title: Chronic stress, depressive symptoms, anger, hostility, and risk of stroke and transient ischemic attack in the multi-ethnic study of atherosclerosis.
abstract: OBJECTIVE
  This study investigated chronic stress, depressive symptoms, anger, and hostility in relation to incident stroke and transient ischemic attacks in middle-aged and older adults.
  
  
  METHODS
  Data were from the Multi-Ethnic Study of Atherosclerosis (MESA), a population-based cohort study of 6749 adults, aged 45 to 84 years and free of clinical cardiovascular disease at baseline, conducted at 6 US sites. Chronic stress, depressive symptoms, trait anger, and hostility were assessed with standard questionnaires. The primary outcome was clinically adjudicated incident stroke or transient ischemic attacks during a median follow-up of 8.5 years.
  
  
  RESULTS
  One hundred ninety-five incident events (147 strokes; 48 transient ischemic attacks) occurred during follow-up. A gradient of increasing risk was observed for depressive symptoms, chronic stress, and hostility (all P for trend ≤0.02) but not for trait anger (P>0.10). Hazard ratios (HRs) and 95% confidence intervals indicated significantly elevated risk for the highest-scoring relative to the lowest-scoring group for depressive symptoms (HR, 1.86; 95% confidence interval, 1.16-2.96), chronic stress (HR, 1.59; 95% confidence interval, 1.11-2.27), and hostility (HR, 2.22; 95% confidence interval, 1.29-3.81) adjusting for age, demographics, and site. HRs were attenuated but remained significant in risk factor-adjusted models. Associations were similar in models limited to stroke and in secondary analyses using time-varying variables.
  
  
  CONCLUSIONS
  Higher levels of stress, hostility, and depressive symptoms are associated with significantly increased risk of incident stroke or transient ischemic attacks in middle-aged and older adults. Associations are not explained by known stroke risk factors.
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.). saer@umn.edu.
authors.forename: Susan A
authors.initials: SA
authors.lastname: Everson-Rose
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.).
authors.forename: Nicholas S
authors.initials: NS
authors.lastname: Roetker
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.).
authors.forename: Pamela L
authors.initials: PL
authors.lastname: Lutsey
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.).
authors.forename: Kiarri N
authors.initials: KN
authors.lastname: Kershaw
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.).
authors.forename: W T
authors.initials: WT
authors.lastname: Longstreth
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.).
authors.forename: Ralph L
authors.initials: RL
authors.lastname: Sacco
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.).
authors.forename: Ana V
authors.initials: AV
authors.lastname: Diez Roux
authors.affiliation: From the Departments of Medicine (S.A.E.-R.) and Epidemiology and Community Health (N.S.R., P.L.L., A.A.), School of Public Health, University of Minnesota, Minneapolis; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (K.N.K.); Departments of Neurology and Epidemiology, University of Washington, Seattle (W.T.L.); Departments of Neurology, Public Health Sciences, Neurosurgery, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (A.V.D.R.).
authors.forename: Alvaro
authors.initials: A
authors.lastname: Alonso
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000786:Anger; D050197:Atherosclerosis / Q000150:complications / Q000208:ethnology / Q000523:psychology*; D003863:Depression / Q000150:complications / Q000208:ethnology / Q000523:psychology*; D005260:Female; D006791:Hostility; D006801:Humans; D015994:Incidence; D002546:Ischemic Attack, Transient / Q000208:ethnology / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D013315:Stress, Psychological / Q000150:complications / Q000208:ethnology / Q000523:psychology*; D020521:Stroke / Q000208:ethnology / Q000209:etiology*; D011795:Surveys and Questionnaires
keywords: anger; depression; emotions; hostility; stress, psychological; stroke