Elsevier

The Lancet

Volume 370, Issue 9592, 22–28 September 2007, Pages 1089-1100
The Lancet

Review
The cardiovascular toll of stress

https://doi.org/10.1016/S0140-6736(07)61305-1Get rights and content

Summary

Psychological stress elicits measurable changes in sympathetic-parasympathetic balance and the tone of the hypothalamic-pituitary-adrenal axis, which might negatively affect the cardiovascular system both acutely—by precipitating myocardial infarction, left-ventricular dysfunction, or dysrhythmia; and chronically—by accelerating the atherosclerotic process. We provide an overview of the association between stress and cardiovascular morbidity, discuss the mechanisms for this association, and address possible therapeutic implications.

Section snippets

Sympathetic nervous system

The peripheral sympathetic nervous system, the other effector limb of the stress response, innervates tissues throughout the body, especially the heart, vasculature, and adrenal medulla. It is the means by which the brain affects body organs in response to acute stress.6 The adrenal medulla responds with systemic catecholamine release (predominantly epinephrine), whereas the sympathetic nerve terminals that line the vasculature release norepinephrine, which accounts for most circulating

Stress physiology

Vascular and metabolic effects of the hypothalamic-pituitary-adrenal axis and sympathetic nervous activity are diverse.10, 13 Both systems potentially harm the vasculature by increasing blood pressure, decreasing insulin sensitivity with or without hyperglycaemia, and activating haemostasis (figure).14, 15 Some evidence suggests that both systems might precipitate endothelial dysfunction—an important early manifestation of atherosclerosis—but these data are inconsistent.16, 17, 18

These two

Cardiovascular effects of stress

Acute physical stressors such as surgery, trauma, and intense physical exertion are well-known triggers of cardiovascular events. Emotional stressors are increasingly recognised as precipitants of such events. For example, on the day of the Northridge earthquake in Los Angeles, CA, USA in 1994, the number of cardiac deaths within the city and surrounding county in individuals who did not undergo direct physical trauma or increased physical exertions was two to five times higher than the usual

Subacute and chronic stressors

Major life changes associated with psychological and emotional adjustment are associated with an increased risk of cardiac events, in many cases with a magnitude of association similar to traditional cardiovascular risk factors. For example, in the months after the death of a spouse, mortality from all causes, particularly cardiovascular ones, is increased.49 Similarly, the fear in the USA subsequent to the terrorist attacks on the World Trade Center in New York in 2001 resulted in a rate of

Effects of chronic psychological states

Major depression, anxiety, post-traumatic stress disorder, and personality types with tendencies toward hostility, pessimism, or social isolation have all been associated with cardiovascular morbidity.56, 57, 58, 59, 60, 61 Depression, however, has received the most attention, since it is common and has a striking and consistent association with cardiovascular disease. The prevalence of major depression is about 20% in cross-sectional studies of patients with known heart disease, and depression

Mechanisms of cardiovascular disease in chronic emotional stress

By contrast with acute stress, which can trigger acute thrombotic, arrhythmic, or mechanical cardiovascular events, chronic stress seems to affect cardiovascular risk mainly by acceleration of the atherosclerotic process. Elucidation of the mechanisms by which chronic stress leads to cardiovascular morbidity is challenging. Although physiological pathways exist through which chronic stress could potentiate cardiovascular disease (such as increased blood pressure), behavioural changes (such as

Variations of stress axis response to stress

Individuals are not equally susceptible to stress-mediated cardiovascular events. To address this issue, Strike and colleagues110 studied the biological changes induced by a standardised laboratory psychological stressor in 34 men who had had myocardial infarction an average of 15 months before the study. These patients were divided into two groups—those who reported an emotional trigger for their myocardial infarction (14 patients) and those who did not. The patients who reported an emotional

Diurnal variations

Activity of both the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system show striking diurnal variation. Peak corticotropin and cortisol concentrations occur in the early morning, and peak cortisol concentrations can be ten times higher than at trough.129 Circulating norepinephrine and epinephrine concentrations show large diurnal variation with increases throughout the day and decreases at night.129

Proposed mechanisms to explain why ischaemic heart events and

Measuring chronic overactivity of the stress response

No gold-standard tests exist for measurement of acute activity or chronic tone of the neuroendocrine stress axes. Although the assumption that circulating hormone concentrations (cortisol or catecholamines) represent the activity of these systems is tempting, the complexity of these systems defies this simple assumption, especially for detection of chronic (sometimes subtle) changes. Tissue effects of the sympathetic nervous system and the hypothalamic-pituitary-adrenal-axis activity depend not

Conclusion

Stress is clearly an important—and potentially modifiable—risk factor for acute and chronic adverse cardiovascular disorders (table 3), and effective medications are already in use (such as β-adrenergic antagonists) that restrict some of the downstream effects of stress-axis activation. Despite few well-controlled studies of stress-reduction in the management of patients with or at risk for cardiovascular disease, ample evidence exists for a strong and consistent association of acute and

Search strategy and selection criteria

We sought to identify epidemiological studies examining the association between chronic or acute stressors and cardiovascular risk factors or events, and studies that clarify the physiological underpinnings for this association. Although we did not undertake a systematic review of all available studies on this topic, we did search for relevant articles in Medline and the Cochrane database (from January, 1990, to March, 2006) linking search terms related to psychological stress (including

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