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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 4  |  Page : 262-266

Perceived stress and cardiovascular disease in a community-based population

1 Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Guangzhou, China
2 Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Guangzhou, China; Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Solna, Sweden, China

Date of Submission22-Oct-2022
Date of Acceptance11-Nov-2022
Date of Web Publication16-Dec-2022

Correspondence Address:
Prof. Yiqiang Zhan
Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Guangzhou
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_55_22

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Background: Perceived stress plays an important role in the pathogenesis of cardiovascular diseases (CVDs). Their associations with CVDs in the Chinese population are less investigated. The present study aims to investigate the associations of perceived stress with well-defined CVDs in a population-based survey in Shenzhen, China. Methods: In the community-based survey, we recruited 2,287 participants aged 18 years and over from 8 communities in Shenzhen, China. Perceived stress was assessed using the modified Chinese version of the Perceived Stress Scale with 14 items and a five-point Likert scale. CVDs including coronary heart disease, heart failure, and atrial fibrillation were ascertained from electronic health records and confirmed by family physicians. Potential confounders included age, sex, educational attainment, occupation, smoking, and alcohol-drinking habits. Multivariable logistic regression models were employed to estimate the magnitude of the associations. Results: Overall, the average perceived stress score was 37.2 (standard error: 7.2 and range: 14–70) among the participants. The prevalence of CVDs was 2.7%. After controlling for age, sex, educational attainment, occupation, smoking, and alcohol-drinking habits, a higher perceived stress score was significantly associated with higher risks of CVDs (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.01–1.55). The associations were comparable among men (OR: 1.20, 95% CI: 1.01–1.43) and women (OR: 1.29, 95% CI: 1.02–1.63). We also examined the potential nonlinear relationship using restricted cubic spines and found that the relationship was almost linear. Conclusions: Our analysis showed that higher perceived stress was associated with higher risks of CVDs among adults. Future studies are warranted to clarify the biological mechanisms and shed light on these associations.

Keywords: Cardiovascular diseases, perceived stress, psychological stress, risk factors

How to cite this article:
Zhang Y, Zhang A, Xiang J, Zhan Y. Perceived stress and cardiovascular disease in a community-based population. Heart Mind 2022;6:262-6

How to cite this URL:
Zhang Y, Zhang A, Xiang J, Zhan Y. Perceived stress and cardiovascular disease in a community-based population. Heart Mind [serial online] 2022 [cited 2023 May 31];6:262-6. Available from: http://www.heartmindjournal.org/text.asp?2022/6/4/262/363954

  Introduction Top

Cardiovascular diseases (CVDs) are one of the leading causes of death from the global perspective.[1] Traditional modifiable risk factors including obesity, smoking, hypertension, diabetes, and abnormal lipid fractions cannot fully clarify the variations in the occurrence of CVD. Psychosocial factors, in particular, play an important role in the development of CVD. Types of chronic stress, such as occupation-related stress and psychosocial stress, were reported to be associated with a higher risk of CVD. It might be that, however, perceived stress, the subjective perception that environmental demands exceed perceived ability and capacity, is also associated with CVD risk and aging-related disorders.[2],[3] A previous meta-analysis using data from six studies summarized the results and reported that people with higher perceived stress were associated with higher risks of the incidence of coronary heart disease.[4] These studies used data from European and Japanese populations. Studies on this topic based on Chinese populations are limited.[5]

In the present study, we aimed to revisit the association between the perceived stress score assessed by the Perceived Stress Scale (PSS)[6] and the risks of CVD in a community-based population in Shenzhen, China. Further, we sought to examine if there were interactions between perceived stress and gender. We made the hypothesis that a higher perceived stress score was related to higher risks of CVD and gender could modify the observed associations.

  Methods Top

Study population

Study participants were recruited from eight communities using a simple sampling method in Shenzhen, China. The primary aim of this survey was to investigate the status of stress levels and health outcomes in this population. Citizens or local permanent residents (people who are registered as Shenzhen citizens, but not those who lived outside of Shenzhen for no <6 months, and nonregistered Shenzhen citizens who have temporary residence permits and have lived in Shenzhen for no <6 months) who were 18 years or older were recruited. Data collection was carried out from July to August 2022. At the beginning of the survey, our administrative staff collaborated with local administrative heads and told them our aim and methods of this survey. Because of their collaboration, we could share and inform them of our study design by social media and printed handouts. All families in the communities were informed, and only one member of a house was invited to our study. An onsite questionnaire was administered by trained staff members and health professionals at the corresponding community health service centers. In total, 2,287 participants aged 18 years and over completed the questionnaires. This study was approved by the Ethical Review Board of the School of Public Health (Shenzhen), Sun Yat-Sen University.

Perceived Stress Scale

The PSS is the most widely used psychological scale for measuring the subjective perception of stress in the general population. The participants should be those whose educational attainment level was at least junior high school.[6] During the PSS administration, the respondents were asked to fill in the forms which described the subjective feeling of how often certain things occurred including nervousness, feeling of upset, loss of control, piling up difficulties that cannot be handled, or on the contrary how often the participants felt they were able to handle situations and were on top of things. We used the Chinese version of the 14-item PSS. The respondents' answers were recorded on a five-point Likert scale (never, almost never, sometimes, often, and very often) following the instructions of the PSS guide. Higher scores imply greater perceived stress levels. The Chinese version of PSS has been validated with a Cronbach's alpha of being 0.87 in our sample and has been extensively used in other studies previously.

Ascertainment of cardiovascular diseases

CVD was ascertained from electronic health records, confirmed by family physicians, and included coronary artery disease, heart failure, and atrial fibrillation.

Potential confounders

Marital status was categorized as single, currently married, currently divorced, separated, and widowed. Participants' educational level was coded as high school and below, vocational college degree, bachelor, and master's and above. Smoking status was recorded as never, current smoker, and ever smoker, while alcohol-drinking status was assessed as never, current alcohol drinking, and ever alcohol drinking. Weight and height were measured by trained staff using a calibrated instrument. Height was recorded to the nearest 0.5 cm wearing no foot wares, and weight was assessed to the nearest 0.1 kg. Body mass index was then estimated as weight (kg) divided by the square of height (m).

Statistical analysis

Descriptive statistics were presented in men and women separately. Mean and standard deviations were presented for continuous variables, while counts and percentages (%) were calculated for categorical phenotypes. Multivariable logistic regression models were employed to estimate the associations and magnitudes between perceived stress scores and the risks of CVD. Results are described as odds ratio (OR) and 95% confidence intervals (CIs) after controlling for potential confounders. A potential nonlinear relationship between the perceived stress sores and CVD was tested and investigated by treating perceived stress scores as restricted cubic splines. We further carried out gender-specific analyses to test the potential effect modification of sex. All the analyses were two-tailed, and P < 0.05 was taken as statistically significant. All analyses were performed using R 4.1 (R Foundation for Statistical Computing, Vienna, Austria).

  Results Top

Demographic characteristics of the study population

The basic demographic characteristics of the study population are shown in [Table 1]. The average ages of the study participants were 41.4 years old and those aged 66 years old only accounted for 6.5%. Among the total study participants, only 2.7% were diagnosed with CVD with 3.0% in men and 2.5% in women.
Table 1: Basic characteristics of study participants

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Cardiovascular disease prevalence by perceived stress scores

In general, as shown in [Figure 1], the prevalence of CVD increased with higher perceived stress scores (P < 0.05 for men, women, and total). Comparable results were observed for both men and women.
Figure 1: Prevalence of CVD by perceived stress scores. CVD=Cardiovascular disease

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Associations between perceived stress and cardiovascular disease

After controlling for age, sex, smoking status, educational attainment, occupation, and alcohol-drinking status, one unit increase in the perceived stress score was associated with a higher risk of CVD in both men and women with ORs (95% CI) being 1.20 (1.01–1.43) and 1.29 (1.02–1.63) for men and women, respectively [Table 2]. Compared with people with lower perceived stress scores, those with higher scores had higher risks of CVD with OR (95% CI) being 2.82 (1.45–1.70). We also tested potential effect modification for sex but did not find significant results. The CIs of these associations overlapped for men and women. In addition, we carried out restricted cubic splines analysis by treating the perceived stress score as a continuous variable and found that the association was almost linear as shown in [Figure 2].
Table 2: Association between perceived stress and cardiovascular diseases, odds ratio (95% confidence interval)

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Figure 2: Association between perceived stress and CVDs in the study participants. The solid line denotes the association (OR) between perceived stress score and cardiovascular diseases and dashed lines represent the 95% CIs, CVD=Cardiovascular disease, OR=Odds ratio, CIs=Confidence intervals

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  Discussion Top

In this study, we investigated the associations between perceived stress and CVD in a Chinese population and found that a higher perceived stress score was associated with a higher risk of CVD. Interestingly, we also found that the magnitudes and directions of these associations were comparable in men and women. No significant effect modification effects were observed for sex and the relationship was almost linear.

Several previous epidemiological surveys have reported the relationships between perceived stress with CVD risk in diverse populations.[4],[7],[8],[9],[10],[11] For example, a previous study leveraging data from six prospective cohort studies found that a high perceived stress level was associated with 27% higher risks of the incidence of coronary heart disease.[4] Similar results were observed in the Japan Collaborative Cohort Study for Evaluation of Cancer Risk Sponsored by Monbusho involving 73,424 patients, which found that high stress was associated with 28% higher risks of coronary heart disease and 64% higher risks of total CVD.[8] Similar results were also reported earlier in a Swedish cohort that reported a 50% higher risk of coronary heart disease among those who had two or more stressors in men.[9] Likewise, one study using data from the Australian population found that perceived stress rather than mental health index was a significant and independent predictor for coronary heart disease.[10] Other studies, however, did not find a significant association with coronary heart disease mortality in the Scottish population.[12] The discrepancies may lie in the fact that different studies used different instruments to measure stress and study designs and populations differ as well. Noticeably, stress is a phenomenon that is dependent on social and cultural contexts. It is, therefore, reasonable that stress may play different roles in diverse societies.

The biological mechanisms behind perceived stress and adverse outcomes of CVD have been not fully clarified yet.[13] Multiple pathways may contribute to the links. For example, the hypothalamus receives afferents from several neural organisms involved in the stress reaction and could trigger the hypothalamic-pituitary-adrenal (HPA) axis.[14],[15],[16] The activation of the HPA axis could in turn stimulate the secretion of cortisol levels in humans. Increased cortisol has a couple of physiological effects on adiposity and blood pressure as well as CVD. Further, the HPA axis can lead to endothelial dysfunctions,[17],[18] which mainly involve inflammatory activities that play an important role in stress and atherosclerosis. Other possible pathways include the activity of the amygdala and leukopoiesis.[19],[20] Further studies, however, are warranted to have a better understanding of the pathways.

Our study has a few strengths. First, we used a validated instrument, the Chinese version of the PSS, to assess stress. The scale has been validated and used in a couple of settings including epidemiological and psychological research.[5],[16],[21] Second, we used both electronic health records and physician diagnosis to ascertain CVD and could therefore reduce bias due to misclassification. Third, we employed an interaction analysis to examine the potential effect modification effects of sex, albeit we did not find a significant association. Finally, we examined the potential nonlinear relationships in the associations between perceived stress and the risks of CVD that were seldom investigated. We found the relationship is almost linear and therefore boosted our confidence in the observed associations for the present and previous studies.

A few limitations should also be acknowledged. Our survey employed a cross-sectional design. The built-in limitation of the cross-sectional study design implies that we cannot draw a firm causal conclusion for the associations between perceived stress and the risk of CVD. Longitudinal data with longer follow-up durations could strengthen our confidence in causal inference. Second, we are unable to employ a multistage sampling method to recruit participants because of the logistic and difficulties during the pandemic. The simple sampling approach may underestimate the prevalence of CVD in this area. However, our sampling approach is much better than social media-based approaches which are commonly used during the pandemic nowadays. Moreover, it has been shown that stress is a dynamic process and should be assessed repeatedly. Future research could incorporate both subjective and objective assessments of stress levels. In addition, more elaborated measurements of the severity, type, and duration of separate stressors could be collected repeatedly, with the primary aim to gain further knowledge on how and why stress can trigger the risks of CVD.

  Conclusions Top

In summary, our present analysis of this survey found that perceived stress scores were associated with higher risks of CVD in the Chinese population and the relationship is almost linear without effect modification by sex. Future studies are warranted to clarify the biological mechanisms and shed light on these associations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: Update from the GBD 2019 study. J Am Coll Cardiol 2020;76:2982-3021.  Back to cited text no. 1
Mathur MB, Epel E, Kind S, Desai M, Parks CG, Sandler DP, et al. Perceived stress and telomere length: A systematic review, meta-analysis, and methodologic considerations for advancing the field. Brain Behav Immun 2016;54:158-69.  Back to cited text no. 2
Schutte NS, Malouff JM. The relationship between perceived stress and telomere length: A meta-analysis. Stress Health 2016;32:313-9.  Back to cited text no. 3
Richardson S, Shaffer JA, Falzon L, Krupka D, Davidson KW, Edmondson D. Meta-analysis of perceived stress and its association with incident coronary heart disease. Am J Cardiol 2012;110:1711-6.  Back to cited text no. 4
Li D, Rong C, Kang Q. Association between perceived stress and hypertension in Chinese adults: A population-based survey. J Hum Hypertens 2022; [Doi 10.1038/s41371-022-00684-y].  Back to cited text no. 5
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.  Back to cited text no. 6
Felix AS, Lehman A, Nolan TS, Sealy-Jefferson S, Breathett K, Hood DB, et al. Stress, resilience, and cardiovascular disease risk among black women. Circ Cardiovasc Qual Outcomes 2019;12:e005284.  Back to cited text no. 7
Iso H, Date C, Yamamoto A, Toyoshima H, Tanabe N, Kikuchi S, et al. Perceived mental stress and mortality from cardiovascular disease among Japanese men and women: The Japan collaborative cohort study for evaluation of cancer risk sponsored by Monbusho (JACC study). Circulation 2002;106:1229-36.  Back to cited text no. 8
Rosengren A, Tibblin G, Wilhelmsen L. Self-perceived psychological stress and incidence of coronary artery disease in middle-aged men. Am J Cardiol 1991;68:1171-5.  Back to cited text no. 9
Strodl E, Kenardy J, Aroney C. Perceived stress as a predictor of the self-reported new diagnosis of symptomatic CHD in older women. Int J Behav Med 2003;10:205-20.  Back to cited text no. 10
Nielsen NR, Kristensen TS, Prescott E, Larsen KS, Schnohr P, Grønbaek M. Perceived stress and risk of ischemic heart disease: Causation or bias? Epidemiology 2006;17:391-7.  Back to cited text no. 11
Macleod J, Davey Smith G, Heslop P, Metcalfe C, Carroll D, Hart C. Limitations of adjustment for reporting tendency in observational studies of stress and self reported coronary heart disease. J Epidemiol Community Health 2002;56:76-7.  Back to cited text no. 12
Dar T, Radfar A, Abohashem S, Pitman RK, Tawakol A, Osborne MT. Psychosocial stress and cardiovascular disease. Curr Treat Options Cardiovasc Med 2019;21:23.  Back to cited text no. 13
Girod JP, Brotman DJ. Does altered glucocorticoid homeostasis increase cardiovascular risk? Cardiovasc Res 2004;64:217-26.  Back to cited text no. 14
Goebel MU, Mills PJ, Irwin MR, Ziegler MG. Interleukin-6 and tumor necrosis factor-alpha production after acute psychological stress, exercise, and infused isoproterenol: Differential effects and pathways. Psychosom Med 2000;62:591-8.  Back to cited text no. 15
Huang QH, Takaki A, Arimura A. Central noradrenergic system modulates plasma interleukin-6 production by peripheral interleukin-1. Am J Physiol 1997;273:R731-8.  Back to cited text no. 16
Mangos GJ, Walker BR, Kelly JJ, Lawson JA, Webb DJ, Whitworth JA. Cortisol inhibits cholinergic vasodilation in the human forearm. Am J Hypertens 2000;13:1155-60.  Back to cited text no. 17
Eisenach JH, Clark ES, Charkoudian N, Dinenno FA, Atkinson JL, Fealey RD, et al. Effects of chronic sympathectomy on vascular function in the human forearm. J Appl Physiol (1985) 2002;92:2019-25.  Back to cited text no. 18
Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007;370:1089-100.  Back to cited text no. 19
Tawakol A, Ishai A, Takx RA, Figueroa AL, Ali A, Kaiser Y, et al. Relation between resting amygdalar activity and cardiovascular events: A longitudinal and cohort study. Lancet 2017;389:834-45.  Back to cited text no. 20
Huang F, Wang H, Wang Z, Zhang J, Du W, Su C, et al. Psychometric properties of the perceived stress scale in a community sample of Chinese. BMC Psychiatry 2020;20:130.  Back to cited text no. 21


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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