Association of Psychosocial Stress With Risk of Acute Stroke
Authors: Reddin Catriona , Murphy Robert , Hankey Graeme J. , Judge Conor , Xavier Denis , Rosengren Annika , Ferguson John , Alvarez-Iglesias Alberto , Oveisgharan Shahram , Iversen Helle K. , Lanas Fernando , Al-Hussein Fawaz , Członkowska Anna , Oguz Aytekin , McDermott Clodagh , Pogosova Nana , Málaga German , Langhorne Peter , Wang Xingyu , Wasay Mohammad , Yusuf Salim , O’Donnell Martin ,   INTERSTROKE investigators, Rangaran Sumathy , Rao-Melacini Purnima , Zhang Xiaohe , Islam Shofiqul , Kabali Conrad , Cassanova Amparo , Chin Siu Lim , DeJesus Jane , Dehghan Mahshid , Agapay Steven , Diaz Rafael , Varigos John , Avezum Alvaro , Liu Lisheng , Zhang Hongye , Lopez-Jaramillo Patricio , Rumboldt Zvonko , Peñaherrera Ernesto , Diener Hans-Christopher , Pais Prem , Albaker Osamah , Yusoff Khalid , Damasceno Albertino , Ogah Okechukwu , Iqbal Romaina , Dans Antonio , Ryglewicz Danuta , De Villiers Linda , Elsayed Ahmed , Nilanont Yongchai , Nidhinandana Samart , Mondo Charles , Yusufali Alfzalhussein 
Published: December 2022

Importance

Psychosocial stress is considered a modifiable risk factor for stroke. Given the prevalence of chronic and acute exposure to stress, it represents a potentially attractive target for population-health interventions.

Objectives

To determine the association of psychosocial stress with the risk of acute stroke and explore factors that might modify the association of stress with risk of acute stroke in a large international population.

Design, Setting, and Participants

INTERSTROKE is an international retrospective case-control study of risk factors for first acute stroke in 32 countries in Asia, North and South America, Europe, Australia, the Middle East, and Africa. A total of 13 462 patients with stroke and 13 488 matched controls were recruited between January 11, 2007, and August 8, 2015. The present analyses were performed from June 1 to 30, 2021, and included 13 350 cases and 13 462 controls with available data on psychosocial stress.

Exposures

Psychosocial stress and occurrence of stressful life events within the preceding year were measured using a standardized questionnaire of self-reported stress at home and work.

Main Outcomes and Measures

The association of stress with acute stroke and its subtypes was examined using multivariable conditional logistic regression and factors that might modify the association, particularly self-reported locus of control.

Results

Among 26 812 participants included in the analysis, the mean (SD) age of cases was 62.2 (13.6) years; that of controls, 61.3 (13.3) years; 7960 cases (59.6%) and 8017 controls (59.6%) were men. Several periods of stress and permanent stress were reported for 2745 cases (20.5%) and 1933 controls (14.4%), with marked regional variation in prevalence, with the lowest in China (201 of 3981 [5.0%] among controls and 364 of 3980 [9.1%] among cases) and highest in South East Asia (233 of 855 [26.1%] among controls and 241 of 782 [30.8%] among cases). Increased stress at home (odds ratio [OR], 1.95 [95% CI, 1.77-2.15]) and at work (OR, 2.70 [95% CI, 2.25-3.23]) and recent stressful life events (OR, 1.31 [95% CI, 1.19-1.43]) were associated with an increased risk of acute stroke on multivariable analyses (vs no self-reported stress). Higher locus of control at home was associated with a reduced odds of all stroke (OR, 0.73 [95% CI, 0.68-0.79]), and higher locus of control both at work and at home were associated with a lower odds of acute stroke and significantly diminished the association with stress at work (OR, 2.20 [95% CI, 1.88-2.58]; P = .008 for interaction) and home (OR, 1.69 [95% CI, 1.44-1.98]; P &amp;lt; .001 for interaction) for acute stroke.

Conclusions and Relevance

Psychosocial stress is a common risk factor for acute stroke. The findings of this case-control study suggest that higher locus of control is associated with lower risk of stroke and may be an important effect modifier of the risk associated with psychosocial stress.