Psychological Distress as a Risk Factor for Cardiovascular Events

Objectives This study sought to estimate the extent to which behavioral and pathophysiological risk factors account for the association between psychological distress and incident cardiovascular events. Background The intermediate processes through which psychological distress increases the risk of cardiovascular disease (CVD) are incompletely understood. An understanding of these processes is important for treating psychological distress in an attempt to reduce CVD risk. Methods In a prospective study of 6,576 healthy men and women (ages 50.9 +/- 13.1 years), we measured psychological distress (using the 12-item version of the General Health Questionnaire >= 4) and behavioral (smoking, alcohol, physical activity) and pathophysiological (C-reactive protein, fibrinogen, total and high-density lipoprotein cholesterol, obesity, hypertension) risk factors at baseline. The main outcome was CVD events (hospitalization for non-fatal myocardial infarction, coronary artery bypass, angioplasty, stroke, heart failure, and CVD-related mortality). Results Cigarette smoking, physical activity, alcohol intake, C-reactive protein, and hypertension were independently associated with psychological distress. There were 223 incident CVD events (63 fatal) over an average follow-up of 7.2 years. The risk of CVD increased in relation to presence of psychological distress in age- and sex-adjusted models (hazard ratio: 1.54, 95% confidence interval: 1.09 to 2.18, p = 0.013). In models that were adjusted for potential mediators, behavioral factors explained the largest proportion of variance (similar to 65%), whereas pathophysiological factors accounted for a modest amount (C-reactive protein similar to 5.5%, hypertension, similar to 13%). Conclusions The association between psychological distress and CVD risk is largely explained by behavioral processes. Therefore, treatment of psychological distress that aims to reduce CVD risk should primarily focus on health behavior change. (J Am Coll Cardiol 2008; 52: 2156-62) (C) 2008 by the American College of Cardiology Foundation