Introduction
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Is stress at work related to cardiovascular morbidity and mortality (coronary heart disease, stroke and hypertension)?
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Which stress models and which CVD outcomes have the strongest evidence for an association?
Methods
Overview of included studies
First author/publication year Cohorta/study Country | Level of evidenceb
| Participants (n) Age | Cases (n) follow-up duration | Outcomec
| Risk estimate (95% CI) Confounders in minimal modeld
| Risk estimate (95% CI) Confoundersd, e in fully adjusted model |
---|---|---|---|---|---|---|
Kuper (2003) Whitehall UK |
2++ | 10,308 35–55 years | 921 cases 11 years | CHD, morbidity and mortality |
f + m 1.57 (1.26–1.96)
Age, sex |
f + m 1.38 (1.1–1.75)
Age, sex, employment grade, coronary risk factors |
Chandola (2008)f
Whitehall UK | 2+ | 10,308 35–55 years | 522 cases 12 years | CHD, morbidity and mortality | Isostrain
f + m 1.33 (1.04–1.69)
Age, sex, biological and behavioural risk factors, employment grade | |
Netterstrøm (2006) MONICA II Denmark | 2+ | 659 30–60 years | 47 cases 13 years | CHD, morbidity and mortality | Job strain m 2.4 (1.0–5.6) age | Job strain m 2.4 (1.0–5.7) Age, biological and behavioural risk factors, social status |
De Baquer (2005) Belstress/JACE Belgium | 2+ | 14,337 35–59 years | 87 cases 3 years | CHD, morbidity and mortality | Job strain m 1.35 (0.73–2.49) Isostrain
m 1.91 (1.07–3.41)
Age, ISCO code | Job strain m 1.26 (0.66–2.41) Isostrain
m 1.92 (1.05–3.54)
Age, ISCO code, BMI, smoking, company |
Eaker (2004) Framingham offspring USA | 2+ | 3,039 18–77 years | 149 cases 10 years | CHD, morbidity and mortality | Job strain m 0.85 (0.5–1.45) f 1.63 (0.57–4.67) Age, SBP, smoking, diabetes | |
André-Petersson et al. (2007) Malmö cancer and diet study Sweden | 2+ | 7,770 47–73 years | 291 cases 7.8 years | CVD, morbidity and mortality | Job strain MI f 1.29 (0.44–3.85) m 1.17 (0.53–2.99) Stroke f 1.16 (0.56–2.40) m 1.03 (0.53–2.99) No adjustment | Isostrain MI or stroke f 1.51 (0.7–3.27) m 1.11 (0.6–2.06) Age, diabetes, anti-hypertensive medication, smoking, low physical activity |
Kivimäki (2002) Valmet Finland | 2+ | 812 18 to >47 years | 73 cases 25.6 years | CVD mortality | Job strain
f + m 2.2 (1.16–4.17)
Age, sex | Job strain
f + m 2.22 (1.04–4.73) Age, sex, behavioural and biological risk factors |
Kivimäki (2008) WOLF Sweden |
2+ | 3,160 19–55 years | 93 cases 9.5 years | CVD, morbidity and mortality | Job strain m 1.76 (1.05–2.95) Age, sex | |
Kornitzer (2006) JACE Spain, France, Belgium, Sweden | 2+ | 20,435 35–59 years | 129 cases 3.25 years | CHD, morbidity and mortality | Job strain m 1.53 (1.0–2.35) Age | Job strain m 1.47 (0.96–2.25) Age, smoking, biological risk factors |
Kuper (2006) Swed. women lifestyle and health cohort Sweden |
2+ | 35,471 30–50 years | 200 cases 11.2 years | Stroke, morbidity and mortality | Job strain f 1.2 (0.8–1.9) Age | |
Kuper (2006) swed. women lifestyle and health cohort Sweden |
2+ | 35,471 30–50 years | 210 cases 11.3 years | CHD, morbidity and mortality | Job strain f 1.4 (0.7–2.7) age | Job strain f 1.0 (0.5–1.9) Age, biological and behavioural risk factors |
Uchiyama (2005) Hypertension follow-up group Japan | 2+ | 1,615 40–65 years | 38 cases 5.6 years | CVD mortality | Job strain f 6.66 (0.93–47.7) m 1.75 (0.49–6.29) Age | Job strain
f 9.05 (1.17–69.86)
m 1.86 (0.51–6.75) Age, biological and behavioural risk factors |
Fauvel (2003) France | 2− | 292 18–55 years | 93 cases 5 years | Progression to hypertension (>7 mm increase in SBP or DBP) | f + m p > 0.05 No adjustment | |
Tsutsumi (2006) Jichi medical school Japan |
2− | 6,509 18–65 years | 35 cases 9.4 years | CVD mortality | Job strain f + m 2.47 (0.81–7.51) Age, sex | Job strain f + m 1.98 (0.59–6.7) Age, sex, occupation, community, biological and behavioural risk factors |
Tsutsumi (2009) Jichi medical school Japan | 2− | 6,553 18–65 years | 147 cases 11 years | Stroke morbidity and mortality | Job strain f 1.25 (0.56–2.78)
m 2.62 (1.13–6.04)
Age, region | Job strain f 1.46 (0.63–3.38)
m 2.53 (1.08–5.94) Age, area, behavioural and biological risk factors |
Lee (2002) Nurses health study USA | 2− | 35,038 46–71 years | 146 cases 4 years | CHD morbidity and mortality | Job strain f 0.8 (0.48–1.34) Age | Job strain f 0.71 (0.42–1.19) Age, smoking alcohol, menopausal status, biological risk factors, parental history of CVD |
Markovitz (2004)f
CARDIA USA | 2− | 3,200 20–32 years | 89 cases 8 years | Hypertension (SBP > 160 or DBP > 95 mmHg) | Job strain f + m 2.06 (1.01–4.26) Age, BMI, baseline blood pressure |
First author/Publication year Cohorta/study Country | Level of evidenceb
| Participants (n) Age | Cases (n) follow-up duration | Outcomec
| Risk estimate (95% CI) Confounders in minimal modeld
| Risk estimate (95% CI) Confoundersd,e in fully adjusted model |
---|---|---|---|---|---|---|
Kuper (2002) Whitehall Whitehall | 2++ | 10,308 35–55 years | 931 cases 11 years | CHD, morbidity and mortality |
f + m 1.22 (1.01–1.46)
Age, sex |
f + m 1.26 (1.03–1.55)
Age, sex, employment grade, behavioural and biological risk factors |
Chandola (2005)f
Whitehall UK | 2+ | 10,308 30–55 years | 206 cases 4 years | Angina pectoris | f n.s.
m
p < 0.01
| |
Kivimäki (2002) Valmet Finland | 2+ | 812 <27 to >47 years | 73 cases 25.6 years | CVD mortality |
f + m 2.36 (1.24–4.42)
Age, sex |
f + m 2.42 (1.02–5.73)
Age, sex, occupational group, behavioural and biological risk factors |
Siegrist (1990) Germany | 2− | 416 25–55 years | 21 cases 6.5 years | CHD, morbidity and mortality |
m 3.42 (0,83)g
Age, BMI, SBP, LDL |
First author/publication year Cohorta/study Country | Level of evidenceb
| Participants (n) Age | Cases (n) follow-up duration | Stress model/work stress items | Outcomec
| Risk estimate (95% CI) Confounders in minimal modeld
| Risk estimate (95% CI) Confoundersd,e in fully adjusted model |
---|---|---|---|---|---|---|---|
Lynch (1997) Kuopio Ischemic Heart Disease Risk Factor Study Finland | 2+ | 2,297 42–60 years | 182 cases 8.1 years | High demand together with low resources and low income | CVD, morbidity and mortality |
m 3.13 (1.48–6.6)
Age | m 1.54 (0.67–3.54) Age, behavioural risk factors, psychosocial risk factors, biological risk factors |
Hibbard (1993) USA | 2− | 1,502 18–65 years | 205 cases 15 years |
Work stress summary of 10 items addressing working hours, flexibility, degree of mentally and physically tiring, skill usage | CVD, morbidity and mortality | CHD f 1 (0.8–1.3) m 1.1 (1.0–1.2) stroke f 0.9 (0.7–1.1) m 1 (0.9–1.1) Age, education, self-reported health | |
Matthews (2002) MRFIT USA | 2− | 12,336 35–57 years | 771 cases 9 years |
Presence of >3 of the following items: new workplace, demotion, business failure, troubles with colleagues, disability, being fired | CVD, morbidity and mortality |
m 1.34 (1.07–1.67)
Age, study group, biological risk factors | |
Suadicani (1993) Copenhagen male study Denmark | 2− | 1,638 55–47 years | 46 cases 4 years | Work pace too fast, little influence on job organisation | CHD, morbidity and mortality | m p > 0.05 No adjustment | |
Theorell (1977) Sweden | 2− | 5,187 41–61 years | 31 cases 2 years |
Workload index: includes items to responsibilities, problems with workmates, unemployment or changes in type of work | CHD morbidity and mortality |
m
p < 0.01
Age | |
Netterström (1988) Denmark | 2− | 2,045 20–64 years | 89 cases 8 years | ‘Suffering from stress several times a months’ | CHD, morbidity and mortality | m 1.1 (0.7–1.8) Age, smoking |