Income change at retirement, neighbourhood-based social support, and ischaemic heart disease: results from the prospective cohort study "Men born in 1914".
ABSTRACT Retirement from active life often leads to decreased finances and reduced social contact, which may increase ischaemic heart disease (IHD) risk in individuals. We examined whether income evolution during the decade before retirement has an impact on subsequent IHD, and explored the mediating effect of common risk factors and social support from different sources (marriage/cohabitation, support from friends/relatives, and neighbourhood-based social support). We analyzed data from the 1982-1983 prospective cohort study, "Men born in 1914" (n=498, follow-up period=10 years) conducted in Malmö, Sweden, merged with yearly income data for 14 years preceding baseline. Low income 10 years before retirement predicted both higher prevalence of IHD risk factors at retirement, and weaker neighbourhood-based social support. Income 10 years before retirement was a strong predictor of IHD incidence and mortality after retirement, but a significant downward income mobility at retirement did not increase IHD risk. After adjustment, low neighbourhood-based social support increased the risk of IHD incidence and mortality, and mediated 7-8% of the income effect. In conclusion, income 10 years before retirement, but not the subsequent income evolution, was a strong predictor of IHD post-retirement. This socioeconomic gradient was partly mediated by the protective effect of neighbourhood-based social support, which may be particularly important among the elderly in compensating for social disruptions related to retirement.
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ABSTRACT: 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.Circulation 05/1999; 99(16):2192-217. · 15.20 Impact Factor
- New England Journal of Medicine 02/1998; 338(3):171-9. · 51.66 Impact Factor
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ABSTRACT: Several studies have indicated that a variety of social relationships are important predictors of morbidity and mortality in patients with coronary artery disease, but little attention has been focused on the prognostic importance of these factors in the growing population of elderly patients with heart failure. To address this issue, we sought to determine whether emotional support is associated with fatal and nonfatal cardiovascular events in elderly patients hospitalized with heart failure. We reviewed the medical records of 292 subjects aged > or =65 years who were hospitalized with clinical heart failure and were part of the New Haven, Conn, cohort of the Established Population for the Epidemiologic Study of the Elderly, a longitudinal, community-based study of aging that included a comprehensive assessment of psychosocial support. In the unadjusted analysis, lack of emotional support was significantly associated with the 1-year risk of fatal and nonfatal cardiovascular outcomes [odds ratio, 2.4; 95% confidence interval, 1.1 to 4.9]. After adjustment for demographic factors, clinical severity, comorbidity and functional status, social ties, and instrumental support, the absence of emotional support remained associated with a significantly higher risk (odds ratio, 3.2; 95% confidence interval, 1.4 to 7.8). The test for interaction between emotional support and sex was significant (P=.01). In the fully adjusted model, the odds ratio for women was 8.2 (95% confidence interval, 2.5 to 27.2) compared with 1.0 (95% confidence interval, 0.3 to 3.3) for men. Among elderly patients hospitalized with clinical heart failure, the absence of emotional support, measured before admission, is a strong, independent predictor of the occurrence of fatal and nonfatal cardiovascular events in the year after admission. In this cohort, the association is restricted to women.Circulation 03/1998; 97(10):958-64. · 15.20 Impact Factor