Copyright: ©Author(s) 2026.
World J Cardiol. May 26, 2026; 18(5): 119108
Published online May 26, 2026. doi: 10.4330/wjc.v18.i5.119108
Published online May 26, 2026. doi: 10.4330/wjc.v18.i5.119108
Table 1 Some recent studies on the cardiac effects of acute stress
| Ref. | Setting | Main results |
| Mostofsky et al[18], 2014 | Systematic review of 9 studies | Despite the heterogeneity, all studies found a higher rate of CV events (heart attacks, strokes, and disturbances in cardiac rhythm) in the 2 hours following outbursts of anger |
| Walker et al[19], 2016 | Healthy participants were monitored during no noise, LF (31.5-125 Hz) or HF (500-2000 Hz) noise exposure scenarios lasting 40 minutes. ECGs were processed for measures of HRV | After adjusting for noise frequency, during LF noise exposure, HF, LF, and SDNN were reduced of 32% (-57, -6.2), 34% (-52, -15), and 16% (-26, -6.1); during HF noise exposure, a 21% (-39, -2.3) reduction in LF was found |
| Modena et al[24], 2017 | Global access of patients who arrived at the ED of the three main hospitals in 2012, when two earthquakes hit the province of Modena and Reggio Emilia, compared with that one detected in the same departments and in the same interval of time in 2010 | No statistically significant differences in number of cases in relation to gender. The gender analysis showed a prevalence of ACS (P = 0.03) in men, whereas women presented more strokes and TIAs (P = 0.05), atrial fibrillation (P = 0.05), DVT/PE (P = 0.05), and TTS (P = 0.05) |
| Chatignoux et al[29], 2018 | Annual hospital discharge with a primary diagnosis of ACS, heart failure, or stroke from the French Hospital Discharge Database was used to differentiate “unusual” variations in daily hospitalization numbers in the 15 days following the terrorist attacks in Paris and Nice in 2015 and 2016 from the expected rate | The daily number of hospitalizations for heart failure and stroke was higher in the 15 days following each attack. However, multivariate analysis showed no significant variation. Watching events on television was not sufficiently potent trigger for CVD, although it may have led to an increase in hospitalizations for stress or anxiety |
| Babaie et al[26], 2021 | Systematic review of full text articles which considered CVD at the time of flood, storm, and earthquake | Prevalence of CVD increases after disasters. Mental stress after disasters is one of the most significant challenges |
| Franzen et al[34], 2022 | Multi-centre prospective trial at three German sites during the UEFA Soccer Cup 2012 and 2021 comprising healthy participants and patients hospitalized with CVD during matches of the German national team (GP) and no GP | Central BP and HR increased significantly during GP as well as no GP matches and remained elevated beyond the end of the matches. Likewise, arterial stiffness parameters and vascular resistance were higher during the matches and remained elevated after the matches |
| Olsson et al[50], 2021 | Nationwide, retrospective postal survey with case-control design. All individuals suffering an AMI during the Christmas holidays in Sweden completed a questionnaire of about 27 potential AMI-triggers | Patients with AMI on Christmas experienced more stress (37% vs 21%, P = 0.002), compared to the control group |
| Chang Liu et al[53], 2021 | Individuals who experienced SCA, divided into an unexplained SCA or explained SCA subgroup, completed the Recent Life Changes Questionnaire, Student Stress Scale, or Social Readjustment Rating Scale for Non-Adults recalling events during the preceding year; all measure stress in LCUs | No significant difference in LCU score between the control group and the SCA group (248181 LCU vs 252227 LCU; P > 0.05). The explained SCA subgroup had significantly lower mean LCU scores than the unexplained SCA subgroup (163183 LCU vs 308237 LCU; P = 0.030) |
| Rosman et al[32], 2021 | Retrospective case-crossover study during 2016 United States presidential election linking cardiac device data, electronic health records, and historic voter registration records from patients with ICD | Significant increase in the incidence of composite outcomes for any arrhythmia (IRR = 1.77, 95%CI: 1.42-2.21), supraventricular arrhythmia (IRR = 1.82, 95%CI: 1.36-2.43), and ventricular arrhythmia (IRR = 1.6 95%CI: 1.22-2.10) during the election period. There was an increase in AF, SVT, non-sustained VT, and daily AF burden (P < 0.001) |
| Batelaan et al[55], 2021 | Systematic review of various types of observational studies examining the association between anxiety or mental stress and SCA | For anxiety, the overall picture suggests that it predisposes for SCA in physically healthy populations (unadjusted OR = 2.44; 95%CI: 1.06-5.59). However, in populations at risk for SCA, associations were heterogeneous but not significant |
| Weber et al[36], 2022 | Systematic review of 107 publications assessing acute physiological stress responses primarily through salivary cortisol and cardiovascular outcomes | Direct, non-moderated positive associations between acute stress exposure and concurrent cortisol levels (44%), SBP (44%), DBP (53%) and HR (53%) |
Table 2 Some recent studies on the cardiovascular effects of chronic stress
| Ref. | Setting | Main results |
| Li et al[163], 2015 | Systematic review of 5 papers derived from 4 prospective studies conducted in Sweden and Canada | Significant effect of work stress (based on the Demand Control model or the Effort-Reward Imbalance model) on the risk of recurrent CHD events (HR = 1.65, 95%CI: 1.23-2.22) |
| Endrighi et al[138], 2016 | HF patients longitudinally evaluated for psychological stress and CV hospitalizations/death | Patients reporting high average perceived stress a higher likelihood of adverse events compared to those with lower stress (OR = 1.10, 95%CI: 1.04-1.17). Perceived stress was elevated after a CV hospitalization (P = 0.004). An association between stress and adverse events was present when accounting for prior hospitalizations (P = 0.05) |
| Hirokawa et al[159], 2016 | Between 2001 and 2009 in Osaka, Japan, authors examined 928 healthy Japanese employees from two occupational statuses: Managers/professionals and general workers. Changes in stress reactivity were calculated as the difference between the measured variables during the tasks and the rest period | Men showed inverse associations between quantitative job overload and DBP, HR, and LF/HF HRV, between physical demands and SBP, DBP, and between a poor physical environment and HF. Men also had positive associations between qualitative job overload and HR, and between physical demands and peripheral blood flow (all P < 0.05). Significant associations between job stress and changes in stress reactivity were observed in male managers/professionals and female general workers (P < 0.05) |
| Theorell et al[164], 2016 | Systematic review of associations between occupational exposures and CHD. Ninety-six articles of high or medium high scientific quality were finally included | Moderately strong evidence for a relationship between job strain and small decision latitude on one hand and CHD incidence on the other hand. Limited evidence was found for pressing work, effort-reward imbalance, low support, lack of justice, lack of skill discretion, insecure employment, night work, long working week, and noise in relation to CHD |
| Jacob and Kostev[162], 2017 | The study population consisted of 7374 patients who experienced a workplace conflict and 7374 controls for analysis identified by 699 general practitioners (Frankfurt, Germany) | After a maximum of five years of follow-up, 2.9% of subjects who experienced workplace conflict were affected by CVD, while 14% in the control group (P < 0.001). Workplace conflict was associated with a 163-fold increase in the risk of developing CVD. Finally, the impact of workplace conflict was higher for AMI than for angina pectoris and stroke (respectively OR = 2.03, 1.79, and 1.56) |
| Stewart et al[82], 2017 | A total of 950 participants in the LIPID trial completed General Health Questionnaires-30. Cox proportional hazards models evaluated the risk of CV and total mortality by increasing levels of psychological distress over a median of 12.1 years | Patients with persistent moderate or greater psychological stress had a higher risk of both CV death (aHR = 3.94, 95%CI: 2.05-7.56, P < 0.001) and all-cause mortality (aHR = 2.85, 95%CI: 1.74-4.66, P < 0.001) compared with patients with no distress. In contrast, patients who reported persistent mild distress did not have an increased risk of CV or all-cause mortality during follow-up |
| Hagström et al[121], 2018 | Psychosocial stress was assessed by a questionnaire in 14577 patients with stable CHD on optimal secondary preventive therapy in the prospective randomized STABILITY clinical trial | After 3.7 years of follow-up, financial stress was associated with increased risk (HR, 95%CI) of CV death (1.19, 1.08-1.30) and the primary composite endpoint of CV death, nonfatal AMI or nonfatal stroke (1.17, 1.10-1.24) |
| Lecca et al[154], 2018 | Overall, 568 healthy workers of a flight logistic company were evaluated using the Health and Safety Executive questionnaire, the Framingham Heart Study General CVD Risk Prediction Score, and the WHO general well-being index (WHO-5) | Low job support significantly increases the CVD risk score and decreases the WHO well-being index with reference to subjects reporting high support on the job. In addition, job control, job support, low strain, and high demand coupled with high control (active job) showed a beneficial effect on psychological well-being |
| Stewart et al[122], 2018 | Systematic review of literature (37 studies examining stress in mid-life and either CVD endpoints or subclinical CVD outcomes) | Significant risk of CVD due to stress. Most studies showed that mid-life women experiencing greater levels of stress had more subclinical CVD, as indicated by CIMT, flow-mediated dilation and arterial stiffness |
| Virtanen and Kivimäki[166], 2018 | Large-scale meta-analyses with published and individual participant observational data on more than 740000 men and women free of CVD | Link between long working hours (≥ 55 hours a week) and the onset of CVD. Overall, 1.12-fold (95%CI: 1.03-1.21) increased risk of CHD and 1.21-fold (95%CI: 1.01-1.45) increased risk of stroke |
| Cabeza de Baca et al[116], 2019 | The cross-sectional association between financial strain and ICH were examined in the Women’s Health Study follow-up cohort (n = 22048; mean age= 72 ± 6.0 years) | Number of financial stressors was associated with lower ideal cardiovascular health after adjustment for potential confounders (1 financial stressor: β = -0.10, 95%CI: -0.13 to -0.07; 2 financial stressor: β = -0.20, 95%CI: -0.26 to -0.15; 3+ financial stressor: β = -0.44, 95%CI: -0.50 to -0.38) |
| Burroughs Peña et al[183], 2019 | In 25062 women participating in the Women’s Health Study, authors examined the relationship between CPS and ICH, as defined by the American Heart Association Strategic 2020 goals. A CPS score summarized acute (e.g., negative life events) and chronic stressors (e.g., work, work-family spillover, financial, discrimination, relationship, and neighbourhood) and traumatic life event stress reported on a stress questionnaire | White women had the lowest mean CPS scores (White: 161.7 ± 50.4; Hispanic: 171.2 ± 51.7; Black: 172.5 ± 54.9; Asian: 170.8 ± 50.6; P overall < 0.01). Mean ICH scores varied by race/ethnicity (P < 0.01) and were significantly lower in Black women and higher in Asian women when compared to White women (β coefficient and 95%CI: Hispanics -0.02: -0.13 to -0.09; Blacks -0.34: -0.43 to -0.25; Asians 0.34: 0.24-0.45). Interactions between CPS and race/ethnicity in ICH models were not significant |
| Endrighi et al[83], 2019 | In a prospective cohort study (BETRHEART), 144 HF patients were evaluated for stress (PSS) and anger at baseline and every 2 weeks for 3 months. Functional status (6MWT) and health status (KCCQ) were also measured | Average PSS and greater than usual increases in PSS were associated with worsened KCCQ scores. Greater than usual increases in PSS were associated with worsened 6MWT. Average anger levels were associated with worsened KCCQ, and increases in anger were associated with worsened 6MWT |
| Moran et al[126], 2019 | The Jackson Heart Study is a longitudinal cohort study of cardiovascular disease risks in 2256 African Americans in the Jackson, Mississippi metropolitan statistical area. Financial stress was assessed from the Jackson Heart Study Weekly Stress Inventory | Participants with moderate to high (vs no) financial stress were more likely to have incident CHD events after controlling for demographics, SES, access to care, and traditional clinical risk factors (HR = 2.42, 95%CI: 1.13-5.17). The association between financial stress and CHD was no longer statistically significant adjusting for three specific risk factors: Depression, smoking status, and diabetes (HR = 199, 95%CI: 0.91-4.39) |
| Song et al[124], 2019 | Population based, sibling-controlled cohort study on 136637 patients in the Swedish National Patient Register with stress related disorders, including PTSD, acute stress reaction, adjustment disorder, and other stress reactions, with a follow-up of 27 years | The crude incidence rate of any CVD was 10.5, 8.4, and 6.9 per 1000 person years among exposed patients, their unaffected full siblings, and the matched unexposed individuals, respectively. In sibling-based comparisons, the HR for any CVD was 1.64 (95%CI: 1.45-1.84), with the highest subtype specific HR observed for heart failure (6.95, 1.88-25.68). Stress related disorders were more strongly associated with early onset CVD (HR = 1.4, 1.32-1.49) for attained age < 50 than later onset ones (1.24, 1.18-1.30) for attained age ≥ 50 (P = 0.002) |
| Wu et al[151], 2019 | The Taiwan bus driver cohort study recruited 1650 professional drivers | Occupational drivers with high overcommitment scores had an elevated risk for CVD (HR = 1.71; 95%CI: 1.04-2.82). Regarding target disease, overcommitment had an increased risk for CVD (HR = 1.27; 95%CI: 1.05-1.54) and CHD (HR = 1.32; 95%CI: 1.05-1.65) |
| Smaardijk et al[185], 2020 | Metanalysis identified studies (44 articles including 227647 women and 321894 men) assessing the risk of psychological factors (anger/hostility, anxiety, depression, psychological distress, social support, type A behaviour pattern, type D personality, and PTSD) for MACE in samples with CHD | The association between psychological factors (all combined) and MACE was stronger in men (HR = 1.37, 95%CI: 1.27-1.48) than in women (HR = 1.21, 95%CI: 1.12-1.30; P = 0.017). A subset of the studies focusing on women showed significant associations between anger/hostility, depression, and distress with MACE. For men, statistically significant associations were found for anxiety, depression, and distress with MACE |
| Crom and Trappe[132], 2021 | 40 patients with an acute STEMI confirmed by ECG. The control group consisted of 80 patients without CAD | Patients with STEMI did not show significantly higher HCC compared to controls, nor was there correlation with the extent of AMI. Correlations were found between HCC and T2DM (P = 0.046, OR = 6.346), low high-density lipoprotein cholesterol concentration (P = 0.107), glycated haemoglobin concentration (P = 0.083), and chronic HF (P = 0.110) |
| Li et al[167], 2021 | Prospective cohort study identified hypertensive workers from the population-based MONICA/KORA study in Southern Germany, who were free of any CVD and diabetes, interviewed at baseline for work stress (high demand plus low control) and impaired sleep (difficulties falling asleep and/or maintaining sleep) | In comparison to participants with low work stress and non-impaired sleep, participants with work stress (HR = 1.56, 95%CI: 0.81-2.98), or impaired sleep (HR = 1.76, 95%CI: 0.96-3.22) had an increased risk of CVD, while participants with both work stress and impaired sleep had the highest risk of CVD mortality (HR = 2.94, 95%CI: 1.18-7.33). Similar risk patterns were found for CHD mortality |
| Cain-Shields et al[146], 2022 | The relationship between GSS and incident hypertension, diabetes, and obesity among 4485 participants in the Jackson Heart Study | Among men, those with high (vs low) GSS were 41% less likely to become obese over a mean period of eight years: 0.59 (0.36, 0.95), P = 0.03 |
| Gaffey et al[120], 2022 | Systematic review (28 studies on 58331 participants without a past psychiatric diagnosis, screened at baseline for depression, anxiety, PTSD, stress, and followed for > 6 months) | Subjects reporting high psychological distress showed a 28% greater risk of incident CVD compared to those with low or no distress |
| Kautzky et al[184], 2022 | Healthy women were assessed for glucose metabolism, fatty liver index and anthropometric parameters. Psychological stress assessment included the “Brief Symptom Inventory”, and PSS. Biological stress response was evaluated with HRV and cortisol levels | Burnout and PSS scores were associated with insulin secretion, sputum cortisol, thyroid-stimulating hormone, anthropometric measures, and gender role. Brief Symptom Inventory ratings for psychiatric symptom dimensions were associated with insulin resistance, sex hormones, anthropometric measures, and gender role |
| Kubera et al[104], 2022 | From the Whitehall II cohort data of 4969 men and 2138 women were analysed. Psychological stress (General Health Questionnaire) and body shape were measured | Increase in the expected hazard to develop CHD with high psychological stress (P = 0.017) in both genders. Subjects with consistently high psychological stress had a 24-fold (men) or 2.3-fold (women) higher risk for later CHD events compared to never-stressed subjects. Subjects with a high sum score of childhood experiences had a 10% increased hazard to develop fatal or non-fatal CHD events in adulthood |
| Gao et al[89], 2022 | In stable CHD patients the Chinese version of the PSS was used. Patients were divided into HPS (Chinese version of the PSS ≥ 31) and NHPS groups | The log-rank analysis showed that risk of cardiovascular events with HPS was higher than NHPS (P = 0.012). After adjusting for demographic, lifestyle, and clinical information, the HPS group had significantly increased risk of events within 24 months (HR = 1.369, 95%CI: 1.037-1.807, P = 0.027), but less impact after 24 months |
| Birdit et al[115], 2023 | A total of 238 individuals from the Stress and Well-being in Everyday Life Study reported life event stress. Of those individuals, 169 completed an ecological momentary assessment study in which they reported stress exposure every 3 hours, and 164 wore a heart rate monitor for up to 5 days | The study revealed 2 longitudinal trajectories of life event stress: Moderate-increasing and low-decreasing. Individuals in the moderate-increasing stress trajectory reported greater daily stress exposure. Black individuals in the low-decreasing trajectory and White individuals in the moderate-increasing trajectory showed positive associations between daily stress and heart rate |
| Söderberg et al[160], 2023 | Cross-sectional study was conducted in a sub-cohort of the SCAPIS. Psychosocial exposure was evaluated with the job demand-control model and analysed according to the standard categorization: High strain (high demands-low control), active, passive (low demands-low control) and low strain | High strain was linked to increased adjusted PR for low HDL cholesterol in women (PR = 1.76; 95%CI: 1.25-2.48). High strain was also related to moderately increased PR for metabolic syndrome in men (PR = 1.25; 95%CI: 1.02-1.52). In addition, passive work was associated with diastolic hypertension in women (adjusted PR = 1.29; 95%CI: 1.05-1.59) |
| Lavigne-Robichaud et al[152], 2023 | Prospective cohort in Quebec, Canada. In six thousand four hundred sixty-five white-collar workers without cardiovascular disease followed for 18 years job strain and ERI were measured with validated questionnaires | Exposure to either job strain or ERI was associated with an adjusted 49% CHD risk increase (HR = 1.49, 95%CI: 1.07-2.09). Combined exposure to job strain and ERI was associated with an adjusted 103% CHD risk increase (HR = 2.03, 95%CI: 1.38-2.97) |
| Pogosova et al[127], 2023 | Patients with arterial hypertension and CHD managed in primary health care institutions in multi-year prospective COMETA study, using a VAS for assessment of stress level | The composite endpoint that included all-cause death and/or severe adverse cardiovascular outcomes was significantly associated with a high (VAS score ≥ 8) stress level (OR = 1.53; 95%CI: 1.00-2.33, P = 0.04) |
| Wendel et al[98], 2023 | In 213 adults participating in the Pittsburgh Cold Study 3, early environment stress was assessed by four self-report measures consistent with the biological sensitivity to context theory. Average HR and mean BP reactivity to the TSTT were assessed on two occasions | Results generally did not support the stress reactivity hypothesis; little evidence that high-stress early environments were reliably associated with exaggerated CV reactivity or slower CV recovery. There was some support for the biological sensitivity to context theory; both high-stress and low-stress early environments were associated with exaggerated CV reactivity |
| Won et al[112], 2024 | Retrospective observational study using data from the National Hospital Ambulatory Care Survey, Federal Reserve Economic Database, National Bureau of Economic Research, and CVD groupings from National Vital Statistics and Center for Medicare and Medicaid Services from 1999 to 2020 to analyse ED visits in relation to macroeconomic indicators | A significantly higher proportion of CVD ED visits related to HF and other acute CHD was observed during recessionary time periods both directly and with a 6-month lead and lag (P < 0.05). The proportion of aortic aneurysm and dissection and atherosclerotic CVD ED visits was significantly higher (P = 0.024) in the recession period with a 6-month lead and lag |
| Swarup et al[140], 2024 | Meta-analysis (7 studies) on the association between financial stress and the incidence of major cardiac outcome | A significant association was found between financial stress and major cardiac outcomes (combined HR = 1.191, 95%CI: 1.00-1.47, P < 0.001) |
| Osibogun et al[117], 2024 | Cross-sectional analysis of 6453 adults from the Multi-Ethnic Study of Atherosclerosis. Financial strain was assessed by questionnaire and responses were categorized as yes or no. ICH was measured from 7 metrics (smoking, BMI, physical activity, diet, total cholesterol, blood glucose and blood pressure) | Participants who reported financial strain had lower odds of average (OR = 0.82, 95%CI: 0.71-0.94) and optimal (0.73, 0.62-0.87) ICH scores. However, in the fully adjusted model, the association was only significant for optimal ICH scores (0.81, 0.68-0.97) |
| Ajibewa et al[203], 2024 | Data from 3401 adults from the Coronary Artery Risk Development in Young Adults study, with no prior CVD event were analysed. Chronic stress lasting ≥ 6 months across five life domains (work, financial, relationships, health of self, and health of close other) was self-reported | Chronic stress was associated with lowered survival (time ratio = 0.92; 95%CI: 0.854-0.989), when adjusted for sociodemographic and lifestyle variables but no longer significant when adjusting for clinical factors. Social support was not a significant modifier (P > 0.05) |
| Méndez-Chacón[129], 2026 | In the Costa Rica Longevity and Healthy Aging Study, multiple logistic regression models were used to analyse the relationship between stress and chronic diseases | Stress related to the health of close relatives is associated with an increased risk of developing cardiovascular events. Financial stress was associated with twice the risk of developing hypertension |
| Gopep et al[118], 2025 | Cross-sectional analysis using publicly available data from 18, adults in the National Health and Nutrition Examination Survey | After adjustment, stress was significantly linked to higher odds of hypertension (β = 0.3, P < 0.03) |
| Ayaz Khan et al[123], 2025 | Overall, 385 young adults from Islamabad, Pakistan completed the PSS in conjunction with the Hill-Bone Compliance to High Blood Pressure Therapy Scale | Perceived stress was moderately positively correlated with blood pressure control (P < 0.001). The greater the stress, the less effective blood pressure is controlled (P < 0.001) |
| Kutal et al[128], 2025 | In young patients with a first-ever CIS and sex/age-matched stroke-free controls from 19 European centres self-perceived stress was assessed using a modified version of the PSS. Scores were categorized into low (0-13), moderate (14-26), and high (27-40) perceived stress | Patients were more often at least moderately stressed compared with controls (46.2% vs 33.3%, P < 0.001). Higher self-perceived stress as a discrete measure was independently associated with CIS (aOR = 1.04 per point increase; 95%CI: 1.01-1.07). Categorical PSS score analysis showed an independent association between moderate stress and CIS (OR = 1.47; 95%CI: 1.00-2.14), but not with high stress (2.62; 0.81-8.45) |
| Eleazu et al[190], 2025 | In participants from the Dallas Heart Study phase 2 without prevalent CVD, individual chronic stress subcomponents (generalized stress, psychosocial, financial, and neighbourhood stress) were standardized and integrated to create a novel CSS | CSS was higher among participants who were younger, women, and Black or Hispanic individuals, with lower income and educational attainment (P < 0.0001 for each). In multivariable regression models, higher CSS associated with hypertension, smoking, higher BMI, haemoglobin A1C, high sensitivity C-reactive protein, and sedentary time (P < 0.01 for each). Over a median follow-up of 12.4 years, higher CSS associated with atherosclerotic CVD (aHR = 1.22 per SD, 95%CI: 1.01-1.47) and global CVD (aHR = 1.2, 95%CI: 1.03-1.40) |
| Hallab et al[139], 2025 | Data from the multiethnic ≥ 50-year-old study population (2173 participants), a subset of the Health and Aging Brain Study: Health Disparities study | Having chronic stress is associated with 53% higher odds of disclosing concomitant CVD (aOR = 1.53, 1.1-2.53), 31% of type 2 diabetes (aOR = 1.31, 1.06-1.62), 23% of hypertension (aOR = 1.23, 1.02-1.49), and 30% obesity (aOR = 1.3, 1.09-1.55) |
| Nakhutina and McFarlane[125], 2025 | From the National Health Interview Survey (2004-2013) (284497 individuals) psychological distress was measured using the Six-Item Kessler Psychological Distress Scale (a score of ≥ 13 indicated distress) | Unadjusted OR for stroke among psychologically distressed individuals was 3.1 (95%CI: 2.8-3.3; P < 0.01). After adjusting, the odds of stroke in those with psychological distress was nearly threefold (OR = 2.7; 95%CI: 2.3-3.2; P < 0.01). Classical risk factors attenuated this association, but the relationship remained highly significant (OR = 2.17, 95%CI: 1.81.3-2.60; P < 0.01) |
| Liu et al[141], 2025 | A total of 7493 participants from Wave 3 (2015) of the China Health and Retirement Longitudinal Study were included. Stressful life events were assessed using five simple questions. CMM was defined as having two or more cardiometabolic diseases, including diabetes, heart disease and stroke | The prevalence of CMM increased with the number of stressful life events, ranging from 5.73% for one stressful life event to 6.61% for two or more. In the fully adjusted model, the OR (95%CI) for CMM were 149 (1.01-2.20) for participants experiencing marital problems. Compared with no stressful life events, an increasing number of stressful life events was associated with a higher risk of CMM (P < 0.001) |
| Lavigne-Robichaud et al[153], 2025 | Prospective cohort study including 6295 employees without CVD at baseline from Quebec, Canada | During 15-year follow-up, the attributable fraction for job strain was 18.2% (95%CI 1.8-34.7), and for ERI 3.3% (95%CI: 1.6-8.2). Combined exposure to both stressors resulted in an attributable fraction of 19.5% (95%CI: 0.7-38.4) |
Table 3 Some recent laboratory studies on the cardiac effects of stress in animal studies
| Ref. | Setting | Main results |
| Morais-Silva et al[207], 2019 | Using a chronic SDS protocol followed by the social interaction test, authors identified Wistar rats as resilient or susceptible to SDS | Susceptible animals showed increased depressive-like behaviours with resting tachycardia and decreased HRV due to increased sympathetic tone in the heart and a less effective baroreflex. In contrast, resilient rats were protected from these alterations by increased vagal tone, resulting in greater HRV values |
| Batschauer et al[225], 2020 | Male Wistar rats were divided into four groups: Control-SD, control-HFD, CVS-SD, and CVS-HFD. The control-HFD and CVS-HFD groups were fed with HFD for six weeks. The CVS-HFD and CVS-SD groups were exposed to a CVS protocol in the last ten days of the six weeks | HFD promoted metabolic disorders and increased angiotensin II and leptin blood levels (P < 0.05). CVS or HFD increased BP and the SNS modulation of the heart and vessels and decreased baroreflex activity (P < 0.05). Combining CVS and HFD exacerbated the cardiac SNS response and increased basal HR (P < 0.05) |
| Hinterdobler et al[261], 2021 | Cell-tracking experiments in animal models of acute mental stress | In mice in which leucocytes deplete rapidly from the blood after a single episode of acute mental stress, stress exposure leads to prompt uptake of inflammatory leucocytes from the blood to distinct tissues including heart, and, if present, atherosclerotic plaques. Acute stress enhances leucocyte influx into mouse atherosclerotic plaques by modulating endothelial cells and increases adhesion molecule expression and chemokine release through locally derived norepinephrine. Either chemical or surgical disruption of norepinephrine signalling diminished stress-induced leucocyte migration into mouse atherosclerotic plaques |
| Wu et al[233], 2021 | PTSD and the potential association with the activities of the RVLM and the Mhb were studied. Multi-channel in vivo recordings were used to simultaneously acquire spontaneous neuronal firing and peripheral physiological indices, and FG retrograde tracing technique was used to observe the projections of labelled neurons in the Mhb | The discharge frequency of RVLM and Mhb neurons, the SBP, and the MAP in the PTSD group were all increased significantly compared with those in control group (P < 0.05). Mhb neurons were retrogradely labelled by FG through microinjection into the RVLM. In the control group, electrical stimulation in the Mhb increased HR at 100-300 μA (P < 0.05), elevated SBP and MAP at 200-300 μA (P < 0.05) and remarkably increased the RVLM neuronal discharge frequency at 100-500 μA (P < 0.05 or P < 0.01). In the PTSD group, however, only the discharge frequency of RVLM neurons was increased by the electrical stimulation at 100-300 μA (P < 0.05) |
| Bangsumruaj et al[219], 2022 | Adult male Sprague Dawley rats exposed to 4-week CMS were used as an animal model for daily stress exposure in humans | CMS had lower body weight and higher sucrose intake. The HRV revealed that CMS increased autonomic activity without affecting its balance. The increased RAAS activity with upregulated angiotensin type 1 receptor mRNA expression was shown in CMS and correlated with stress |
| Duarte et al[100], 2023 | Adult rats subjected to a 10-day protocol of RRS, habituating] or CVS (non-habituating) during adolescence, adulthood, or repeated exposure to either RRS or CVS in adolescence and adulthood | CVS increased basal circulating corticosterone levels and caused adrenal hypertrophy in the adolescence + adulthood group, an effect not identified in animals subjected to this stressor only in adulthood or adolescence. CVS also caused a sympathetically mediated resting tachycardia in the adulthood group. Moreover, the impairment in baroreflex function observed in the adulthood group subjected to CVS was shifted to an improvement in animals subjected to repeated exposure to this stressor during adolescence and adulthood |
| Wu et al[214], 2023 | A compound stress method combining electrical stimulation and single prolonged stress was used to prepare a PTSD model, and the difference of weight gain before and after modelling and the elevated plus maze were used to assess the PTSD model. In addition, the distribution of retrogradely labelled neurons was observed using the FG retrograde tracking technique. To further investigate the effects, ACSF, non-selective amygdala glutamate receptors blocker KYN and AMPA receptor blocker CNQX were microinjected into the CeA in the PTSD rats | Compared with the control group, the PTSD group exhibited significantly lower weight gain (P < 0.01) and significantly decreased ratio of open arm time (P < 0.05). Retrograde labelling of neurons was observed in the CeA after microinjection of 0.5 μL FG in the RVLM. The content of AMPA receptor in the PTSD group was lower than that in the control group (P < 0.05), while there was no significant difference in RVLM neuron firing frequency and HR following ACSF injection. However, increases in RVLM neuron firing frequency and HR were observed after the injection of KYN or CNQX into the CeA (P < 0.05) in the PTSD group |
| Scott et al[215], 2025 | Authors employed CSDS in adult male mice. CSDS results in increases in body mass, that are accompanied by elevated lean and fluid mass, as well as several somatic indices of chronic stress. Moreover, mice exposed to CSDS exhibit increased anxiety-like behaviour, spending more time in the closed arms of the elevated plus maze and less time in the center of an open field arena | Initial social defeat sessions result in increases in BP, activity, and temperature in comparison with control mice. Interestingly, while BP returns to basal levels by the start of the light cycle for the first few days of defeat, 14 days of CSDS results in sustained BP elevations, lower activity and lower body temperature. Finally, the results of HRV, spontaneous baroreflex sensitivity and adrenal transcriptome analyses were consistent with CSDS-induced autonomic dysfunction |
Table 4 Some recent studies on laboratory induction of stress
| Ref. | Setting | Main results |
| Meyer et al[235], 2016 | Hospitalized female PTSD patients and controls completed standardized laboratory-based stress testing including a MA test and an audiotape recording of a crying infant | Controls and PTSD patients both showed a significantly increased HR and reduced pre-ejection period from baseline rest to the arithmetic stressor. Parasympathetic activation caused by the crying infant stressor was blunted in PTSD patients as compared to healthy individuals. Under the crying infant condition, a vagal dominance was observed only in controls |
| Brindle et al[297], 2016 | Multivariate cluster analysis examined the relationship between HR and BP reactivity patterns and hypertension in a large prospective cohort (age range 55-60 years). Four clusters emerged with statistically different SBP, DBP and HR reactivity patterns | Cluster 1 was characterised by a relatively exaggerated BP and HR rate response while the responses of cluster 2 were in line with the sample mean. Cluster 3 was characterised by blunted CV stress reactivity and cluster 4 by an exaggerated BP and modest HR response. Membership to cluster 4 conferred an increased risk of hypertension at 5-year follow-up (HR = 2.98, 95%CI: 1.50-5.90, P < 0.01) |
| Wang et al[272], 2016 | A total of 34 young healthy male subjects were recruited and performed a MA task | MA task increased HR, SBP, DBP, and CO. The HFr power component of HRV decreased during MA, but the normalized LF power component and LF/HFr ratio of HRV increased only at the late stage |
| Sherwood et al[301], 2017 | Overall, 199 outpatients diagnosed with HF, with ejection fraction ≤ 40%, underwent an evaluation of BP and HR reactivity to a laboratory-based simulated public-speaking stressor. Cox proportional hazards regression models were used to examine the prospective association between BP and HR reactivity on a combined endpoint of death or CV hospitalization over a 5-year median follow-up period | Both SBP and DBP reactivity were inversely related to risk of death or CV hospitalization (P < 0.01) after controlling for established risk factors. HR reactivity was unrelated to outcome (P = 0.12). High SBP reactivity, compared to intermediate SBP reactivity, was associated with lower risk (HR = 0.498, 95%CI: 0.335-0.742, P = 0.0019); while low SBP reactivity did not differ from intermediate reactivity. For DBP, high reactivity was marginally associated with lower risk compared to intermediate DBP reactivity (HR = 0.767, 95%CI: 0.515-1.14, P = 0.193), while low DBP reactivity was associated with greater risk (HR = 1.49, 95%CI: 1.027-2.155, P = 0.0359) |
| Ginty et al[99], 2017 | Data from 64 participants were collected. HR, SBP, and DBP were measured at baseline and during a standard MA stress task | Individuals who experienced abuse showed diminished CVR to acute psychological stress, specifically by the history of sexual abuse |
| Xie et al[273], 2017 | In total, 25 male subjects were recruited. RR intervals, SBP, DBP, SV, CO, and SVR values were collected during rest and MA. BRS was derived using the transfer function method | MA was characterized by increased HR, SBP, DBP, and CO with decreased BRS attributable to prolonged parasympathetic withdrawal. Moreover, cardiovascular coupling was disrupted in MA |
| Xin et al[193], 2017 | The stress response to a standardized laboratory stress induction procedure (TSST) was measured with a combination of cardiovascular reactivity, hypothalamic-pituitary-adrenal axis reactivity, and subjective affect in healthy individuals | Higher neuroticism predicted lower HR stress reactivity, lower cortisol stress response, more decline of positive affect and lower subjective controllability. Individuals higher in extraversion showed smaller cortisol activation to stress and less increase of negative affect. In addition, higher openness score was associated with lower cortisol stress response |
| Antoun et al[35], 2018 | Twenty healthy adults performed three tasks: Control, driving and exercise plus driving. HR, HRV, BP and cortisol were measured to quantify the acute stress response to each condition | HR was elevated and HRV was reduced during the driving task compared with control. HR was elevated and HRV was reduced comparing the exercise plus driving with the driving condition |
| Chou et al[284], 2018 | Individuals with PTSD recalled a traumatic memory | Significant increase in parasympathetic activity during trauma recall, with greater parasympathetic dominance being indicative of greater state depersonalisation/derealisation. Overall, decreases in HR during trauma recall were associated with increased fear and perceived threat; flashbacks were accompanied by short-term increases in HR |
| Emery et al[279], 2018 | Cardiac activity was recorded via ECG during a standardized speech stress task with three phases: 5-minute rest, 5-minute speech, and 5-minute recovery | Women exhibited higher HR than did men and greater HR reactivity in response to the speech stress. However, women also exhibited greater HRV in both the time and frequency domains |
| O'Súilleabháin et al[298], 2018 | In a sample of 62 healthy young female adults, CV responsivity during a stress exposure was examined | Significant linear interaction for openness across the entire exposure for SBP, and CO. A significant between-subjects effect for HR also emerged. Those highest in openness exhibited an increasingly adaptive myocardial hemodynamic response profile throughout the exposure |
| Grinberg et al[223], 2018 | Authors examined the association between adults’ subjective separation-related distress and changes in HR and BP across the acute-stress laboratory paradigm | Adults who reported greater separation-related distress exhibited higher initial BP, a slower linear increase in BP, and significantly slower declines in DBP following the acute stress task |
| Kibler[280], 2018 | The sample consisted of 50 trauma-exposed civilian women ranging from 19 years to 49 years of age. Cardiovascular recovery was assessed after oral speaking stressor as percentage return to baseline; the recovery measures consisted of impedance cardiography-derived CO and TPR, HR and BP | Total PTSD severity was associated with less CO recovery, r = -0.39, P = 0.006; this effect was similar across PTSD symptom categories. However, only PTSD severity in the avoidance cluster was associated with less TPR recovery, r = -0.29, P = 0.047. Total PTSD severity was associated with greater threat appraisal, r = 0.30, P = 0.035, and greater threat appraisal was associated with less CO recovery, r = -0.33, P = 0.019 |
| Zaffalon et al[304], 2018 | In a total of 96 young women divided into SW and AW, the R-R interval was recorded to quantify the cardiac autonomic modulation at rest and in response to the Stroop Color Test | The physical health domain of quality of life was compromised in the SW group. The SW group presented higher HR, lower variance of RR interval and higher cardiac sympathovagal balance (LF/HF) both at rest and in response to the mental stress test |
| Delliaux et al[305], 2019 | A 1-hour computerized switching task (letter recognition) was performed by 24 subjects while monitoring their performance (accuracy, response time) and ECG. The HRV was evaluated from the beat-to-beat RR intervals in time-, frequency-, and informational- domains, before and during the task | The HR, BP, and baroreflex function were unchanged, whereas most of the HRV parameters markedly decreased. The maximum decrease occurred during the first 15 minutes of the task, before starting to return to the baseline values reached at the end of the task. The RR interval dimension correlation decrease was the most significant (P < 0.001) |
| Kim et al[281], 2019 | Overall, 549 patients with stable CAD underwent mental stress testing with a standardized public speaking stressor and followed prospectively for cardiovascular endpoints. Digital pulse wave amplitude was continuously measured using PAT. sPAT was calculated and dichotomized by into “low” and “high” sPAT ratio groups | The median sPAT ratio was 0.68 (IQR: 0.48-0.88), indicating 32% vasoconstriction with mental stress. Men were more likely to have low sPAT ratio than women (OR = 1.79, P = 0.007) while those on beta blockers were less likely to have low sPAT ratio (OR = 0.52, P = 0.003). After adjusting for demographic and cardiovascular risk factors, medications, and rate-pressure product change during mental stress, those with low sPAT ratio were at significantly higher risk of adverse outcomes (HR = 1.77, 95%CI: 1.12-2.80) |
| Lima et al[282], 2019 | Cohort study of 569 individuals with stable CAD conducted at a university-affiliated hospital network. Participants were subjected to a laboratory mental stress task (public speaking) | FMD decreased from a mean (SD) of 4.8% (3.7%) before mental stress to 3.9% (3.6%) after (23% reduction; P < 0.001). The presence of transient endothelial dysfunction with mental stress was associated with a 78% increase (HR = 1.78, 95%CI: 1.15-2.76) in the incidence of MACE |
| Riordan et al[174], 2019 | A sample of 76 healthy undergraduate students completed the DS14 type D measure, before undergoing a traditional cardiovascular reactivity protocol. SBP, DBP, and HR were monitored throughout | No associations were evident for BP. However, a significant personality × sex × social context interaction on HR reactivity was found; here type D was associated with a higher HR response to the social task amongst males, while type D females typically exhibited blunted reactions |
| Sullivan et al[283], 2019 | The study used data from 632 patients with CAD. Patients’ residential addresses were geocoded with poverty data. SBP, DBP, HR, rate-pressure product, epinephrine, interleukin-6, and hs-CRP were measured before and after a public speaking stress task | After adjusting for potential confounders, participants living in high (vs low) poverty neighbourhoods had similar hemodynamic values at rest and lower values during mental stress for SBP (P = 0.07), HR (P = 0.02) and rate-pressure product (P = 0.01). There were no significant differences in inflammatory and epinephrine responses to mental stress |
| Wittbrodt et al[313], 2019 | Participants with CAD underwent brain imaging with HIGH RESOLUTION POSITRON EMISSION TOMOGRAPHY and radiolabelled water during control (verbal counting, neutral speaking) and mental stress (MA, public speaking). Traumatic events in childhood were assessed with the ETI-SR-SF and participants were separated by presence (ETI+) or absence (ETI-) | Compared to ETI-, ETI+ experienced greater (P < 0.005) activations during mental stress within the left anterior cingulate, left occipital lobe, bilateral frontal lobe and deactivations (P < 0.005) within the left insula, left parahippocampal gyrus, right dorsal anterior cingulate, bilateral cerebellum, bilateral fusiform gyrus, left inferior temporal gyrus, right occipital lobe, and right parietal lobe. Significant (P < 0.005) positive correlations between brain activation and ETI-SR-SF scores were observed within the left hippocampus, bilateral frontal lobe, left occipital cuneus, right parietal precuneus, and bilateral temporal lobe |
| Lee et al[274], 2020 | In a sample of 125 undergraduates, during a modified TSST, appraisals of the stressor were assessed and BP and HR were measured | PTSD symptoms are associated with current physical health (resting BP and HR) and more negative appraisals of the stressor; in turn, more negative appraisals were associated with increases in cardiovascular response |
| Liu et al[324], 2020 | A total of 77 patients with known CAD underwent echocardiography before and during MA stress task. MSIMI was diagnosed by new or worsening wall motion abnormalities greater than or equal to a 5% reduction of left ventricle ejection fraction | MA induced a significant increase in stromal cell-derived factor-1α and monocyte chemoattractant protein-1 in all subjects; 20.78% of the patients with known CAD developed MSIMI during the arithmetic task. MSIMI positive patients had significantly lower baseline levels of interleukin-1β and tumour necrosis factor-α, but a higher response in levels of stromal cell-derived factor-1α than MSIMI negative patients |
| Lucas et al[290], 2020 | Authors examined changes in HR tracked via an Apple Watch during three typical work shifts in a retail store setting | Increase in HR during a work shift to a level observed during a moderate stressor (P < 0.0001). Female subjects demonstrated a significantly elevated maximum HR, a larger change in HR, and a larger percent change in HR compared with males (all P < 0.05) |
| Widmer et al[322], 2020 | In a prospective study 417 patients with ACS were enrolled in two sites at the United States and Qatar. Response to three different mental stress examinations (Stroop colour word, MA, and Spiral Omnibus) as assessed by ratio of reactive hyperaemia tonometry (EndoPAT) | Women were more likely to experience MACE in the year following ACS (RR = 2.42, 95%CI: 1.53-3.84, P = 0.044) and had a significantly lower mental stress ratio compared to women who did not (P = 0.04). In multivariate analyses, baseline peripheral endothelial dysfunction (EndoPAT < 1.7) (P = 0.005) and mental stress ratio (P = 0.0069, were independently predictive of MACE in women, but not men |
| Schneider et al[299], 2021 | Participants completed the life experience survey and positive and negative affect schedule and undertook a standardized social-evaluative stress task. Cardiac activity was measured via HR and non-linear HRV indices sample entropy, SD1, SD2 and SD1/SD2 ratio | Higher HR reactivity in individuals reporting higher number and impact of negative and total life events. Life-events are associated with elevated HR and diminished HR complexity in response to acute stress |
| Kim et al[224], 2021 | Using smartphones, ten young participants completed ecological assessments 6 times a day for two weeks regarding their current affective state. They also wore a chest-mounted HR monitor and a wrist accelerometer to monitor cardiovascular response and physical activity, respectively | Higher HR and lower HRV were related to subsequent greater feelings of stress at the 5-minute and 30-minute time intervals |
| Formolo et al[277], 2022 | Sixty-six young men underwent anthropometric and body fat assessment (dual-energy X-ray absorptiometry) and carotid artery ultrasonography. Accelerometers assessed physical activity levels and sleep efficiency. MS was induced through the Stroop colour-word test while BP, HR, and cardiac interval were measured | An interaction between fat mass index and time for HR reactivity was observed. Cardiac interval variability analysis showed that only participants with normal fat displayed parasympathetic withdrawal during MS (P < 0.05). Multiple linear regression analysis supported the role of adiposity and autonomic modulation in the HR reactivity to MS and showed involvement of carotid distensibility and sleep efficiency (P < 0.05). Carotid distensibility was the only predictor for BP reactivity (P < 0.05) |
| Zhang et al[309], 2022 | The scale of CTQ was administered to 192 healthy undergraduates who underwent continuous cardiovascular monitoring while facing two consecutive psychosocial stress (public speaking tasks | Childhood maltreatment was negatively associated with HR and cardiac output reactivity to the first stress exposure and HR reactivity to the second stress exposure |
| Lee et al[303], 2022 | Using a cross-sectional observational design, 84 trauma-exposed community adults who endorsed at least one core PTSD symptom were enrolled. Participants completed a physical exam, self-reports of trauma history and PTSD symptoms, and BP and HRV frequency-domain measurements during rest, stressor (MA task), and recovery | Arousal/reactivity was not associated with BP or HRV reactivity but with a higher LF/HF ratio during recovery reflecting sympathetic predominance. During the stressor, more avoidance and intrusion were associated with increased DBP from baseline; more avoidance was associated with parasympathetic predominance (lower LF/HF); and more negative cognitions/mood was associated with decreased SBP, DBP, and LF from baseline. During recovery, more intrusion and negative cognitions/mood were associated with increased SBP from baseline; less negative cognitions/mood was associated with sympathetic predominance (higher LF/HF) |
| Legaz et al[274], 2022 | Hypertensive patients and healthy controls groups performed TSST. During both stages, a sensitive HRV parameter (the LF/HF ratio) and an online neurophysiological measure. the HEP were assessed. Neuroanatomical data via voxel-based morphometry were obtained for correlation with online markers | Relative to controls, hypertensive patients exhibited increased LF/HF ratio and greater HEP modulations during baseline, reduced changes between baseline and stress periods, and lack of significant stress-related HRV modulations associated with the grey matter volume of putative frontrostriatal regions. They presented signs of stress-related autonomic imbalance, reflected in a potential basal stress overload and a lack of responsiveness to acute psychosocial stress, accompanied by neuro-physio-anatomical alterations |
| Griffin and Howard[192], 2022 | Forty-eight participants completed a standardized laboratory stress paradigm incorporating a 20-minute acclimatization period, a 10-minute baseline, and two 5-minute speech tasks separated by a 10-minute rest period. CV parameters were measured using the Finometer Pro | Greater habitual use of suppression was associated with exaggerated BP responding to both tasks. However, only in response to the negative-emotion task was greater use of reappraisal associated with a challenge-oriented cardiovascular response |
| McLoughlin et al[276], 2022 | Eighty-six participants reported their exposure to lifetime non-sport and sport-specific stressors before completing two consecutive TSST, while cardiovascular (i.e., HR) and endocrine (i.e., salivary cortisol) data were recorded | Exposure to a moderate number of lifetime non-sport and sport-specific stressors was associated with adaptive cardiovascular reactivity, whereas very low or very high stressor exposure was related to maladaptive reactivity. Moreover, experiencing a very low number of lifetime non-sport (but not sport-specific) stressors was associated with poorer habituation. In contrast, lifetime stressor severity was unrelated to cardiovascular reactivity. Finally, greater lifetime non-sport and sport-specific stressor counts were associated with blunted cortisol reactivity and poorer habituation |
| Winzeler et al[310], 2017 | One hundred eighteen healthy young women provided data on ACEs and underwent psychosocial stress testing. SBP and RSA, quantified by HF-HRV variability, were assessed as measures of sympathetic and parasympathetic CV activity, respectively | The effect of ACEs on HR reactivity was mediated by SBP reactivity but not by RSA reactivity. ACEs were associated with reduced SBP at rest. ACEs were associated with down-regulation in a measure of sympathetic but no alteration in a measure of parasympathetic cardiovascular stress reactivity in adulthood |
| Almuwaqqat et al[315], 2023 | Authors studied 300 patients with a recent AMI. Patients underwent myocardial perfusion imaging with mental stress and were followed for 5 years | A diffuse MSIMI increment of 1 standard deviation was associated with a 40% higher risk for adverse events (HR = 1.4, 95%CI: 1.2-1.5). In sex-specific analysis, higher levels of MSIMI (per SD increment) were associated with 53% higher risk of adverse events in women (HR = 1.5, 95%CI: 1.2-2.0) but not in men (HR = 0.9, 95%CI: 0.5-1.4), P = 0.001 |
| Bremner et al[221], 2023 | CHD patients underwent cardiac imaging with Tc-99m sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of 18F2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress | Patients with MSIMI showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group, activity increases with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (P = 0.038 and P = 0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (P = 0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (P = 0.004) |
| Gentilin et al[312], 2023 | The carotid hf-PWV index, MAP, PP, TPR, and HR were measured in 26 young at rest and throughout a 10-minute bout of MA stress | Mental stress increased hf-PWV, MAP, PP, and HR from baseline throughout the entire stimulation period (P < 0.005). TPR diminished in the first minute of stimulation (P < 0.001) in both sexes and increased in the last minutes in women only (P < 0.005). Hf-PWV was lower in women than men (P < 0.001) at rest and during mental stress, but the changes from baseline were similar |
| Lee et al[300], 2023 | A sample of 92 adolescent girls self-reported early life stressors. SBP, DBP, and HR were continuously measured before, during, and after a laboratory peer rejection paradigm | Adolescent girls with higher early life stress had lower, not higher, HR during the recovery period. Early life stress was not associated with SBP or DBP recovery. Additionally, early life stress was not associated with SBP, DBP, or HR reactivity |
| Liu et al[196], 2023 | In 883 treatment-naive individuals from a longitudinal cohort study of Midlife in the United States, symptoms of stress were assessed by PSS. Cardiovascular reactivity was measured using standardized, laboratory-based stressful tasks | Treatment-naive individuals with higher stress levels (PSS ≥ 27) had blunted cardiovascular reactivity multivariate linear regression showed that stress was associated with reduced SBP and DBP reactivity but with a nonsignificant association with HR reactivity (P = 0.056) |
| Lü et al[266], 2023 | The CTQ was administered to 359 junior school students who underwent a two-successive stress exposures protocol with continuous cardiovascular monitoring. HR and SBP, DBP, and their saliva samples for deoxyribonucleic acid genotyping were collected | ELA was associated with blunted HR reactivity to the first and second stress exposures, blunted SBP reactivity to the first stress exposure, and attenuated SBP habituation to repeated stress exposures. Moreover, COMT rs4680 moderated these associations, such that the associations between ELA and blunted HR, SBP, and DBP reactivity to the first stress and disrupted DBP habituation to repeated stress exposures only existed in GA/AA genotype carriers |
| Mrug et al[287], 2023 | The sample included 1027 adolescents and young adults who reported on ELS exposure and coping styles. Participants completed a standardized TSST, with HR and BP measured before, during, and after. Self-reports of negative emotions during the TSST indexed emotional stress reactivity | ELS was associated with lower HR stress reactivity; avoidant coping was related to lower SBP and DBP during stress and lower SBP during recovery; and higher emotion-oriented coping and lower task-oriented coping predicted greater emotional stress reactivity. A consistent pattern emerged where emotion-oriented coping amplified the associations between ELS and maladaptive stress responses (blunted cardiovascular stress reactivity and recovery; enhanced emotional stress reactivity), whereas lower levels of emotion-oriented coping were associated with resilient profiles among those who experienced ELS (lower resting HR; lower emotional stress reactivity; average HR and BP stress reactivity and recovery) |
| Okoh et al[316], 2023 | In 812 patients with stable CHD at a university-affiliated hospital network, FMD was assessed before and 30 minutes after mental stress. TED was defined as a lower post-stress FMD than prestress | FMD significantly declined with mental stress in both groups. TED occurred more often in Black than non-Black patients (aOR = 1.6, 95%CI: 1.5-1.7). Black participants had a 419% higher risk of either cardiovascular death or nonfatal AMI than non-Black participants (95%CI: 1.01-1.95). TED with mental stress explained 69% of this excess risk |
| O’Riordan et al[176], 2023 | Undergraduate students competed a standardised cardiovascular reactivity experimental protocol consisting of resting baseline and stressor phase (MA), with SBP, DBP and HR monitored throughout | The continuous Type D interaction term (negative affect × social inhibition) significantly predicted lower SBP reactivity to the MA stressor amongst women, independent of confounding variables. This remained significant after adjustment for anxiety and depressive symptoms |
| Perez Alday et al[269], 2023 | Overall, 238 male Veteran twins listened to audio recordings of a one-minute neutral script followed by a one-minute trauma script. Authors examined two HRV metrics: DC and log-LF power from beat-to-beat intervals extracted from ambulatory ECG and assessed longitudinal PTSD status with a structured clinical interview and the severity with the PTSD symptoms scale | PTSD status and acute PTSD symptom severity were not associated with DC or log-LF measured during the neutral session but were significantly associated with lower DC and log-LF during the traumatic script listening session. Long-standing PTSD was associated with a 038 (95%CI: -0.83 to -0.08) and 0.79 (-1.30 to -0.29) standardized unit lower DC and log-LF, respectively, compared to no history of PTSD |
| Sullivan et al[317], 2023 | In the MIMS2 study, 263 patients hospitalized for an AMI were prospectively followed for 5 years. Reactive hyperaemia index and flow-mediated dilation were used to measure microvascular and endothelial function, respectively, before and 30 minutes after a public-speaking mental stress task | Worse microvascular response to stress (for each SD decrease in the reactive hyperaemia index) was associated with 50% greater risk of MACE (HR = 1.5, 95%CI: 1.05-2.13; P = 0.03) among women only (sex interaction: P = 0.03). Worse TED in response to stress (for each SD decrease in flow-mediated dilation) was associated with a 35% greater risk of MACE (HR = 1.35, 95%CI: 1.07-1.71; P = 0.01); the association was similar in women and men |
| Tyra et al[270], 2023 | A sample of 453 participants completed a repeated stress paradigm, which consisted of two 10-minute baselines and two identical 4-minute stress tasks, separated by a 10-minute recovery period. HR was measured continuously; SBP/DBP every 2 minutes. Participants completed the ERQ and DERS | Impulse control difficulties when distressed (a DERS subscale) were significantly associated with blunted SBP, DBP, and HR reactivity to both stressors, as well as impaired HR habituation across the stressors. None of the ERQ subscales (cognitive reappraisal, expressive suppression) were found to be associated with cardiovascular stress reactivity or habituation |
| Ji et al[288], 2024 | Chinese adolescents first reported their childhood trauma and social anxiety using the Childhood Trauma Questionnaire and the Social Interaction Anxiety Scale, then participated in a social stress task, during which their cardiovascular data (HR, SBP, DBP) were monitored | The results showed that high levels of childhood trauma were associated with blunted HR, SBP, and DBP reactivity, which in turn were associated with high levels of social anxiety. Mediation analysis indicated that childhood trauma was indirectly associated with social anxiety via blunted cardiovascular reactivity |
| Gallagher et al[286], 2024 | Two hundred and six participants from the Pittsburgh Cold Study underwent a modified version of the TSTT | Social network size was positively associated with DBP reactivity (β = 0.19, 95%CI: 0.05-0.29, P = 0.005), while loneliness was not. In addition, social network size moderated the loneliness-DBP reactivity relationship |
| Sinnot et al[289], 2024 | The study aimed to examine the influence of both PTSS and self-blame (negative appraisal after trauma, commonly sexual) on BP and HR reactivity measured before, during, and after a laboratory-based sexual trauma reminder among 72 young adult women who have experienced sexual trauma | Higher PTSS predicted lower DBP reactivity during the trauma reminder. Higher levels of self-blame predicted higher HR and SBP reactivity during and after the trauma reminder. Overall, these findings suggest that survivors of sexual trauma with higher levels of PTSS experience a blunting reaction of DBP when exposed to trauma reminders |
| Almuwaqqat et al[314], 2024 | In 427 patients with stable CAD undergoing a laboratory-based MS test, CPCs were enumerated using flow cytometry as CD34-expressing mononuclear cells before and 45 minutes after stress. Changes in brain regional blood flow with MS were measured using high resolution-positron emission tomography | MS increased CPC counts by a mean of 150 cells/mL (15%), P < 0.001. Greater limbic lobe activity, indicative of activation of emotion-regulating centres, was associated with greater CPC mobilization (P < 0.005). After adjustment, greater CPC mobilization was associated with a higher adjusted risk of adverse events during a 5-year follow-up; a rise of 1000 cells/mL was associated with a 50% higher risk of cardiovascular death/MI (HR = 1.5, 95%CI: 1.1-2.2) |
| Osei et al[325], 2024 | Authors examined the relationship between stress-induced autonomic dysfunction, measured by low HRV using Holter monitoring, and MSIMI in patients with stable CAD before and during a standardized laboratory-based speech stressor. HRV at rest and stress were categorized into low HRV vs high HRV; the low category was used as an indicator of autonomic dysfunction | Compared with high HRV during stress, low HRV during stress (both HF and LF) was associated with higher odds of MSIMI after adjusting for demographic and clinical factors (OR for HF HRV: 2.1, 95%CI: 1.3-3.3; OR for LF HRV: 2.1, 95%CI: 1.3-3.3). LF HRV at rest was also associated with MSIMI but with slightly reduced effect estimates |
| Rasero et al[318], 2025 | Midlife adults from two different cohorts underwent two information-conflict tasks, in which patterns of hemodynamic brain responses exhibited a generalizable association with carotid artery intima-media thickness, which was mediated by an area-under-the-curve measure of aggregate SBP reactivity | Task-averaged patterns of hemodynamic brain responses exhibited a generalizable association with CA-IMT, which was mediated by an area-under-the-curve measure of aggregate SBP reactivity. Importantly, this effect held in sensitivity analyses. Implicated brain areas in this mediation included the ventromedial prefrontal cortex, anterior cingulate cortex, insula and amygdala |
| Nawar et al[291], 2024 | This pilot study investigated data from a validated, multimodal, wearable patch to examine physiological correlations of laboratory-based hypertensive stress responses. The device collected ECG and photoplethysmogram signals during a protocol involving a public speaking stressor | MAP changes correlated significantly with changes in HR (P < 0.001, r = 0.69), left ventricular ejection time (P < 0.001, r = -0.63), pulse arrival time (P < 0.001, r = -0.58), and pulse transit time (P < 0.001, r = -0.56) captured by the patch |
| Martin et al[76], 2024 | In 179 older male twins from the Vietnam Era Twin Registry, lifetime history of PTSD and last month PTSD symptoms were assessed. Participants listened to neutral and personalized trauma scripts while peripheral vascular tone (peripheral arterial tonometry ratio) and systemic vascular tone (TVC) were measured | Compared to their brothers without PTSD, during trauma recall, participants with a history of PTSD had greater increases in peripheral (β = -1.01, 95%CI: -1.72 to -0.30) and systemic (TVC: β = -1.12, 95%CI: -1.97 to -0.27) vasoconstriction after adjusting. Analysis of current PTSD symptom severity showed consistent results |
| Maffei et al[201], 2025 | A version of TSST was employed to experimentally induce stress in a sample of 40 dyads, each comprising a target participant who was paired with a second participant, acting as a supporter. In half of the dyads the target and the supporter were in a romantic relationship (partner group), while in the other half not (stranger group) | Participants in the partner group exhibited a lower HR during the acute stress compared to the participants in the stranger group, highlighting that the buffering of the physiological stress activity is stronger within close relationships. Nonetheless, participants in the partner group reported more anxiety and stress during the task |
| Strotsava and Brindle[271], 2025 | Participants completed the CTQ and a socially evaluative MA stressor in the laboratory. HR, BP, and baroreflex function were measured during both baseline and stress conditions. Stress reactivity was defined as the change in HR, BP, or baroreflex function from baseline to stress | HR and BP significantly increased and baroreflex function significantly decreased in response to mental stress (all P < 0.001). However, after controlling for sex, cohort, baseline values, and perceived stress, no significant associations emerged between CTQ scores, total or subscales, and either cardiovascular or baroreflex reactivity (all P ≥ 0.55) |
| Bigalke et al[319], 2025 | In adult volunteers beat-by-beat blood pressure (finger plethysmography), heart rate, and MSNA reactivity (microneurography) were recorded during a 10-minute quiet rest followed by the TSST | Endorsement of a threat appraisal was positively associated with changes in MSNA burst frequency (P = 0.018), burst incidence (P = 0.009), and total MSNA (P = 0.037) during the speech stress period. Moreover, increase in threat appraisal across tasks was associated with elevated MSNA burst frequency (P = 0.023), incidence (P = 0.030), and total MSNA (P = 0.027) responsiveness |
| Tyra et al[293], 2025 | Participants completed a 10-minute baseline, 5-minute speech preparation, and 5-minute speech delivery, which was repeated after a 10-minute recovery. They were randomly assigned to either suppression or control instructions before the second speech prep. HR, SBP/DBP, and pre-ejection period were measured throughout. Habitual use of suppression was assessed using the Emotion Regulation Questionnaire | All participants exhibited significant CV habituation, irrespective of condition, suggesting instructed suppression did not hinder habituation. Instructed suppression was not associated with changes in perceived psychological stress or positive affect across tasks; however, instructed suppression was associated with greater habituation of negative affect |
| Costello et al[294], 2025 | This study used previously collected data from the Pittsburgh Cold Study 3. One-hundred and eighty-nine participants completed two separate, identical, standardized stress-testing protocols and had their BP and HR monitored throughout a baseline, stress task and recovery phase | Delta change score from task, percent change task and area under the curve with respect to ground demonstrated the strongest temporal stability for blood pressure and HR recovery between visits |
| Zhou et al[320], 2025 | Using data collected from involving acute mental stress and TMNS (with stress-mitigating effect), authors examined the ability of six plausibly explainable physio-markers to capture cardiovascular responses to acute mental stress and TMNS | The synthetic multi-modal variable showed explainable responses to acute mental stress and TMNS in more experiments. It also exhibited superior consistency, balanced sensitivity, and robustness compared to individual physio-markers |
| Martin et al[321], 2025 | Using a cross-sectional design, authors assessed childhood trauma and HR and BP responses to public speaking in AMI survivors | Black participants showed significantly lower HR and SBP and DBP reactivity to mental stress compared with White participants. High childhood trauma was independently associated with lower HR and SBP reactivity. Black participants with high trauma had the lowest HR (β = |
| Linsley et al[278], 2025 | Participants completed passive (IAPS and active PASAT) stress task cardiovascular measures (including SBP, DBP, HR) and blood samples determining inflammatory responses (circulating and stimulated IL-6, SIRI, NLR, TNF-α, and P- and E-selectin) were collected | Cardiovascular measures were higher during the PASAT than IAPS (P < 0.001). Circulating IL-6 levels increased from baseline to 45-minute after both tasks (P ≤ 0.001), with no difference between 45-minute post-PASAT and 45-minute post-IAPS. SIRI increased from baseline to post-IAPS (P = 0.013), 45-minute post-IAPS (P = 0.004), and 45-minute post-PASAT (P < 0.001). No difference in SIRI between 45-minute post-PASAT and 45-minute post-IAPS existed. NLR increased from baseline to 45-minute post-PASAT (P = 0.008). There were no significant time effects for TNF-α, P-selectin, or E-selectin |
| Lee et al[295], 2025 | Authors conducted a laboratory-based study with 84 adult trauma survivors to test threat and challenge appraisals as mediators of the relationships of positive states of mind with HRV responses to stress | Stronger appraisal of challenges mediated the effects of more positive states of mind on lower LF during recovery. Threat appraisal was not a significant mediator of any association between positive states of mind and HRV reactivity or recovery. Challenge appraisal may explain the association between greater positive states of mind and lower sympathetic arousal during recovery |
| Goldberg et al[285], 2025 | Overall, 67 participants underwent BP measurements during baseline, after a 5-10-minute GR task, and during a 10-minute recovery period. Repeated measures compared SBP and DBP at baseline and 0-, 5-, and 10-minute post-GR. Participants meeting PGD criteria were descriptively compared to individuals reporting grief severity below the median of the Prolonged Grief-13 questionnaire and to those above the median without PGD | SBP and DBP increased post-GR and remained elevated during the 10-minute recovery (SBP: P = 0.009; DBP: P = 0.03). Pairwise comparisons revealed significant differences between SBP and DBP at baseline compared to post-GR measurements. Descriptively, the PGD subgroup showed higher baseline values, similarly pronounced reactivity compared to the rest of the sample, and a delayed decline in SBP and DBP, particularly compared to participants with low grief severity |
| Naliboff et al[296], 2025 | Fifty healthy women designated as HS based on above threshold scores on a measure of perceived stress were compared to 50 women with LS. Psychological, autonomic nervous system and plasma metabolite assessments were obtained before, during and after exposure to multiple tasks including viewing affective pictures, performing stressful MA and figure ground discrimination | The HS group showed a greater increase in negative affect when challenged with a laboratory stressor (P < 0.001) and in response to neutral affective pictures (P = 0.040); this same group showed overall less sympathetic arousal than the LS group during a MA challenge (P = 0.034). The HS group had a higher plasma metabolite tryptophan/kynurenine ratio than the LS group at baseline, but this did not change with stress |
Table 5 Some recent studies on various interventions against stress
| Ref. | Setting | Main results |
| Hewett et al[369], 2017 | Eligible adults were randomized to an experimental group or a CTRL group. Experimental group participants were instructed to attend three to five supervised Bikram yoga classes per week for 16 weeks at local studios | No significant change in the high-frequency component of HRV (P = 0.912) or in any secondary outcome between groups. Regression analyses revealed that higher attendance in the experimental group was associated with significant reductions in DBP (P = 0.039), body fat percentage (P = 0.001), fat mass (P = 0.003), and BMI (P = 0.05) |
| Cheung et al[359], 2018 | Twenty TC practitioners and 20 non-practitioners volunteered joined the study. After baseline measurements were taken, the TC group performed TC for 10 minutes while their cognitive states and cardiovascular responses were concurrently monitored. Stress levels were measured using PSS | Perceived stress level decreased from baseline to post-test in exclusively the TC group (P = 0.005). HR increased during TC (P = 0.001) and decreased thereafter (P = 0.001) |
| von Känel et al[340], 2018 | Within 48 hours of hospital admission, patients with high distress during ACS were randomized to a single-session intervention of either trauma-focused counselling or an active control intervention targeting the general role of stress in patients with heart disease. Blind interviewer-rated PTSD (primary outcome) and additional health outcomes were assessed at 3 months of follow-up | No difference in interviewer-rated PTSD between trauma-focused counselling (mean = 11.33; 95%CI: 923-13.43) and stress counselling (9.88; 7.36-12.40; P = 0.40), global psychological distress (5.15, 4.07-6.23, vs 3.80, 2.60-5.00; P = 0.11), and the risk for CV-related hospitalization/all-cause mortality (OR = 0.67; 95%CI: 0.37-1.23). Self-rated PTSD indicated less beneficial effects with trauma-focused (6.54; 4.95-8.14) vs stress counselling (3.74; 2.39-5.08; P = 0.017) |
| Jalali et al[346], 2019 | Overall, 60 patients were selected, clinically interviewed by a cardiologist and randomized to two groups; experimental and control, to investigate the effectiveness of a mindfulness-based stress reduction; then they completed General Self-Efficacy Scale and 36-item Short Form Survey | The mean pre-test scores of self-efficacy and QoL of patients were not significantly different between the experimental and control groups (P = 0.05). However, the mean scores of the two variables were found to be significantly different between the experimental group and the control group on the post-test and follow-up (P = 0.01) |
| Bourassa et al[338], 2021 | Secondary analysis of a large intervention study of active-duty soldiers with PTSD randomized to an exposure therapy-either or a waitlist control condition | Changes in resting HR and HR reactivity were not significantly correlated with either self-reported or clinician-rated PTSD symptom change |
| Chandler et al[343], 2020 | Twelve-month RCT of a breathing meditation smart phone app (TT) involving pre-hypertensive adults. The TT app captures continuous real-time HR from a user’s fingertip placed over a video camera lens during sessions. Users receive both immediate feedback graphs, showing their HR changes, and motivational and social reinforcement SMS text messages. Each group received a twice-daily dosage schedule of TT or walking | Mixed modelling results revealed a significant group x time effect for SBP (P < 0.01). The TT group showed greater SBP reductions at months 3 (-8.0 vs -1.9), 6 (-10.0 vs -0.7), and 12 (-11.6 mmHg vs |
| Chelidoni et al[345], 2020 | The study aimed to assess the effectiveness of a brief app-based breathing intervention (BioBase) in enhancing physiological recovery among employees who were induced to cognitive and emotional stress. Interbeat (RR) intervals were recorded continuously for 5 minutes at baseline and during cognitive and emotional stress induction. The session ended with a 5-minute recovery period during which participants were randomly allocated into 3 conditions: Commercially available app-based breathing BioBase, mindfulness body scan, or CTRL | Subjective tension significantly increased following stress induction. HRV significantly decreased following the stress period. In the recovery phase, the root mean square of successive RR interval differences (P = 0.002), the percentage of successive RR intervals that differed by > 50 milliseconds (P = 0.008), and HF (P = 0.01) were significantly higher in the BioBase breathing condition than in the mindfulness body scan and the CTRL groups |
| Fonkoue et al[344], 2020 | Veterans with PTSD were studied and randomized to either 8 weeks of daily DGB or of sham device (Sham). BP, HR, and MSNA were measured at rest and during mental math. Arterial BRS was assessed using the modified Oxford technique | Resting MSNA, BP, and HR remained comparable before and after 8 weeks in both groups. Likewise, the change in sympathetic and cardiovagal BRS was not different. DGB significantly decreased MSNA reactivity to mental math when expressed as burst frequency (P = 0.012) or burst incidence (P = 0.008) compared with Sham. Pulse pressure reactivity was also comparable |
| Hruska et al[380], 2020 | Fifty-four workers eligible for paid vacation time were recruited; stress ratings obtained via weekly surveys and ambulatory HR readings obtained via a wrist-worn consumer device were collected before and after the vacation | A statistically significant interaction was observed between weekly stress and the period leading up to the vacation on ambulatory HR (P = 0.01). The relationship between weekly stress and HR was stronger when the vacation was further away in the future and imparted less of an effect as the vacation approached |
| Kirk et al[347], 2020 | Fully randomized 10-day longitudinal trial of mindfulness practice, explicitly controlling for practice effects with an active-control group (music listening) and CTRL group. To assess chronic CV effects, authors asked participants to complete 2-day HRV pre- and post-intervention measurement sessions | Increased HRV during the daily practice sessions in both the mindfulness and active-control group indicating that both interventions were effective in decreasing acute physiological stress. For the chronic phase increased HRV in both the day- and nighttime indicating increased sleep quality, specifically in the mindfulness group |
| Lachowska et al[354], 2020 | BP and HR were measured in 21 patients with HFrEF (23.9% ± 5.9%) at rest, during laboratory stressors handgrip, mental and CPT, before and after acute SLOWB, and 12 weeks after SLOWB home training (30 minutes daily). HRQoL (MacNew questionaries) was assessed before and 12 weeks after SLOWB home training | Both acute and long-term SLOWB significantly reduced BP and HR responses to mental stress (P < 0.05), but not to isometric and cold pressor tests. SLOWB improved scores of all domains of QoL (P < 0.05) at 12 weeks follow-up |
| Nourisaeed et al[398], 2021 | Overall, patients after AMI were randomly divided into 3 groups of 15 individuals (2 interventions including cognitive-behavioural therapy and dialectical behavioural therapy, and 1 CTRL group). In the IG, participants underwent 8 weekly 90-minute sessions. Data were collected including the Ways of Coping Questionnaire, and the PSS-14 | Significant main effects of group (P = 0.005) and time (P < 0.001), and a significant group-by-time interaction (P < 0.001) on PSS. For problem-focused coping scores, findings indicated significant main effects of group (P = 0.002) and time (P < 0.001), and a significant group-by-time interaction (P < 0.001). For emotion-focused coping scores, significant main effects of group (P < 0.001) and time (P < 0.001), and a significant group-by-time interaction (P < 0.001) were observed |
| Kunikullaya Ubrangala et al[374], 2022 | Single session of auditory stimulation with three different ‘Modes’ of Indian music (Mode/Raga Miyan ki Todi, Malkauns, and Puriya) musical stimuli on anxiety, biomarkers of stress, and CV parameters were measured among 140 healthy young adults. The outcome measurements of the State-Trait Anxiety Inventory, BP, and HRV were collected | State anxiety was reduced significantly with raga Puriya (P = 0.018), followed by raga Malkauns and raga Miyan Ki Todi. All the groups showed a significant reduction in sAA. Raga Miyan ki Todi and Puriya caused an arousal effect (as evidenced by HRV) during the intervention and significant relaxation after the intervention (both P < 0.005). Raga Malkauns and the CTRL group had a sustained rise in parasympathetic activity over 30 minutes |
| Balakrishnan et al[371], 2023 | Cross-sectional study, conducted at a regional university and community wellness centre, included convenience sampling of Hatha yoga practitioners and healthy controls | Compared with CTRL group, the yoga group had significantly greater mean HF power (P = 0.04) and mean HF normalized units (P = 0.02) and a significantly lower LF/HF ratio (1.1 ± 0.5 vs 2.2 ± 1.1; P = 0.01). No significant intergroup differences were observed for LF power, or any time-domain measures of HRV |
| Banerjee et al[373], 2023 | Participants were subjected to a 10-item yoga questionnaire. Based on Likert scale scoring, 32 subjects (group I) were selected as long-term yogic breathing practitioners, and autonomic function tests using HRV and a provocative stress test and CV reactivity to HUT | A highly significant decrease in values of both high HF and LF variables was observed in group ІІ as compared to group I. A highly significant rise in LF/HF has been observed in group ІІ compared to group I (P = 0.004), indicating a greater withdrawal of vagal tone during the HUT test and during recovery (P = 0.001) |
| Bhagat et al[366], 2023 | Pre-training measurements of SBP, DBP, HRV, and BRS were done, and the Medical Student Stressor Questionnaire was administered to participants. They were then trained in RYM | RYM training decreased DBP (P = 0.01) but not SBP. BRS showed a trend towards an increase after RYM practice, but it was not statistically significant (P = 0.44). The SDNN (P = 0.03), LF (P = 0.003), and HF (P = 0.04) showed a statistically significant change |
| Raj et al[367], 2023 | Cross-sectional study included 202 yoga and 181 non-yoga participants | Following adjustments, cfPWV was significantly lower in yoga participants with a mean difference: -0.28 (95%CI: -0.55 to 0.08) |
| Ng et al[387], 2024 | Participants from the Stress and Well-being in Everyday Life Study which included adults residing in the United States provided background and social network information in a baseline interview, followed by a 4-day ecological assessment in which they reported social encounters every 3 hours | At times when individuals encountered friends (particularly positive encounters), they exhibited a momentary reduction in HRV (within-person association). But those with more friend encounters during the study period had higher HRV than those with fewer friend encounters during the study period |
| Zou et al[349], 2024 | This study was a 2-arm, parallel-group RCT. Patients with ACS recruited at 2 tertiary hospitals in Jinan, China were randomly assigned to a Mindfulness Psycho-Behavioural Intervention group or control group. The 6-week intervention consisted of 1 face-to-face session (phase I) and 5 weekly WeChat (Tencent Holdings Ltd) - delivered sessions (phase II) on mindfulness training and health education and lifestyle modification | Significantly greater improvements were observed in psychological stress (β = -1.186, 95%CI: 1.678-0.694, P < 0.001), physical HRQoL (β = 0.088, 95%CI: 0.008-0.167, P = 0.03), emotional HRQoL (β = 0.294, 95%CI: 0.169-0.419, P < 0.001), and general HRQoL (β = 0.147, 95%CI: 0.070-0.224) at T1, as well as dietary behaviour (β = 0.069, 95%CI: 0.003-0.136, P = 0.04), physical activity level (β = 177.542, 95%CI: -39.073 to 316.011, P = 0.01), and SBP (β = -3.326, 95%CI: -5.928 to 0.725, P = 0.01) at T2 |
| Weiss et al[356], 2024 | Controlled non-randomized longitudinal pilot intervention study enrolling individuals with CVD. After the first interview, a 12-week Metta meditation course starts for the IG, while the CTRL group will receive no intervention | The health-promoting personal competencies of sense of coherence, resilience, and self-compassion were not strengthened by the practice of Metta meditation in individuals with cardiovascular disease. However, there was a significant reduction in perceived stress and improved stress coping skills in the IG. Furthermore, the frequency of rehospitalization differed significantly in the pre-post comparison |
| Zureigat et al[389], 2024 | A subset of participants from the Mass General Brigham Biobank adults who completed a PA period underwent 18F-fluorodeoxyglucose positron emission tomography/computed tomographic imaging. Stress-related neural activity was measured as the ratio of resting AmygAC | Greater PA was associated with both lower AmygAC (standardized β = -0.245; 95%CI: -0.444 to -0.046; P = 0.016) and CVD events (HR = 0.802; 95%CI: 0.719-0.896; P < 0.001). AmygAC reductions partially mediated PA’s CVD benefit (OR = 0.96; 95%CI: 0.92-0.99; P < 0.05) |
| Cui et al[360], 2025 | Patients with CCS were randomly assigned to 12 weeks of either a TCCRP or a CECRP | Within the TCCRP group, the Chinese version of the PSS score significantly decreased (P < 0.05) from baseline to the end of the intervention. Notably, in the CECRP group, the Chinese PSS score increased (P < 0.05) at the end of the intervention. The antioxidant enzymes catalase and glutathione peroxidase levels increased markedly in the TCCRP group after the intervention (P < 0.001). Chinese version of the PSS was positively correlated with oxidised low-density lipoprotein (P < 0.05) |
| Johnson and Ezouah[368], 2025 | In this 4-week pilot study, grounded in Pender’s Health Promotion Model, participants engaged in daily online health education and yoga activities through YouTube videos. Using Fitbit trackers, electronic blood pressure monitors, and web-based logs, the study measured metabolic syndrome risk factors and sedentary behaviour. Participant experiences were further explored through postintervention focus groups aiming to contextualize the intervention’s impact | Specifically, viewing over one-half of the instructional videos (P = 0.04) and daily BP monitoring (P = 0.02) were key to participant adherence. The qualitative focus group data unveiled 4 major themes: (1) Accountability, emphasizing the shift toward self-prioritization and collective health responsibility; (2) Increased awareness, highlighting enhanced understanding of health behaviours and metabolic syndrome risks; (3) Health benefits, noting observed improvements in blood pressure and stress levels; and (4) Unanticipated stressors, identifying external factors that challenged engagement |
| Canella et al[348], 2025 | This one-group pretest-posttest quasi-experimental design recruited adult volunteers to partake in a standard 8-week MBSR program. The main outcomes were psychological well-being (perceived stress, anxiety and awareness) and stress-related biomarkers (SBP, DBP, salivary cortisol, IL-6 and IL-8 levels, plasma carotenoids concentration) | MBSR decreased stress (P = 0.002) and anxiety (P = 0.05) and increased awareness (P = 0.01). MBSR also significantly lowered SBP and DBP (P = 0.02 and 0.001), cortisol (P = 0.01), and IL-6 and IL-8 pro-inflammatory cytokines (P = 0.02 and 0.03), and enhanced carotenoids (P = 0.03). A strong positive correlation between ΔPSS and ΔSTAI-Y1 (P = 0.008), ΔSTAI-Y1 and ΔIL8 (P = 0.0007), and ΔPSS and ΔIL8 (P = 0.04), and significant negative correlations were observed between ΔPSS and ΔMAAS (P = 0.0003), ΔSTAI-Y1 and ΔMAAS (P = 0.04), and ΔMAAS and ΔIL8 (P = 0.003) |
Table 6 Key points
| Topic | Summary |
| Changing paradigm | Atherosclerosis is now viewed as an “inflammatory/immune-driven” disease, not just passive lipid buildup |
| Residual risk | Many acute coronary syndromes or strokes occur without classic risk factors (arterial hypertension, diabetes, dyslipidaemia, smoking) |
| Psychosocial factors | Stress, negative affect, and psychosocial context are independent cardiovascular risk contributors |
| Stress syndromes | Modern stress-related disorders include acute stress reactions, adjustment disorders, and PTSD |
| Guidelines positioning | ESC guidance recognizes psychosocial factors as risk modifiers to refine cardiovascular risk assessment, encouraging clinicians to incorporate psychosocial evaluation into care decisions |
| What stress is | Stress occurs when perceived demands exceed coping resources/homeostatic reserve; this explains inter-individual variability in cardiovascular impact and vulnerability |
| Main stressor domains | Major life events, adverse work conditions, and family conflict are repeatedly linked to higher cardiovascular risk. This identifies “high-yield” psychosocial exposures relevant for clinical history-taking |
| High risk populations | Type D personality, individuals with elevated neuroticism polygenic risk scores, women, Black and Hispanic people show a greater cardiovascular risk |
| Social inequities | Socioeconomic/structural factors and inequities (unsafe environments, limited healthy options) create chronic stress burdens, hitting disadvantaged groups harder |
| Neuro-cardiac axis | Stress responses are regulated by corticolimbic regions influencing autonomic outputs (“brain-to-heart” pathways with feedback loops) |
| Acute stress outcomes | Acute triggers (anger/fear, bereavement, disasters, noise, temperature shifts, sports, traffic) can precipitate myocardial infarction, arrhythmia, stroke/TIA, and transient left ventricle dysfunction in predisposed individuals |
| Takotsubo syndrome | Stress cardiomyopathy accounts for approximately 2%-3% of suspected acute coronary syndromes, often in post-menopausal women; it is linked to catecholamine surge, microvascular spasm, and myocardial stunning |
| Arrhythmias | Acute stress can destabilize repolarization via autonomic activation; anxiety may increase sudden cardiac risk directly/indirectly |
| PTSD & cardiovascular risk | PTSD a major, clinically meaningful risk state, is associated with approximately 25%-50% higher cardiovascular risk, including coronary heart disease, heart failure, stroke and mortality; mechanisms include inflammation, unhealthy behaviors, autonomic imbalance, and microvascular dysfunction |
| Chronic stress & prevention | Chronic stress correlates with poorer cardiovascular health metrics and recurrent events; interventions integrating mental well-being into cardiovascular care (mindfulness, cognitive behavioural therapy, breathing techniques, exercise/cardiac rehabilitation, etc.) show promise, but hard-outcome evidence remains limited and structured assessment is underused |
- Citation: Abrignani MG, Renda N, Abrignani V, Lombardo A, Lucà F. Mental stress: A novel cardiovascular risk factor. World J Cardiol 2026; 18(5): 119108
- URL: https://www.wjgnet.com/1949-8462/full/v18/i5/119108.htm
- DOI: https://dx.doi.org/10.4330/wjc.v18.i5.119108