Rosengren, A., Hawken, S., ‘unpuu, S.,
Zubaid, M., Almahmeed, W. A., Blackett, K. N., Sitthi-amorn, C., Sato,
H., Yusuf, S. (2004) Association of psychosocial risk factors
risk of acute myocardial infarction. www.thelancet.com Vol 364
Psychosocial factors have been reported to be independently associated
with coronary heart disease. However, previous studies have been in
North American or European populations. The aim of the present analysis
was to investigate the relation of psychosocial factors to risk of
infarction in 24 767 people from
Methods. We used a
with 11 119 patients with a first myocardial infarction and 13 648
(up to 5 years older or younger) and sex-matched controls from 262
in Asia, Europe, the Middle East, Africa, Australia, and North and
America. Data for demographic factors, education, income, and
risk factors were obtained by standardised approaches. Psychosocial
was assessed by four simple questions about stress at work and at home,
Findings. People with
infarction (cases) reported higher prevalence of all four stress
(p<0∑0001). Of those cases still working, 23∑0%
experienced several periods of work stress compared with 17∑9%
of controls, and 10∑0% (540) experienced permanent work stress
the previous year versus 5∑0% (372) of controls.
Odds ratios were 1∑38 (99% CI
for several periods of work stress and 2∑14
for permanent stress at work, adjusted for age, sex, geographic region,
and smoking. 11∑6% (1288) of cases had several periods of stress
at home compared with 8∑6% (1179) of controls (odds ratio
[99% CI 1∑34–1∑72]), and 3∑5% (384) of cases
reported permanent stress at home
1∑9% (253) of controls (2∑12 [1∑68–2∑65]).
General stress (work, home, or both) was associated with an odds ratio
of 1∑45 (99% CI 1∑30–1∑61) for several periods and
2∑17 (1∑84–2∑55) for permanent stress. Severe
stress was more typical in cases than controls (14∑6%  vs
12∑2% ; odds
ratio 1∑33 [99% CI
Stressful life events in the past year were also more frequent in cases
than controls (16∑1%  vs 13∑0% ; 1∑48
[1∑33–1∑64]), as was depression (24∑0%  vs
; odds ratio 1∑55 [1∑42–1∑69]). These
were consistent across regions, in different ethnic groups, and in men
Presence of psychosocial stressors is associated with increased risk of
acute myocardial infarction, suggesting that approaches aimed at
these factors should be developed.
1 Anda R, Williamson D, Jones D,
hopelessness, and the risk of
heart disease in a cohort of
US adults. Epidemiology 1993; 4:
2 Barefoot JC, Schroll M. Symptoms of
depression, acute myocardial
infarction, and total mortality in a
1996; 93: 1976–80.
3 Ferketich AK, Schwartzbaum JA, Frid
DJ, Moeschberger ML.
Depression as an antecedent to heart
among women and
men in the NHANES I study. Arch
Med 2000; 160: 1261–68.
4 Hemingway H, Marmot M. Evidence based
factors in the aetiology and
of coronary heart disease:
systematic review of prospective
studies. BMJ 1999; 318:
5 Yoshimasu K. Relation of type A behavior
pattern and job-related
psychosocial factors to nonfatal
infarction: a case-control
study of Japanese male workers and
Psychosom Med 2001;
6 Sacker A, Bartley MJ, Frith D, Fitzpatrick
RM, Marmot MG. The
relationship between job strain and
heart disease: evidence
from an English sample of the
male population. Psychol
Med 2001; 31: 279–90.
7 Li J, Hansen D, Mortensen PB, Olsen
J. Myocardial infarction in
parents who lost a child: a
prospective cohort study in
Denmark. Circulation 2002; 106:
8 Matthews KA, Gump BB. Chronic work stress
dissolution increase risk of
mortality in men from the
Multiple Risk Factor Intervention
Arch Intern Med 2002; 162:
9 Iso H, Date C, Yamamoto A, et al. Perceived
mental stress and
mortality from cardiovascular
among Japanese men and
women: the Japan Collaborative
Study for Evaluation of
Cancer Risk Sponsored by Monbusho
2002; 106: 1229–36.
10 Kivimaki M, Leino-Arjas P, Luukkonen
R, Riihimaki H, Vahtera J,
Kirjonen J. Work stress and risk of
prospective cohort study of
employees. BMJ 2002; 325:
11 Stansfeld SA, Fuhrer R, Shipley MJ,
Marmot MG. Psychological
distress as a risk factor for
heart disease in the Whitehall II
Study. Int J Epidemiol 2002; 31:
12 Welin C, Rosengren A, Wedel H, Wiklund
I, Wilhelmsen L.
Psychological characteristics in
with myocardial infarction:
a case-control study. Cardiovasc
Factors 1994; 4: 154–61.
13 Welin C, Rosengren A, Wedel H, Wilhelmsen
infarction in relation to work,
and life events. Cardiovasc Risk
Factors 1995; 5: 30–38.
14 Rosengren A, Tibblin G, Wilhelmsen
L. Self-perceived psychological
stress and incidence of coronary
disease in middle-aged men.
Am J Cardiol 1991; 68: 1171–75.
15 Prescott E, Holst C, Gronbaek M, Schnohr
P, Jensen G, Barefoot J.
Vital exhaustion as a risk factor
ischaemic heart disease and allcause
mortality in a community sample: a
study of 4084
men and 5479 women in the Copenhagen
Int J Epidemiol 2003; 32: 990–97.
16 Yusuf S, Hawken S, ‘unpuu S,
et al. Effect of potentially modifiable
risk factors associated with
infarction in 52 countries (the
INTERHEART study): case-control
Lancet 2004; 364: 937–52.
17 ‘unpuu S, Negassa A, Yusuf S.
INTERHEART: a global study of
risk factors for acute myocardial
Am Heart J 2001; 141:
18 Bobak M, Pikhart H, Rose R, Hertzman
C, Marmot M.
Socioeconomic factors, material
and perceived control
in self-rated health:
data from seven postcommunist
countries. Soc Sci Med 2000; 51:
19 Patten SB. Performance of the Composite
Interview Short Form for major
in community and
clinical samples. Chronic Dis Can
20 Breslow N, Day N. Statistical methods
in cancer research, vol 1: the
analysis of case-control studies.
IARC Scientific Publications,
21 Benichou J, Gail M. Variance calculations
and confidence intervals
for estimates of the attributable
based on logistic models.
Biometrics 1990; 46: 991–1003.
22 Engel L, Chow W, Vaughan T. Population
attributable risks of
esophageal and gastric cancers. J
Cancer Inst 2003; 95:
23 Marmot M, Stansfeld S. Stress and the
pathways to coronary heart disease.
BMJ books, 2001.
24 Orth-Gomer K, Wamala SP, Horsten M,
Schneiderman N, Mittleman MA.
stress worsens prognosis
in women with coronary heart
the Stockholm Female
Coronary Risk Study. JAMA 2000; 284:
25 Lee S, Colditz G, Berkman L, Kawachi
I. A prospective study of job
strain and coronary heart disease in
women. Int J Epidemiol
2002; 31: 1147–53.
26 Rugulies R. Depression as a predictor
for coronary heart disease:
a review and meta-analysis. Am J
Med 2002; 23: 51–61.
27 Demyttenaere K, Bruffaerts R, Posada-Villa
J, et al. Prevalence,
severity, and unmet need for
of mental disorders in the
World Health Organization World
Health Surveys. JAMA
2004; 291: 2581–90.
28 Croyle RT, Sande GN. Denial and confirmating
consequences of medical diagnosis. J
Soc Psychol 1988; 18:
29 Moore L, Meyer F, Perusse M, et al.
Psychological stress and
incidence of ischaemic heart
Int J Epidemiol 1999; 28:
30 Macleod J, Smith GD, Heslop P, Metcalfe
C, Carroll D, Hart C. Are
the effects of psychosocial
attributable to confounding?
Evidence from a prospective
study on psychological
stress and mortality. J Epidemiol
Health 2001; 55:
31 Eaker ED, Sullivan LM, Kelly-Hayes
M, D’Agostino RB Sr,
Benjamin EJ. Does job strain
the risk for coronary heart
disease or death in men and women?
Study. Am J Epidemiol 2004; 159:
32 Kaplan JR, Pettersson K, Manuck SB,
Olsson G. Role of
sympathoadrenal medullary activation
the initiation and
progression of atherosclerosis.
1991; 84: VI23–32.
33 Strawn WB, Bondjers G, Kaplan JR, et
al. Endothelial dysfunction
in response to psychosocial stress
monkeys. Circ Res 1991; 68:
34 Ghiadoni L, Donald AE, Cropley M, et
al. Mental stress induces
transient endothelial dysfunction in
35 Kop WJ, Krantz DS, Howell RH, et al.
Effects of mental stress on
coronary epicardial vasomotion and
velocity in coronary artery
disease: relationship with
J Am Coll Cardiol 2001; 37: 1359–66.
36 Lewthwaite J, Owen N, Coates A, Henderson
B, Steptoe A.
Circulating human heat shock protein
in the plasma of British
civil servants: relationship to
and psychosocial stress.
Circulation 2002; 106: 196–201.
37 Brunner E, Davey-Smith G, Marmot M,
Canner R, Beksinska M,
O’Brien J. Childhood social
and psychosocial and
behavioural factors as determinants
plasma fibrinogen. Lancet
1996; 347: 1008–13.
38 von Kanel R, Mills PJ, Fainman C, Dimsdale
JE. Effects of
psychological stress and psychiatric
on blood coagulation
and fibrinolysis: a biobehavioral
to coronary artery
disease? Psychosom Med 2001; 63: