title: Perceived stress in myocardial infarction: long-term mortality and health status outcomes.
abstract: OBJECTIVE
  This study sought to determine the association of chronic stress with long-term adverse outcomes after acute myocardial infarction (AMI).
  
  
  BACKGROUND
  Chronic stress has been shown to be associated with the development of cardiovascular disease and, in the case of particular types of stress such as job and marital strain, with recurrent adverse events after AMI. Little is known, however, about the association of chronic stress with mortality and adverse health status outcomes in a general AMI population.
  
  
  METHODS
  In a cohort of 4,204 AMI patients from 24 U.S. hospitals completing the Perceived Stress Scale-4 (sum scores ranging from 0 to 16) during hospitalization, moderate/high stress over the previous month was defined as scores in the top 2 quintiles (scores of 6 to 16). Detailed data on sociodemographics, psychosocial status, and clinical characteristics were collected at baseline. Outcomes included patients' 1-year health status, assessed with the Seattle Angina Questionnaire, Short Form-12, and EuroQol Visual Analog Scale, and 2-year mortality.
  
  
  RESULTS
  AMI patients with moderate/high stress had increased 2-year mortality compared with those having low levels of stress (12.9% vs. 8.6%; p < 0.001). This association persisted after adjusting for sociodemographics, clinical factors (including depressive symptoms), revascularization status, and GRACE (Global Registry of Acute Coronary Events) discharge risk scores (hazard ratio: 1.42: 95% confidence interval: 1.15 to 1.76). Furthermore, moderate/high stress was independently associated with poor 1-year health status, including a greater likelihood of angina, worse disease-specific and generic health status, and worse perceived health (p < 0.01 for all).
  
  
  CONCLUSIONS
  Moderate/high perceived stress at the time of an AMI is associated with adverse long-term outcomes, even after adjustment for important confounding factors. Future studies need to examine whether stress mediates observed racial and socioeconomic disparities and whether novel interventions targeting chronic stress and coping skills can improve post-AMI outcomes.
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Missouri 64111, USA. suz.v.arnold@gmail.com
authors.forename: Suzanne V
authors.initials: SV
authors.lastname: Arnold
authors.forename: Kim G
authors.initials: KG
authors.lastname: Smolderen
authors.forename: Donna M
authors.initials: DM
authors.lastname: Buchanan
authors.forename: Yan
authors.initials: Y
authors.lastname: Li
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000401:mortality / Q000523:psychology*; D010465:Perception; D011379:Prognosis; D011569:Psychiatric Status Rating Scales; D012306:Risk; D013315:Stress, Psychological; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States