Job Demands, Job Decision Latitude, and Mental Strain: Implications for Job Redesign

Background—The objective of this study was to examine the association of Joint National Committee (JNC-V) blood pressure and National Cholesterol Education Program (NCEP) cholesterol categories with coronary heart disease (CHD) risk, to incorporate them into coronary prediction algorithms, and to compare the discrimination properties of this approach with other noncategorical prediction functions. Methods and Results—This work was designed as a prospective, single-center study in the setting of a community-based cohort. The patients were 2489 men and 2856 women 30 to 74 years old at baseline with 12 years of follow-up. During the 12 years of follow-up, a total of 383 men and 227 women developed CHD, which was significantly associated with categories of blood pressure, total cholesterol, LDL cholesterol, and HDL cholesterol (all P,.001). Sex-specific prediction equations were formulated to predict CHD risk according to age, diabetes, smoking, JNC-V blood pressure categories, and NCEP total cholesterol and LDL cholesterol categories. The accuracy of this categorical approach was found to be comparable to CHD prediction when the continuous variables themselves were used. After adjustment for other factors, ’28% of CHD events in men and 29% in women were attributable to blood pressure levels that exceeded high normal ($130/85). The corresponding multivariable-adjusted attributable risk percent associated with elevated total cholesterol ($200 mg/dL) was 27% in men and 34% in women. Conclusions—Recommended guidelines of blood pressure, total cholesterol, and LDL cholesterol effectively predict CHD risk in a middle-aged white population sample. A simple coronary disease prediction algorithm was developed using categorical variables, which allows physicians to predict multivariate CHD risk in patients without overt CHD. (Circulation. 1998;97:1837-1847.)

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Prediction of Coronary Heart Disease Using Risk Factor Categories

High density lipoprotein as a protective factor against coronary heart disease: The Framingham study

Objective: This article presents a new formulation of the relationship between stress and the processes leading to disease. It emphasizes the hidden cost of chronic stress to the body over long time periods, which act as a predisposing factor for the effects of acute, stressful life events. It also presents a model showing how individual differences in the susceptibility to stress are tied to individual behavioral responses to environmental challenges that are coupled to physiologic and pathophysiologic responses. Data Sources: Published original articles from human and animal studies and selected reviews. Literature was surveyed using MEDLINE. Data Extraction: Independent extraction and cross-referencing by us. Data Synthesis: Stress is frequently seen as a significant contributor to disease, and clinical evidence is mounting for specific effects of stress on immune and cardiovascular systems. Yet, until recently, aspects of stress that precipitate disease have been obscure. The concept of homeostasis has failed to help us understand the hidden toll of chronic stress on the body. Rather than maintaining constancy, the physiologic systems within the body fluctuate to meet demands from external forces, a state termed allostasis . In this article, we extend the concept of allostasis over the dimension of time and we define allostatic load as the cost of chronic exposure to fluctuating or heightened neural or neuroendocrine response resulting from repeated or chronic environmental challenge that an individual reacts to as being particularly stressful. Conclusions: This new formulation emphasizes the cascading relationships, beginning early in life, between environmental factors and genetic predispositions that lead to large individual differences in susceptibility to stress and, in some cases, to disease. There are now empirical studies based on this formulation, as well as new insights into mechanisms involving specific changes in neural, neuroendocrine, and immune systems. The practical implications of this formulation for clinical practice and further research are discussed. (Arch Intern Med. 1993;153:2093-2101)

https://jamanetwork.com/journals/INTEMED/articlepdf/617820/archinte_153_18_004.pdf

Stress and the Individual: Mechanisms Leading to Disease

Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.

Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy.

Three groups of men, selected solely according to the behavior pattern which they habitually manifested in their work, were compared with respect to their serum cholesterol levels, clotting times, presence of clinical coronary disease, and presence of arcus senilis. A group (A) of 83 men were chosen as manifesting an intense, sustained drive for achievement and as being continually involved in competition and deadlines, both at work and in their avocations. In this group the serum cholesterol level, the frequency of arcus senilis, and the incidence of coronary artery disease were much higher than in a group (B) of 83 men who manifested the opposite sort of behavior pattern and a group (C) of 46 unemployed blind men selected as manifesting a chronic state of insecurity and anxiety. Clinical coronary artery disease was seven times more frequent in group A than in group B or group C. Analysis of factors other than the overt behavior pattern described indicated that this pattern per se was largely responsible for the striking differences found.

https://jamanetwork.com/journals/jama/articlepdf/325609/jama_169_12_005.pdf

Association of specific overt behavior pattern with blood and cardiovascular findings: blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease

Clinical coronary heart disease (CHD) occurred in 257 subjects during eight to nine years of follow-up (average, 8 1/2 years) in a prospective study of 39- to 59-year-old employed men. Incidence of CHD was significantly associated with parental CHD history, reported diabetes, schooling, smoking habits, overt behavior pattern, blood pressure, and serum levels of cholesterol, triglyceride, and beta-lipoproteins. The type A behavior pattern was strongly related to the CHD incidence, and this association could not be explained by association of behavior pattern with any single predictive risk factor or with any combination of them.

Coronary heart disease in Western Collaborative Group Study. Final follow-up experience of 8 1/2 years

Clinical coronary heart disease (CHD) occurred in 257 subjects during eight to nine years of follow-up (average, 8 1/2 years) in a prospective study of 39- to 59-year-old employed men. Incidence of CHD was significantly associated with parental CHD history, reported diabetes, schooling, smoking habits, overt behavior pattern, blood pressure, and serum levels of cholesterol, triglyceride, and β-lipoproteins. The type A behavior pattern was strongly related to the CHD incidence, and this association could not be explained by association of behavior pattern with any single predictive risk factor or with any combination of them. ( JAMA 233:872-877, 1975)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=jama&articleId=337636&pdfFileName=jama_233_8_016.pdf

Coronary heart disease in the Western collaborative group study. A follow-up experience of two years.

This study was designed to (1) compare "predictive" abilities of different parameters and their interrelationships in the future incidence of coronary heart disease (CHD) and (2) define the profile of coronary-prone males through retrospective analysis of prospectively obtained data. Comprehensive studies of overt behavior pattern, blood lipids and coagulation, body measurements, socioeconomic factors, individual habits, and cardiovascular status were obtained annually since 1960 in 3,524 men, aged 39 to 59 years. Manifest CHD was found in 113 of 3,411 "well" men, but this was unknown to the investigators at the time of the study. The men with CHD exhibited higher serum beta/alpha lipoprotein ratios and 80 of them had been adjudged in "blind" assessments to exhibit an overt behavior pattern (type A) previously found associated with occurrence of CHD in middle-aged men.

https://jamanetwork.com/journals/jama/articlepdf/1163684/jama_189_1_004.pdf

A Predictive Study of Coronary Heart Disease: The Western Collaborative Group Study

Accountants were selectively chosen as a self-controlled group for studying effects of cyclic occupational stress upon serum cholesterol and blood clotting time, since their routine work schedule is interrupted by urgent tax deadlines, associated with severe occupational stress. Forty male accountants (age 28 to 56) were bled biweekly for serum cholesterol and monthly for blood clotting time from January to June 1957. Complete records also were kept of weight, exercise, diet, relative work load, and any exposure to unusual avocational stress. When studied individually, each subject's highest serum cholesterol consistently occurred during severe occupational or other stress, and his lowest at times of minimal stress. The results could not be ascribed to any changes of weight, exercise, or diet. Marked acceleration of blood clotting time consistently occurred at the time of maximum occupational stress, in contrast to normal blood clotting during periods of respite. The possible implications of these results...

Ray H. Rosenman

Papers

Association of specific overt behavior pattern with blood and cardiovascular findings: blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease

Coronary heart disease in Western Collaborative Group Study. Final follow-up experience of 8 1/2 years

Coronary heart disease in the Western collaborative group study. A follow-up experience of two years.

A Predictive Study of Coronary Heart Disease: The Western Collaborative Group Study

Changes in the Serum Cholesterol and Blood Clotting Time in Men Subjected to Cyclic Variation of Occupational Stress