Greater Perceived Stress Levels Signal Increased Heart Failure Risk

A recent study from Weill Cornell Medicine is providing clinicians an overview of the impact stress can have on cardiovascular health.

An analysis of the REGARDS study, results suggest elevated stress levels were linked to increases in incident heart failure with preserved ejection fraction (HFpEF) but this association was not present for heart failure with reduced ejection fraction (HFrEF).

“Within the REGARDS cohort, increased psychological stress measured by PSS-4 was associated with incident HFpEF. HFpEF in general is thought to be a progressive systemic disorder influenced by aging and key comorbidities such as chronic kidney disease and obesity. It is possible that increased psychological stress is also one of these comorbid conditions,” said Lauren Balkan, MD, during her presentation at the Heart Failure Society of America (HFSA) 2020 Annual Meeting.

With an increased interest in the impact the inflammatory and neurohormonal pathways of psychological stress might impact cardiovascular health, and more specifically incident heart failure, Balkan and a team of colleagues from institutions across the US sought to describe these potential associations using data from a large cohort study. For their analysis, investigators chose to assess data from within the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, which was sponsored by the National Institutes of Health (NIH) and included data from more than 30,000 patients.

Of the 30,239 included in REGARDS, investigators included 25,785 in their final sample for the current analysis. Investigators excluded patients missing follow-up data, those not free of heart failure at baseline, and any remaining patients with missing or incomplete data from the 4-item Perceived Stress Scale (PSS-4) questionnaire.

Scores from the PSS-4 were used as the exposure variable for the analysis and, due to their differing pathways, HFpEF and HFrEF were used as separate outcome variables. For the purpose of analysis, patients were categorized into 4 groups based on PSS-4 scores. These groups were defined as having scores of 0, 1-2, 3-4, and 5 or greater.

From REGARDS, investigators were able to obtain sociodemographic information as well as data on lifestyle factors such as smoking status, alcohol use, and physical activity. REGARDS also provided information related to systolic and diastolic blood pressure, BMI, and data related to comorbid conditions. All of the aforementioned factors were included as covariates in Cox proportional hazard model to examine associations between PSS-4 and incident heart failure.

The mean age of the 25,785-patient cohort was 64 (9.3) years, 55% were female, 40% were Black, and the median follow-up time was 10.1 years. During the follow-up period, 1109 (4.3%) of patients experienced an incident heart failure event—356 HFpEF and 465 HFrEF events, respectively.

Upon analysis of PSS-4 questionnaires, 6585 had a PSS-4 score of 0, 6136 had scores of 1-2, 5834 had scores of 3-4, and 7230 had a score of 5 or greater. Compared to their counterparts in the lowest quartile, those with the highest PSS-4 scores were more likely to be female, black, and have an annual household income of less than $35,000.

In adjusted analyses, those investigators found participants with scores of 1 or greater were at an increased risk for incident HFpEF when compared to those with a PSS-4 of 0. Specific with hazard ratios for each group were 1.37 (95% CI, 1.00-1.89) for those with a PSS-4 of 1-2, 1.42 (95% CI, 1.04-1.95) for those with a PSS-4 of 3-4, and 1.41 (95% CI, 1.04-1.92) for those with a PSS-4 of 5 or greater. In contrast, the associations for PSS-4 and HFrEF did not reach statistical significance.

During her presentation, Balkan noted strengths and limitations within the design of the study for clinicians to take into account when interpreting data from within the study. Among the strengths, investigators noted the adjudication of heart failure events and generalizability of the REGARDS cohort. Investigators also noted self-reporting, only assessing PSS-4 at a single time point, and the inability to determine causation as limitations of their study.

This study, “Perceived Stress Is Associated With Incident Heart Failure With Preserved Ejection Fraction,” was presented at HFSA 2020.