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. “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.”


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.

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