Marital stress worsens prognosis in women with coronary heart disease

Fran Lowry

December 20, 2000

Wed, 20 Dec 2000 16:37:07

Chicago, IL - Marital stress, but not work stress, predicts poor prognosis in women aged 30 to 65 with coronary heart disease (CHD). The finding, from the Stockholm Female Coronary Risk (FemCorRisk) study, suggests that specific preventive measures be tailored to the needs of women with CHD, Dr Kristina Orth-Gomer (Karolinska Hospital, Stockholm, Sweden) and FemCorRisk co-investigators conclude in the December 20, 2000 issue of JAMA.

Married with CHD: Swedish researchers say women who had a recurrent coronary event reported more severe marital stress than those who did not (Source: FOX TV)

Psychosocial stress, particularly work stress, has been linked to CHD in men, but the impact of such stress has rarely been studied in women, Orth-Gomer et al write, explaining their rationale for undertaking the population-based, prospective follow-up study, which was conducted among women residing in Stockholm. The study has shown that low socioeconomic position and work stress increase CHD risk, and that lack of social support and depression worsen prognosis among women. This population-based study prospectively investigated the effect of marital and work stress in 292 consecutive female patients aged 30 to 65 years, working or living with a male partner, who were hospitalized for an acute coronary event and followed for an average of 5 years. Marital stress was assessed by the Stockholm Marital Stress Scale (SMSS), while work stress and traditional risk factors were assessed by standard measures, the investigators write.

Marital stress raised risk of new event 3-fold

Women who had a recurrent coronary event reported more severe marital stress than those who did not (p = .007). Self-reported experience of marital stress at baseline worsened prognosis, as manifested by cardiac death, acute MI (AMI) or revascularization. Women with severe marital stress had a 3-fold increased risk of a new coronary event compared with women without marital stress, even after possible confounding factors, including left ventricular dysfunction, poor health habits, and standard coronary risk factors were controlled for, Orth-Gomer et al found.


Strain from a problematic spousal relationship significantly contributed to a poor prognosis over and above the effect of clinical predictors.


Specifically, of the 292 women in the FemCorRisk study, the investigators found that 64% were married or living with a male partner, and 70% were working. During the follow-up period, women living with husbands or partners had 8 deaths, including 5 from ischemic heart disease. There were 11 recurrent AMIs, 24 percutaneous transluminal coronary angioplasties (PTCAs), and 22 CABG procedures during the 5-year follow-up period. In total, 52 patients died of ischemic heart disease, had a recurrent AMI or a revascularization procedure, or a combination of these, and were considered to have had a new coronary event, the investigators reported.

Work stress did not affect women's heart health

However, there was no statistical evidence that work stress affected women's coronary events, whether they were in a live-in relationship, or lived alone. This contrasts with the finding that work stress adversely affects both incident and recurrent CHD in men.

However, the authors say that caution is needed to interpret this result, because statistical power in the follow-up of cohabiting working women patients (n=130) was diminished. Still, they add that their analyses of all working women (n=200), including those living alone, did not alter the results.

The investigators found some interesting differences between how men and women perceive support in their respective relationships. While men tended to say their wives or partners were their main source of social support, women were more likely to name a relative, usually female, as their main source of social support. Women were also more likely to feel that they gave more than they received in their relationships.

Bad relationships mean "a poor prognosis" for women

"In fact, being married or cohabiting in itself did not provide any extra protection, but strain from a problematic spousal relationship significantly contributed to a poor prognosis over and above the effect of clinical predictors," the investigators wrote.

Orth-Gomer et al say further investigation into the effects of family and work stress combined, as well as women's multiple roles and role conflicts in relation to their cardiovascular health, is needed. They would like to see their results reproduced in other studies, and also to determine the "pathogenic pathways of these novel findings."

In another study on a related topic, Dr Brian Baker, (St Michael's Hospital, University of Toronto, Toronto, ON) followed married couples, who all were mildly hypertensive at the start of the study, and found that those who had stressful, unhappy marriages had greater incidences of increased left ventricular mass and a rise in blood pressure after 3 years of follow-up. Like Orth-Gomer et al, Brown would like to see his results, which were published in the December 2000 issue of the Archives of Internal Medicine, reproduced and the pathological mechanisms of this finding elucidated.

Larger US study should include more ethnic backgrounds

New York, NY - Although the Swedish findings are "important" and help reveal how stressful marriages might affect future female heart events, a US study would have to be larger and include women of various ethnic backgrounds, says Dr Nieca Goldberg (spokesperson for the American Heart Association and Chief of the Women's Heart Program at Lenox Hill Hospital, New York, NY) in a December 20, 2000 report in CBSHealthWatch: "We have to include Hispanic women, Black women, Asian women, and Caucasian women in the study. It would be very interesting to assess this issue in all populations. As more and more women are in the work force, and most of them are married, it would be interesting to look at the relationship of marital stress and work stress in association with heart disease."

Psychosocial issues such as marital stress should be evaluated along with traditional heart risk factors, Goldberg says, "since psychosocial issues may have a negative impact on heart disease, especially in women who already had such disease."

-Mark L Fuerst


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