CME: Gender, Stress, & Acute Myocardial Infarction

CME: Gender, Stress, & Acute Myocardial Infarction
Author Information (click to view)

Xiao Xu, PhD

Assistant Professor
Department of Obstetrics, Gynecology and Reproductive Sciences
Yale University School of Medicine
Center for Outcomes Research and Evaluation
Yale-New Haven Hospital

Xiao Xu, PhD, has indicated to Physician’s Weekly that she has no financial interests to report.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:


  • Discuss the findings of a study that looked at the implications of stress on health outcomes and recovery in younger acute myocardial infarction patients.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)


Christopher Cole – Senior Editor
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Xiao Xu, PhD
Discloses no financial relationships with pharmaceutical or medical product manufacturers:

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


Xiao Xu, PhD (click to view)

Xiao Xu, PhD

Assistant Professor
Department of Obstetrics, Gynecology and Reproductive Sciences
Yale University School of Medicine
Center for Outcomes Research and Evaluation
Yale-New Haven Hospital

Xiao Xu, PhD, has indicated to Physician’s Weekly that she has no financial interests to report.

Research suggests that patients with acute myocardial infarction, or AMI, who experience mental stress—particularly women—appear to be at higher risk for poor short-term outcomes when compared with those reporting that they experience little or no stress.

Studies have shown that women and younger patients are at increased risk for mental stress when compared with the male or older counterparts, respectively. Whether or not the same holds true for young and middle-aged patients presenting with acute myocardial infarction (AMI) has not been well established. “In general, psychosocial factors are increasingly recognized as important influences on patients’ health status and recovery after major health events,” says Xiao Xu, PhD. “However, studies focusing on AMI tend to recruit older patients. Therefore, little is known about how psychosocial factors may influence outcomes among younger people with AMI.”


A Look at Younger Patients

Dr. Xu and colleagues conducted a study that looked at the implications of stress on health outcomes and recovery in younger AMI patients. Published in Circulation, the authors used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes in Young AMI Patients) study. “VIRGO is the largest prospective study that has been conducted in the relatively younger AMI patient population,” Dr. Xu explains. “When that data became available, it presented an ideal opportunity to conduct our analysis. Because the VIRGO study focused on a uniquely large sample of young and middle-age patients, we were able to look at how stress is associated with recovery at 1 month in a younger population and also assess how gender affects outcomes.”

For the study, the researchers examined gender differences in stress, factors contributing to these differences, and whether these differences helped explain gender-based disparities observed in 1-month recovery after AMI. Data on more than 3,500 AMI patients aged 18 to 55 were assessed. Self-perceived psychological stress was measured at baseline using the 14-item Perceived Stress Scale (PSS-14). The PSS-14 asks respondents about the degree to which their life situations were unpredictable, uncontrollable, and overloaded during the previous month. Total scores could range from 0 to 56, with higher scores indicating greater stress.


Important Findings

“The most important finding from our study was that patients with greater baseline stress were more likely to have worse recovery 1 month after their AMI,” says Dr. Xu. When compared with patients with low stress, those with moderate or high stress had significantly worse recovery in angina frequency, angina-related quality of life, general mental health status, and health-related quality of life.

The study team was also able to confirm that the gender differences seen in stress levels in the general population also exist among younger AMI patients (Figure). “In the younger AMI population, women tend to have greater stress than men,” adds Dr. Xu. “This is similar to what has been documented in the general population.” Average baseline PSS-14 scores were 23.4 for men, compared with scores of 27.0 for women. In general, women in the study perceived greater stress across all 14 items, perceiving negatively stated items more often than men and positively stated items less often.

At baseline, women had significantly higher rates of diabetes, chronic lung disease, chronic renal dysfunction, depression, cancer, congestive heart failure, and stroke compared with men in the study. Women also had worse scores on measures of general physical and mental health. Additionally, women were more likely to report stressful life events during the past year, including:

  • Major intra-family conflict (33.1% vs 20.8%).
  • Major personal injury or illness (22.4% vs 16.6%).
  • Death or major illness of a close family member (36.6% vs 27.8%).

Women were also more likely than men to have children or grandchildren living in their household and to experience greater financial strain. Women were more likely to not work for pay (43.9% vs 27.3%) or work part-time (15.5% vs 9.2%).

After adjusting for patient sociodemographic, health, and psychosocial characteristics, the gender difference in average baseline PSS-14 scores was substantially reduced but remained statistically significant.


Implementing the Findings

“Clinicians are accustomed to caring for patients when physical symptoms or conditions arise,” says Dr. Xu, “but as we learn more about the importance of psychosocial factors in overall health, we need to pay more attention to patient’s stress levels. This is especially true when patients are recovering from a major health event like an AMI.”

Dr. Xu also stresses the importance of making AMI patients aware of how stress may influence their recovery. “Many changes to their lifestyles after an AMI could increase stress levels, including the need to adhere to rigorous medication regimens, new diets, and exercise plans,” she says. “Patients should be informed on when and how to seek help when necessary, whether that be with formal help from healthcare professionals or from informal resources like family and friends who can listen and help address their burdens and perhaps reduce stress levels. Patients should also be taught proper coping skills for stressful situations to not only improve their psychosocial well-being but also help their recovery following an AMI.”


*This article was posted by Brady Cole, son of PW Senior Author Chris Cole, on April 28, 2016 for Bring Your Kids to Work Day.

Readings & Resources (click to view)

Xu X, Bao H, Strait K, et al. Sex differences in perceived stress and early recovery in young and middle-aged patients with acute myocardial infarction. Circulation. 2015;131:614-623. Available at

Parashar S, Rumsfeld J, Reid K, et al.Impact of depression on sex differences in outcome after myocardial infarction. Circ Cardiovasc Qual Outcomes. 2009;2:33-40.

Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the interheart study): Case-control study. Lancet. 2004;364:953-962.

Garavalia L, Decker C, Reid K, et al. Does health status differ between men and women in early recovery after myocardial infarction? J Womens Health (Larchmt). 2007;16:93-101.

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