Stressful Jobs Linked to Repeat Heart Attacks

Stress at work more than doubles the risk of a repeat heart attack.

Oct. 10, 2007 — -- Recently had a heart attack? If so, getting back behind the desk at your high-stress job could be a killer.

For those who have already suffered a heart attack, too much stress at work may increase the chances of experiencing a second or third such episode, Canadian researchers found.

Men and women who survive one heart attack and return to their stressful jobs, are more than two times as likely to have a second attack, heart-disease-related death or severe chest pains.

Past research has shown that chronic stress can increase the risk of having a first heart attack, but this study, published in the current issue of the Journal of the American Medical Association, is the first to show that it can also increase the risk of a second attack.

"By showing that when they assessed job strain two years after the heart attack and found that patients with chronic elevations of job strain had higher mortality and recurrent events, they have made a strong case that job strain is a factor that affects prognosis following heart attack," says Dr. Redford Williams, head of psychiatry and behavioral sciences at Duke University.

By definition, a stressful job is one with high demands and low decision-making ability. A demanding pace at work, little authority and few opportunities to develop personal skills are all characteristics of such occupations.

Dr. Kristina Orth-Gomér of the Karolinska Institute in Sweden, writes in an accompanying editorial that "demands may be healthy as long as one can say yes or no to them. If authority over decisions, and opportunities for skills development are insufficient, chronic adaptation to a job strain situation may lead to illness."

And corporate America is the prime place for recurring heart attacks to strike.

"In the U.S., we work longer and harder than anyone," says Dr. Shukri David, chief of cardiology at Providence Hospital and medical director of the Providence Heart Institute. "We really overdo it here. The work environment should be more conducive to the American people's needs."

Taking Your Job to Heart

For two years, researchers in Quebec followed about 1,000 patients who returned to work after a heart attack. They found that chronic job strain was the major predictor of recurring heart problems.

"If you put yourself in a stressful situation, you don't exercise regularly, and you don't eat well because you don't have time," David says, "you pay little attention to the environment around you, and you don't get enough sleep."

David goes on to explain that in a high-stress situation, the heart beats faster and the "fight-or-flight" hormones, such as adrenaline, are released, which tend to decrease good cholesterol and increase bad cholesterol.

"This can cause a spasm in the artery, making a plaque rupture and triggering a heart attack," David says.

Authors of the article agree. In the study, they explain that job strain activates the sympathetic nervous system, which mediates the fight-or-flight response, causing an accentuated inflammation of the arterial wall, and the formation of a blood clot.

Researchers considered more than 20 other factors that might increase one's risk for a second heart attack. They took into account uncontrollable factors, such as sex, age and education.

They also controlled for cardiovascular disease risk factors, such as high blood pressure, smoking and obesity, and lifestyle factors, like alcohol consumption and exercise. But still, job stress was seen as a solid predictor of a repeat attack.

Critics Debate Stress Effect

Some experts remain skeptical, citing a variety of confounding factors.

"If you look at enough variables, something is going to turn up that is statistically significant," says Dr. Steven Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic Foundation. "Compared with controllable risk factors, such as smoking, job stress is likely to be a minor factor at best."

But others disagree, and say the study shows there is a need to reduce stress in the workplace.

"I think this is an important study that further strengthens the case for assessing psychosocial factors, like job strain and depression, in all patients with coronary heart disease," says Williams. "It means we should really start to develop and test behavioral interventions that can reduce these psychosocial risk factors."

David agrees that employers have a responsibility to ensure the good health of their employees. Recalling the story of one 50-year-old patient who had just had open heart surgery, David notes, "He was lying on a hospital bed with a big scar on his chest, and the first thing he asked me is if I could fill out these papers so he could get paid. He had just had open heart surgery, and he had to worry about these papers."

No Sure Solution to Stress

Of course, the ideal solution would be to change the workplace so that workers have fewer demands and more control, but that is not always so easy in the global market.

For the present, doctors recommend cardiac rehabilitation after surviving the first heart attack, and stress management skills to prevent a second one.

"Everyone who has suffered from a heart attack should go through cardiac rehabilitation," David says. "You go through a facility that emphasizes diet, exercise and stress management. It's a six- to eight-week program that is covered by most insurance companies."

In addition, Williams believes workers can learn to manage their stress better at work.

"I see the best hope being to train the workers in stress-coping skills, so that they will be more resilient and resistant to the health-damaging effects of high-strain jobs," he says.

During a distressing situation, Williams emphasizes the need to be aware of your thoughts and feelings, and to make rational decisions to either change your thoughts, by relaxing, or to change the situation, by using constructive problem solving.

"Relationship skills — speaking clearly, listening, empathy and increasing positives in encounters with others — can also reduce the frequency [with which] you are exposed to distressing situations, and can increase your social support levels," he says.