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Fall 2024

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Psychosocial Stress and Cardiovascular Risk: State of the Science and Areas for Attention

Gabrielle M. Salvatore, Ph.D.1, Laura E. Laumann, Ph.D.2, Heather Y. Neifert, M.A.3, Abbey Collins, B.A.4, & Allison E. Gaffey, Ph.D.5 - Cardiovascular Disease SIG

Psychosocial stress is “a real or interpreted threat to the physiological or psychological integrity of an individual that results in physiological and/or behavioral responses.”1 Thus, the term stress may refer to a stimulus, a reaction to a stimulus, or the psychophysiological effects of that response. Stress, especially that which is long-term or chronic, has been associated with the development of cardiovascular disease (CVD),2-4 and this association is consistent across geographic regions, ages, and sexes.5 For example, acute or short-term stressors may lead to increased blood pressure, heart rate, or blood sugar, or negative emotions such as feelings of frustration, anger, or anxiety.1 Over time these changes can increase vulnerability to systemic physiological dysregulation and psychopathology. For example, occupational stressors (i.e., high workload, increased working hours, job insecurity, low wages) are shown to increase the incidence of hypertension.6 Importantly, the effects of stress on CVD risk are a recognized public health challenge.4

The biological mechanisms linking stress with CVD are highly complex. In the context of chronic stress, structural and physiological changes to the autonomic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis are involved.3,5 Stress-related activation of the sympathetic nervous system is related to atherosclerosis, cardiac events, and other adverse cardiometabolic outcomes.5 High amygdala metabolic activity, catecholamine release, and inflammatory processes have all been identified as potential mechanisms of the stress response.3,5,7 In particular, pro- and anti-inflammatory cytokines have been implicated, and correlate with immune dysregulation, atherosclerosis, arterial stiffening, and other downstream CVD outcomes.5,8 Yet further research is needed to discern which stress mechanisms are most salient to CVD risk and the interactions between these pathways.

When studying the relations between stress and CVD, researchers commonly rely on self-report instruments to measure perceived stress levels and exposure to stressful life events.3,5 Although there are advantages to self-report measures (e.g., inexpensive, quick to administer), they are also subjective (thus introducing response bias), and may not sufficiently detail the timing and chronicity of stressors.9 In contrast, psychophysiological measures of stress are used to monitor biological changes that are associated with the body’s stress response, and are more objective.

These tools include skin-conductance response, heart rate variability (HRV), hormone assays (e.g., the HPA axis hormone cortisol), and advanced neuroimaging.3,5 Smartphone applications and wearable devices allow for real-time monitoring of an individual’s stress exposure and physiological responses.3 These newer technologies have improved our understanding of the temporal relationship between stress and cardiovascular outcomes, and also provide a promising avenue for better implementing and testing stress management interventions.10

As stress may be a modifiable risk factor for CVD,11 identifying which stressors are particularly impactful, and for whom, will help us to better understand the role of stress in the onset and progression of CVD and how to best intervene.2,4,12-17 Thus, we outline 5 key areas for high-impact future research:

  1. Refine measures of psychosocial stress and test their feasibility and effectiveness in predicting CVD risk in clinical settings.16,21
  2. Ensure randomized controlled trials are sufficiently powered to evaluate screening and treatment methods for psychosocial stressors in diverse populations (e.g., women and minorities).14,18-19
  3. Conduct more epidemiological studies on psychosocial stress and CVD risk across the lifespan, beginning in childhood.17-18
  4. Examine stress and cardiovascular risk in real-life situations, between- and within-person, using intensive ambulatory assessment methods (e.g., wearable technologies, ambulatory devices).16,17,20
  5. Assess the effectiveness of community-level interventions to reduce psychosocial stress as part of a multifactor approach to CVD risk mangement.3,18,22-23

Affiliations

  1. Postdoctoral Research Fellow,  Department of Psychology, Rowan University
  2. Postdoctoral Research Fellow, The Warren Alpert Medical School of Brown University 
  3. Doctoral Candidate, Department of Psychological Sciences, Kent State University
  4. Graduate Student, Department of Psychology, North Carolina State University
  5. Assistant Professor of Medicine, Department of Internal Medicine, Yale University School of Medicine

References

  1. McEwen, B. S. (2007). Stress, Definitions and Concepts of. In Encyclopedia of Stress (p. 653). Elsevier. https://doi.org/10.1016/B978-012373947-6.00364-0
  2. Steptoe, A., & Kivimäki, M. (2012). Stress and cardiovascular disease. Nature Reviews Cardiology, 9(6), 360–370. https://doi.org/10.1038/nrcardio.2012.45
  3. Kivimäki, M., & Steptoe, A. (2018). Effects of stress on the development and progression of cardiovascular disease. Nature Reviews Cardiology, 15(4), 215–229. https://doi.org/10.1038/nrcardio.2017.189
  4. Shawqat Ali, M., Mahfuz Rabbani, G., Touhidul Islam, M., Haque Khalid, M. F., Islam, M. M., & Uddin, M. H. (2024). Association of Chronic Stress with Cardiovascular Diseases: A Single Centre Experience. Medicine Today, 36(2), 127–131. https://doi.org/10.3329/medtoday.v36i2.74822
  5. Osborne, M. T., Shin, L. M., Mehta, N. N., Pitman, R. K., Fayad, Z. A., & Tawakol, A. (2020). Disentangling the Links Between Psychosocial Stress and Cardiovascular Disease. Circulation: Cardiovascular Imaging, 13(8), e010931. https://doi.org/10.1161/CIRCIMAGING.120.010931
  6. Marwaha, K. (2022). Examining the Role of Psychosocial Stressors in Hypertension. Journal of Preventive Medicine and Public Health, 55(6), 499–505. https://doi.org/10.3961/jpmph.21.266
  7. Harris, K. M., Jacoby, D. L., Lampert, R., Soucier, R. J., & Burg, M. M. (2021). Psychological stress in heart failure: a potentially actionable disease modifier. Heart Failure Reviews, 26(3), 561–575. https://doi.org/10.1007/s10741-020-10056-8
  8. Mozos, I., Malainer, C., Horbańczuk, J., Gug, C., Stoian, D., Luca, C. T., & Atanasov, A. G. (2017). Inflammatory Markers for Arterial Stiffness in Cardiovascular Diseases. Frontiers in Immunology, 8, 1058. https://doi.org/10.3389/fimmu.2017.01058
  9. Shields, G. S., & Slavich, G. M. (2017). Lifetime stress exposure and health: A review of contemporary assessment methods and biological mechanisms. Social and Personality Psychology Compass, 11(8), e12335. https://doi.org/10.1111/spc3.12335
  10. Jerath, R., Syam, M., & Ahmed, S. (2023). The Future of Stress Management: Integration of Smartwatches and HRV Technology. Sensors, 23(17), 7314. https://doi.org/10.3390/s23177314
  11. Yusuf, S., Hawken, S., Ôunpuu, S., Dans, T., Avezum, A., Lanas, F., McQueen, M., Budaj, A., Pais, P., Varigos, J., & Lisheng, L. (2004). Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. The Lancet, 364(9438), 937–952. https://doi.org/10.1016/S0140-6736(04)17018-9
  12. Braun, J., Patel, M., Kameneva, T., Keatch, C., Lambert, G., & Lambert, E. (2024). Central stress pathways in the development of cardiovascular disease. Clinical Autonomic Research, 34(1), 99–116. https://doi.org/10.1007/s10286-023-01008-x
  13. Dimsdale, J. E. (2008). Psychological Stress and Cardiovascular Disease. Journal of the American College of Cardiology, 51(13), 1237–1246. https://doi.org/10.1016/j.jacc.2007.12.024
  14. Gill, A., Aldosoky, W., Ong, M. B. H., Mir, T., Dar, T., & Abohashem, S. (2023). A Narrative Review on Mental Stress and Cardiovascular Disease: Evidence, Mechanisms, and Potential Interventions. Heart and Mind, 7(2), 62–69. https://doi.org/10.4103/hm.HM-D-22-00002
  15. O’ Riordan, A., Howard, S., & Gallagher, S. (2023). Blunted cardiovascular reactivity to psychological stress and prospective health: a systematic review. Health Psychology Review, 17(1), 121–147. https://doi.org/10.1080/17437199.2022.206863916.
  16. Vaccarino, V., Shah, A. J., Mehta, P. K., Pearce, B., Raggi, P., Bremner, J. D., & Quyyumi, A. A. (2021). Brain-heart connections in stress and cardiovascular disease: Implications for the cardiac patient. Atherosclerosis, 328, 74–82. https://doi.org/10.1016/j.atherosclerosis.2021.05.020
  17. Vaccarino, V., & Bremner, J. D. (2024). Stress and cardiovascular disease: an update. Nature Reviews Cardiology, 21(9), 603–616. https://doi.org/10.1038/s41569-024-01024-y
  18. Ebong, I. A., Quesada, O., Fonkoue, I. T., Mattina, D., Sullivan, S., Oliveira, G. M. M. D., Spikes, T., Sharma, J., Commodore, Y., Ogunniyi, M. O., Aggarwal, N. R., & Vaccarino, V. (2024). The Role of Psychosocial Stress on Cardiovascular Disease in Women. Journal of the American College of Cardiology, 84(3), 298–314. https://doi.org/10.1016/j.jacc.2024.05.016
  19. Gaffey, A. E., Gathright, E. C., Fletcher, L. M., & Goldstein, C. M. (2022). Screening for Psychological Distress and Risk of Cardiovascular Disease and Related Mortality: A SYSTEMATIZED REVIEW, META-ANALYSIS, AND CASE FOR PREVENTION. Journal of Cardiopulmonary Rehabilitation and Prevention, 42(6), 404–415. https://doi.org/10.1097/HCR.0000000000000751
  20. Schwartz, A. R., Gerin, W., Davidson, K. W., Pickering, T. G., Brosschot, J. F., Thayer, J. F., Christenfeld, N., & Linden, W. (2003). Toward a Causal Model of Cardiovascular Responses to Stress and the Development of Cardiovascular Disease: Psychosomatic Medicine, 65(1), 22–35. https://doi.org/10.1097/01.PSY.0000046075.79922.61
  21. Garcia, M., Moazzami, K., Almuwaqqat, Z., Young, A., Okoh, A., Shah, A. J., Sullivan, S., Lewis, T. T., Elon, L., Ko, Y.-A., Hu, Y., Daaboul, O., Haddad, G., Pearce, B. D., Bremner, J. D., Sun, Y. V., Razavi, A. C., Raggi, P., Quyyumi, A. A., & Vaccarino, V. (2024). Psychological Distress and the Risk of Adverse Cardiovascular Outcomes in Patients With Coronary Heart Disease. JACC: Advances, 3(2), 100794. https://doi.org/10.1016/j.jacadv.2023.100794
  22. Powell-Wiley, T. M., Baumer, Y., Baah, F. O., Baez, A. S., Farmer, N., Mahlobo, C. T., Pita, M. A., Potharaju, K. A., Tamura, K., & Wallen, G. R. (2022). Social Determinants of Cardiovascular Disease. Circulation Research, 130(5), 782–799. https://doi.org/10.1161/CIRCRESAHA.121.319811
  23. Schultz, W. M., Kelli, H. M., Lisko, J. C., Varghese, T., Shen, J., Sandesara, P., Quyyumi, A. A., Taylor, H. A., Gulati, M., Harold, J. G., Mieres, J. H., Ferdinand, K. C., Mensah, G. A., & Sperling, L. S. (2018). Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions. Circulation, 137(20), 2166–2178. https://doi.org/10.1161/CIRCULATIONAHA.117.029652