantly associated with CVD (aHR = 1.22, 95% CI 1.08 – 1.37) and stroke (aHR = 1.30).

The authors concluded that all levels of psychosocial stress were independently associated with a higher risk of CVD and death and suggested that these findings emphasised the need for the development and evaluation of strategies to determine whether stress modification might reduce CVD.


Santosa A et al. Psychosocial Risk Factors and Cardiovascular Disease and Death in a Population-Based Cohort From 21 Low-, Middle-, and High-Income Countries JAMA Netw Open 2021.