Source/Disclosures
Disclosures: Malik reports no relevant financial disclosures. Smolderen reports she received research grants from Abbott, Boston Scientific, Terumo and W.L. Gore and Associates and consulted for Optum Labs. Please see the study for the other authors’ relevant financial disclosures.
June 23, 2020
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Chronic stress after new, worsening PAD diagnosis predicts long-term mortality

Source/Disclosures
Disclosures: Malik reports no relevant financial disclosures. Smolderen reports she received research grants from Abbott, Boston Scientific, Terumo and W.L. Gore and Associates and consulted for Optum Labs. Please see the study for the other authors’ relevant financial disclosures.
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Kim Smolderen

Among patients with new or worsening peripheral artery disease, chronic stress was independently associated with elevated risk for all-cause mortality in the subsequent 4 years, researchers reported.

Self-reported chronic stress at 1 year was common in this population, occurring in nearly 20% of patients, the researchers wrote.

woman stressed at work
Source: Adobe Stock.

“This is the first time that we have documented this association in peripheral artery disease,” Kim Smolderen, PhD, FAHA, co-director of the Vascular Medicine Outcomes Program in cardiovascular medicine section at Yale University, told Healio. “While there are evidence-based treatments to lower individuals’ stress, we do not know whether that may also help in lowering the risk for mortality in PAD. What we do know is that the burden of stress is real in these patients and more holistic chronic disease management should also integrate awareness and care for mental health concerns in this vulnerable population.”

In an analysis of the PORTRAIT study registry published in JAMA Cardiology, researchers used the Perceived Stress Scale, with a score range of 0 to 16, to assess stress at baseline, 3, 6 and 12 months among patients with new or worsening PAD (mean age, 68 years; 58% men; 72% white). A score of 6 or more was indicative of high stress, which was reported in 65% of participants at baseline and 17.6% at the 12-month follow-up. Chronic stress was defined as high levels of stress reported at two or more follow-up visits.

Stress and mortality in PAD

After adjustment for demographics, comorbidities, disease severity, treatment type and socioeconomic status, chronic stress at 12 months was associated with increased risk for all-cause mortality in the cohort in the subsequent 4 years (HR = 2.12; 95% CI, 1.14-3.94).

Moreover, among patients who developed chronic stress during the follow-up period, neither the presence nor absence of stress at baseline was significantly associated with all-cause mortality (HR with baseline stress = 1.43; 95% CI, 0.61-3.36; HR without baseline stress = 2.94; 95% CI, 1.31-6.63; P for interaction = .18).

“Chronic stress can manifest in the context of other psychiatric conditions, such as depression, or even without a clinically diagnosed mental condition,” the researchers wrote. “Various idiosyncratic triggers can overwhelm or stress individuals, such as marital and financial strain and job insecurity. Regardless of its trigger or root cause, chronic stress is associated with increased cardiovascular risk.

“However, stress is also known as a modifiable risk factor for which evidence-based management strategies exist,” the researchers wrote.

Chronic stress among subgroups

In other findings, patients with chronic stress, compared with those without chronic stress, were:

  • younger (mean age, 63.4 years vs. 69.5 years);
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  • more likely to be women (56.6% vs. 39.1%);
  • less likely to be white (59.7% vs. 74.2%);
  • more likely to smoke (44.1% vs. 27.8%);
  • more likely to have prior MI (25.6% vs. 21.2%); and
  • and were more likely to delay care due to cost (31.5% vs. 13.4%).

“Coping skills and stress reduction have been associated with improved quality of life in patients with coronary artery disease,” the researchers wrote. “Stress management learned through cognitive behavioral therapy programs and transcendental meditation, in addition to standard care, have also been associated with reduced risk of recurrent cardiovascular events in patients with coronary artery disease and longer life expectancy in women after acute myocardial infarction. Given the associations found in this study and that stress has been largely ignored as a risk factor in PAD, future research is needed to test the implications of stress management strategies for cardiovascular outcomes in patients with PAD.”