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Perceived Stress After Acute Myocardial Infarction: A Comparison Between Young and Middle-Aged Women Versus Men

Xu, Xiao PhD; Bao, Haikun PhD; Strait, Kelly M. MS; Edmondson, Donald E. PhD; Davidson, Karina W. PhD; Beltrame, John F. MBBS, PhD; Bueno, Héctor MD, PhD; Lin, Haiqun MD, PhD; Dreyer, Rachel P. PhD; Brush, John E. MD; Spertus, John A. MD, MPH; Lichtman, Judith H. PhD, MPH; D'Onofrio, Gail MD, MS; Krumholz, Harlan M. MD, SM

doi: 10.1097/PSY.0000000000000429
Original Articles

Objective The aim of the study was to examine how psychological stress changes over time in young and middle-aged patients after experiencing an acute myocardial infarction (AMI) and whether these changes differ between men and women.

Methods We analyzed data obtained from 2358 women and 1151 men aged 18 to 55 years hospitalized for AMI. Psychological stress was measured using the 14-item Perceived Stress Scale (PSS-14) at initial hospitalization and at 1 month and 12 months after AMI. We used linear mixed-effects models to examine changes in PSS-14 scores over time and sex differences in these changes, while adjusting for patient characteristics and accounting for correlation among repeated observations within patients.

Results Overall, patients' perceived stress decreased over time, especially during the first month after AMI. Women had higher levels of perceived stress than men throughout the 12-month period (difference in PSS-14 score = 3.63, 95% confidence interval = 3.08 to 4.18, p < .001), but they did not differ in how stress changed over time. Adjustment for patient characteristics did not alter the overall pattern of sex difference in changes of perceived stress over time other than attenuating the magnitude of sex difference in PSS-14 score (difference between women and men = 1.74, 95% confidence interval = 1.32 to 2.16, p < .001). The magnitude of sex differences in perceived stress was similar in patients with versus without post-AMI angina, even though patients with angina experienced less improvement in PSS-14 score than those without angina.

Conclusions In young and middle-aged patients with AMI, women reported higher levels of perceived stress than men throughout the first 12 months of recovery. However, women and men had a similar pattern in how perceived stress changed over time.

Supplemental digital content is available in the text.

From the Department of Obstetrics, Gynecology and Reproductive Sciences (Xu), Yale School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation (Xu, Bao, Strait, Lin, Dreyer, Krumholz), Yale-New Haven Hospital, New Haven, Connecticut; Department of Psychiatry (Edmondson, Davidson), Center for Behavioral Cardiovascular Health (Edmondson, Davidson), Division of General Medicine, Columbia University Medical Center, New York, New York; Department of Medicine (Beltrame), University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia; Centro Nacional de Investigaciones Cardiovasculares (Bueno), Instituto de investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre, and Universidad Complutense de Madrid, Madrid, Spain; Division of Cardiology (Brush), Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia; Saint Luke's Mid America Heart Institute and University of Missouri - Kansas City (Spertus), Kansas City, Missouri; Departments of Biostatistics (Lin), Chronic Disease Epidemiology (Lichtman), and Health Policy and Management (Krumholz), Yale School of Public Health, New Haven, Connecticut; and Department of Emergency Medicine (D'Onofrio, Dreyer), Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program (Krumholz), Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.

Supplemental Content

Address correspondence and reprint requests to Harlan M. Krumholz, MD, SM, Center for Outcomes Research and Evaluation, 1 Church St, Suite 200, New Haven, CT 06510. E-mail:

Dr. Bueno was affiliated with the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, during the time the work was conducted.

Received for publication September 18, 2015; revision received September 23, 2016.

Copyright © 2017 by American Psychosomatic Society
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