title: Psychological stress and short-term hospitalisations or death in patients with heart failure.
abstract: OBJECTIVE
  Standard predictors do not fully explain variations in the frequency and timing of heart failure (HF) adverse events (AEs). Psychological stress can trigger acute cardiovascular (CV) events, but it is not known whether stress can precipitate AEs in patients with HF. We investigated prospective associations of psychological stress with AEs in patients with HF.
  
  
  METHODS
  144 patients with HF (77% male; 57.5±11.5, range 23-87 years, left ventricular ejection fraction ≤40%) were longitudinally evaluated for psychological stress (Perceived Stress Scale) and AEs (CV hospitalisations/death) at 2-week intervals for 3 months and at 9-month follow-up.
  
  
  RESULTS
  42 patients (29.2%) had at least one CV hospitalisation and nine (6.3%) died. Patients reporting high average perceived stress across study measurements had a higher likelihood of AEs during the study period compared with those with lower stress (odds ratio=1.10, 95% confidence interval=1.04 to 1.17). In contrast to average levels, increases in stress did not predict AEs (p=0.96). Perceived stress was elevated after a CV hospitalisation (B=2.70, standard error (SE)=0.93, p=0.004) suggesting that CV hospitalisations increase stress. Subsequent analysis indicated that 24 of 38 (63%) patients showed a stress increase following hospitalisation. However, a prospective association between stress and AEs was present when accounting for prior hospitalisations (B=2.43, SE=1.23, p=0.05).
  
  
  CONCLUSIONS
  Sustained levels of perceived stress are associated with increased risk of AEs, and increased distress following hospitalisation occurs in many, but not all, patients with HF. Patients with chronically high stress may be an important target group for HF interventions aimed at reducing hospitalisations.
authors.affiliation: Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.|Division of Behavioral Science Research, Department of Health Policy and Health Services Research, Boston University, Boston, Massachusetts, USA.
authors.forename: Romano
authors.initials: R
authors.lastname: Endrighi
authors.affiliation: Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Waters
authors.affiliation: University of Maryland School of Medicine, Baltimore, Maryland, USA.
authors.forename: Stephen S
authors.identifier: http://orcid.org/0000-0002-8922-1840
authors.initials: SS
authors.lastname: Gottlieb
authors.affiliation: Cardiopulmonary Behavioral Medicine Laboratory, The Ohio State University, Columbus, Ohio, USA.
authors.forename: Kristie M
authors.initials: KM
authors.lastname: Harris
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, Florida, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Wawrzyniak
authors.affiliation: Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Nadine S
authors.initials: NS
authors.lastname: Bekkouche
authors.affiliation: Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Yisheng
authors.initials: Y
authors.lastname: Li
authors.affiliation: Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.
authors.forename: Willem J
authors.initials: WJ
authors.lastname: Kop
authors.affiliation: Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: David S
authors.identifier: http://orcid.org/0000-0002-1671-1355
authors.initials: DS
authors.lastname: Krantz