Work, marital status, and heart disease

Divorce and Severity of Coronary Artery Disease: A Multicenter Study

The association between marital status and coronary artery disease (CAD) is supported by numerous epidemiological studies. While divorce may have an adverse effect on cardiac outcomes, the relationship between divorce and severe CAD is unclear. We conducted a multicenter, observational study of consecutive patients undergoing coronary angiography during the period between April 1, 2013, and March 30, 2014. Of 1,068 patients, 124 (12%) were divorced. Divorce was more frequent among women (27%) compared to men (6%). Most divorced patients had been divorced only once (49%), but a subset had been divorced 2 (38%) or ≥3 (12%) times. After adjusting for baseline differences, there was no significant association between divorce and severe CAD in men. In women, there was a significant adjusted association between divorce and severe MVD (OR 2.31 [1.16, 4.59]) or LMD (OR 5.91 [2.19, 15.99]). The modification of the association between divorce and severe CAD by gender was statistically significant for severe LMD (Pinteraction 0.0008) and marginally significant for CAD (Pinteraction 0.05). Among women, there was a significant adjusted association between number of divorces and severe CAD (OR 2.4 [95% CI 1.2, 4.5]), MVD (OR 2.0 [95% CI 1.4, 3.0]), and LMD (OR 3.4 [95% CI 1.9, 5.9]). In conclusion, divorce, particularly multiple divorces, is associated with severe CAD, MVD, and LMD in women but not in men.

Widowhood and severity of coronary artery disease: a multicenter study

OBJECTIVES

The aim of this study was to assess the association of widowhood with the severity and extent of coronary artery disease (CAD), and whether it is modified by sex or socioeconomic status.

PATIENTS AND METHODS

A total of 1068 patients undergoing coronary angiography at five centers in Saudi Arabia and the United Arab Emirates were included in the study. CAD was defined as more than 70% lumen stenosis in a major epicardial vessel or more than 50% in the left main coronary artery. Multivessel disease was defined as more than one diseased vessel.

RESULTS

Of 1068 patients, 65 (6%) were widowed. Widowed patients were older (65±15 vs. 59±12), more likely to be female (75 vs. 25%), less likely to be smokers (18 vs. 47%), of lower economic and education status, and more likely to have undergone coronary angiography for urgent/emergent indications (75 vs. 61%) (P<0.05 for all). There was a significant association between widowhood and the number of coronary arteries with more than 70% lumen stenosis. Consequently, such a high degree of lumen stenosis in those who were widowed was more likely to require coronary artery bypass graft surgery (38 vs. 16%; P<0.01). After adjusting for baseline differences, widowhood was associated with a significantly higher odds of CAD [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI) 1.2-10.5] and multivessel disease (adjusted OR 4.6; 95% CI 2.2-9.6), but not left main disease (adjusted OR 1.3; 95% CI 0.5-3.1). All associations were consistent in men and women and not modified by age, community setting (urban vs. rural), employment, income, or educational levels (Pinteraction>0.1 for all).

CONCLUSION

Widowhood is associated with the severity and extent of CAD. The association is not modified by sex or socioeconomic status.

Polygamy and Risk of Coronary Artery Disease in Men Undergoing Angiography: An Observational Study

Epidemiologic evidence suggests a link between psychosocial risk factors such as marital status and coronary artery disease (CAD). Polygamy (multiple concurrent wives) is a distinct marital status practiced in many countries in Asia and the Middle East, but its association with CAD is not well defined. We conducted a multicenter, observational study of consecutive patients undergoing coronary angiography during the period from April 1, 2013, to March 30, 2014. Of 1,068 enrolled patients, 687 were married men. Polygamy was reported in 32% of married men (1 wife: 68%, 2 wives: 19%, 3 wives: 10%, and 4 wives: 3%). When stratified by number of wives, significant baseline differences were observed in age, type of community (rural versus urban), prior coronary artery bypass grafting (CABG), and household income. After adjusting for baseline differences, there was a significant association between polygamy and CAD (adjusted OR 4.6 [95% CI 2.5, 8.3]), multivessel disease (MVD) (adjusted OR 2.6 [95% CI 1.8, 3.7]), and left main disease (LMD) (adjusted OR 3.5 [95% CI 2.1, 5.9]). Findings were consistent when the number of wives was analyzed as a continuous variable. In conclusion, among married men undergoing coronary angiography for clinical indications, polygamy is associated with the presence of significant CAD, MVD, and LMD.

Association between divorce and risks for acute myocardial infarction

BACKGROUND

Divorce is a major life stressor that can have economic, emotional, and physical health consequences. However, the cumulative association between divorce and risks for acute myocardial infarction (AMI) is unknown. This study investigated the association between lifetime exposure to divorce and the incidence of AMI in US adults.

METHODS AND RESULTS

We used nationally representative data from a prospective cohort of ever-married adults aged 45 to 80 years (n=15,827) who were followed biennially from 1992 to 2010. Approximately 14% of men and 19% of women were divorced at baseline and more than one third of the cohort had ≥1 divorce in their lifetime. In 200,524 person-years of follow-up, 8% (n=1211) of the cohort had an AMI and age-specific rates of AMI were consistently higher in those who were divorced compared with those who were continuously married (P<0.05). Results from competing-risk hazard models showed that AMI risks were significantly higher in women who had 1 divorce (hazard ratio, 1.24; 95% confidence interval, 1.01-1.55), ≥2 divorces (hazard ratio, 1.77; 95% confidence interval, 1.30-2.41), and among the remarried (hazard ratio, 1.35; 95% confidence interval, 1.07-1.70) compared with continuously married women after adjusting for multiple risk factors. Multivariable-adjusted risks were elevated only in men with a history of ≥2 divorces (hazard ratio, 1.30; 95% confidence interval, 1.02-1.66) compared with continuously married men. Men who remarried had no significant risk for AMI. Interaction terms for sex were not statistically significant.

CONCLUSIONS

Divorce is a significant risk factor for AMI. The risks associated with multiple divorces are especially high in women and are not reduced with remarriage.

Employment status, coronary heart disease, and stroke among women

PURPOSE

To investigate the association of employment status with coronary heart disease (CHD) and ischemic stroke among middle-aged women.

METHODS

Proportional hazards regression was used to assess the association of employment status, incident CHD, and incident ischemic stroke among 7,058 women, ages 45-64 years at baseline (1987-1989), from the Atherosclerosis Risk in Communities Study.

RESULTS

After adjusting for age and race-field center, women employed outside the home had a decreased risk of CHD (hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.56-0.86) and ischemic stroke (HR, 0.62; 95% CI, 0.47-0.84) compared with homemakers. Differences in cardiovascular disease risk factors partially accounted for the association of employment status and CHD (HR, 0.79; 95% CI, 0.63-0.99) and stroke (HR, 0.79; 95% CI, 0.58-1.08). Also, modest differences were noted when the results were stratified by education, with employed women having a lower risk of CHD (HR, 0.65; 95% CI, 0.45-0.93) than homemakers among those with less than a high school education.

CONCLUSIONS

Women employed outside of the home had a lower risk of CHD and stroke compared with homemakers and, for CHD, this association was stronger among women with less than a high school education. These findings suggest additional research into the varied occupational experiences of women, socioeconomic status, and health is warranted.

Women's Employment Status and Mortality: The Atherosclerosis Risk in Communities Study

BACKGROUND

As women's labor force participation in the United States has increased over the past decades, there has been an interest in the potential health effects of employment. To date, however, research findings have been contradictory.

METHODS

Thus, the aim of this study was to investigate the association between employment status and mortality among 7361 middle-aged African American and white women who participated in the Atherosclerosis Risk in Communities (ARIC) Study. Women were classified as employed or homemakers at the baseline examination (1987-1989) and were followed for approximately 11 years. Proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios.

RESULTS

After adjusting for sociodemographic factors and selected risk factors for mortality, employed women had a lower risk of mortality than homemakers (hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.49, 0.86). This decreased risk of mortality persisted in additional analyses that excluded those who died within the first 2 years of follow-up or, alternatively, those with a history of coronary heart disease (CHD), stroke, cancer, hypertension, diabetes, or a perception of fair or poor health at baseline. In cause of death-specific analyses, the mortality advantage among employed women persisted for circulatory system-related deaths; however, the association for cancer-related deaths was weaker, and the CI included one.

CONCLUSIONS

As the association between employment status and mortality was not explained by known risk factors for mortality, additional research is needed to identify other potential factors that may help to explain this relationship.

Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers

OBJECTIVES

This study compares 3- and 6-month outcomes of a woman-focused HIV intervention for crack abusers, a revised National Institute on Drug Abuse standard intervention, and a control group.

METHODS

Out-of-drug-treatment African American women (n = 620) who use crack participated in a randomized field experiment. Risk behavior, employment, and housing status were assessed with linear and logistic regression.

RESULTS

All groups significantly reduced crack use and high-risk sex at each follow-up, but only woman-focused intervention participants consistently improved employment and housing status. Compared with control subjects at 6 months, woman-focused intervention participants were least likely to engage in unprotected sex; revised standard intervention women reported greatest reductions in crack use.

CONCLUSIONS

A woman-focused intervention can successfully reduce risk and facilitate employment and housing and may effectively reduce the frequency of unprotected sex in the longer term.

Women, work, and well-being 1950–2000:

In this research synthesis, we summarize 161 measures of the effects of women's employment on well being reported between 1950 and 2000. Variations in the conceptualization and measurement of employment and health outcomes and the difficulty in distinguishing social selection from social causation limit the inferences that can be drawn from the evidence. Therefore, we distinguish two types of studies. Longitudinal studies measuring relevant covariates at the first measurement occasion and statistically controlling them in multivariate analyses providing effect-size information are classified as Type II studies. The remaining studies are classified as Type I studies. The main findings were that (1) results from methodologically sound Type II studies confirm the cross-sectional finding that paid employment has no adverse effects on women; (2) the outcome groups psychological distress, subjective health, cardiovascular risks and disease, and mortality do not converge completely.

Employment, Social Support, and HIV Sexual-Risk Behavior in Puerto Rican Women

This study examined psychosocial factors associated with HIV-risk behavior among Latina women at self-disclosed heterosexual risk for HIV infection. Data were collected via structured interviews for 187 Puerto Rican women, aged 18-35, who attended a health clinic in the Bronx, New York. Over 64% of all participants reported unprotected vaginal sex with primary sexual partners. Higher levels of unprotected vaginal sex were associated with living with the partner, residing with children, current employment, heightened negative mood, and greater social support from the partner. The relationship between increased negative mood and increased unprotected vaginal sex use was mediated by employment, after controlling for educational level, living with the partner, and residing with children. The findings suggest that interventions designed to facilitate HIV-protective behaviors may need to consider that employment may supercede relationship factors among populations of urban women identified at increased heterosexual risk for HIV infection.

Heart disease risk factor prevalence and profiles in a randomized community sample of Canadian women

This study examined the prevalence and profiles of behavioural and biomedical risk factors of heart disease in a randomized community sample of 843 Canadian women. Sociodemographic characteristics were also examined to determine their association with women who have multiple primary risk factors versus risk factor-free women. A greater proportion of high-risk women (n = 81) reported to have less education, lower income and employment levels and were more likely to live without a partner than women with no primary risk factors (n = 135). These findings contribute to the understanding of the growing complexity of addressing heart health beyond lifestyle behaviours as articulated by the Victoria (1992), Catelonia (1995), Singapore (1998) and Women's International (2000) Declarations on Heart Health. Public health planning should continue to address physical activity, smoking and dietary behaviours across age groups with a concentrated effort to target high-risk, socio-economically disadvantaged women. Risk assessment for heart disease must also include sociodemographic characteristics for tailoring heart health programs in the community.

Psychosocial influences on blood pressure during daily life

Ambulatory blood pressure (ABP) monitoring allows frequent non-invasive blood pressure (BP) recordings in a variety of settings. Emerging evidence suggests that ABP is a better predictor of cardiovascular morbidity than clinic BP. Ambulatory blood pressure is influenced by a variety of physical, psychological and behavioral factors that comprise an individual's daily life. The present article reviews psychosocial research relating ABP to psychological factors (e.g. Type A behavior pattern, anger/hostility) and environmental influences (e.g. job strain). Psychological factors and environmental factors alone and in interaction with each other appear to substantially influence ABP. Interacting physical, psychosocial and behavioral factors that comprise daily life provide unique methodological challenges to ABP research. Methodological considerations (e.g. activity patterns, caffeine and alcohol consumption) for performing ABP research are discussed. Evidence outlined in this review suggests that psychosocial factors contribute to ABP level. To the extent that psychosocial factors contribute to ABP cardiac disease, it will be important to analyze their effects on underlying disease processes.

Are life stress and social support related to parity in women?

Although an increased risk of coronary heart disease has been demonstrated among women with high gravidity/parity, the mechanism by which this association may be mediated is unclear. One possible pathway that has been suggested is that pregnancy and child rearing may result in changes in factors such as stress or lifestyle. This hypothesis was tested in a sample of 541 middle-aged women who participated in a prospective study of the effects of menopause on behavioral and biological cardiovascular risk factors. Married women generally reported less chronic stress, less perceived stress, and more structural support than did unmarried women. However, the findings in this study indicated no consistent relationship between parity and stress or parity and social support in this group of middle-aged women. Only unmarried women with more children reported a higher number of life events than did women with fewer children.

Failure of three decision rules to predict the outcome of in-hospital cardiopulmonary resuscitation

The objective of this study was to evaluate three decision-support tools (the Pre-Arrest Morbidity or PAM score, the Prognosis After Resuscitation or PAR score, and the Acute Physiology and Chronic Health Evaluation or APACHE III score) for their abilities to predict the outcomes of in-hospital cardiopulmonary resuscitation (CPR). The medical records of all 656 adult inpatients undergoing CPR during a two-to-three-year period in three large hospitals were retrospectively reviewed, and demographic and clinical variables were abstracted. Of 656 patients undergoing resuscitation, 248 (37.8%) survived the resuscitation attempt long enough to be stabilized (immediate survival), but only 35 (5.3%) survived to discharge. Only 11 patients had PAM scores higher than 8, none of whom survived to discharge; 131 patients had PAR scores above 8, of whom six survived to discharge. The PAR score and the APACHE III score had the greatest areas under the receiver operating characteristic curves (when predicting the outcome of survival to discharge), although no individual area for either outcome was greater than 0.6. None of the decision-support tools studied was able to effectively discriminate between survivors and non-survivors for the outcomes of immediate survival and survival to discharge following in-hospital CPR. This is consistent with previous work utilizing the APACHE II score, which did not identify a threshold above which patients did not benefit from CPR. The findings for the PAR score and the PAM score stand in contrast to previous studies that found them to be potentially useful decision rules. Further work is needed to develop a decision-support tool that better discriminates between survivors and non-survivors of in-hospital CPR.

Relationship of social roles and nutrition beliefs to fat avoidance practices: investigation of a US model among Danish women

OBJECTIVE

This study was designed to investigate the associations among women's social roles, their nutrition beliefs, and their dietary fat avoidance practices. Role theory and prior qualitative research among US women provided the theoretical framework.

DESIGN/SUBJECTS

A random-sample mail survey (76% response) was used to gather information on the usual pattern of dietary fat use, nutrition beliefs, and social positions of Danish women aged 30 to 60 years. A fat avoidance score was calculated for each respondent on the basis of 12 fat consumption practices. Sequential multiple linear regression was used to develop an explanatory model for fat avoidance using responses from 594 women.

RESULTS

Interactions between nutrition attitudes and beliefs and social roles suggested that the roles themselves did not influence fat avoidance practices, but the nutrition beliefs associated with particular roles did have an influence. Among employed women, fat avoidance was lower among those who perceived many barriers to healthful eating. Among women who were not employed, fat avoidance was lower among those who perceived little social support for healthful eating. The association of fat avoidance with caretaking responsibility varied by age group. Caretaking was positively associated with fat avoidance among women in their forties, but not in older or younger age groups.

CONCLUSIONS

Nutrition messages should be tailored to fit women's unique social roles and the beliefs associated with them. Nutrition professionals in Denmark and the United States can adapt these findings to their own cultural context.

Contribution of job strain, job status and marital status to laboratory and ambulatory blood pressure in patients with mild hypertension

The effects of job strain, occupational status, and marital status on blood pressure were evaluated in 99 men and women with mild hypertension. Blood pressure was measured during daily life at home and at work over 15 h of ambulatory blood pressure monitoring. On a separate day, blood pressure was measured in the laboratory during mental stress testing. As expected, during daily life, blood pressure was higher at work than at home. High job strain was associated with elevated systolic blood pressure among women, but not men. However, both men and women with high status occupations had significantly higher blood pressures during daily life and during laboratory mental stress testing. This was especially true for men, in that men with high job status had higher systolic blood pressures than low job status men. Marital status also was an important moderating variable, particularly for women, with married women having higher ambulatory blood pressures than single women. During mental stress testing, married persons had higher systolic blood pressures than unmarried individuals. These data suggest that occupational status and marital status may contribute even more than job strain to variations in blood pressure during daily life and laboratory testing.