title: Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men.
abstract: OBJECTIVE
  To examine the association between self perceived psychological stress and cardiovascular disease in a population where stress was not associated with social disadvantage.
  
  
  METHODS
  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.
  
  
  METHODS
  27 workplaces in Scotland.
  
  
  METHODS
  5606 men (mean age 48 years) at first screening and 2623 men at second screening with complete data on all measures.
  
  
  METHODS
  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.
authors.affiliation: Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT. j.a.macleod@bham.ac.uk
authors.forename: John
authors.initials: J
authors.lastname: Macleod
authors.forename: George
authors.initials: G
authors.lastname: Davey Smith
authors.forename: Pauline
authors.initials: P
authors.lastname: Heslop
authors.forename: Chris
authors.initials: C
authors.lastname: Metcalfe
authors.forename: Douglas
authors.initials: D
authors.lastname: Carroll
authors.forename: Carole
authors.initials: C
authors.lastname: Hart
mesh_terms: D000328:Adult; D000367:Age Factors; D000787:Angina Pectoris / Q000209:etiology; D015982:Bias; D002318:Cardiovascular Diseases / Q000209:etiology*; D019317:Evidence-Based Medicine; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000209:etiology; D016017:Odds Ratio; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D012923:Social Class; D013315:Stress, Psychological / Q000150:complications*