Could Stress Type Influence Risk for Specific Stroke Subtypes?

All types of psychosocial stress, such as family and financial stress, are risk factors for intracerebral hemorrhage (ICH), even after controlling for hypertension, according to the results of a study published in Journal of the American Heart Association.

Recent research demonstrates an association between psychosocial stressors and risk for stroke and hypertension. However, this research focused mainly on ischemic stroke and did not elaborate on racial/ethnic differences or hemorrhage location (nonlobar vs lobar).

Researchers analyzed data from a prospective, multicenter, case-control study (ClinicalTrials.gov Identifier: NCT01202864) to determine whether psychosocial stress factors were associated with ICH risk, and whether the effect was mediated by hypertension. Stress subtypes measured included financial, health, emotional well-being, family, and total stress. Self-reported stress was measure on a scale of 0 to 10, with 0 being no stress and 10 being maximal stress. The researchers used multivariable logistic regression models for statistical analysis.

After exclusions, 2964 participants with spontaneous ICH were matched with healthy control participants (N=5928; women, 41.4%; Black, 33.7%). Approximately 23% of respondents reported significant stress.

After controlling for hypertension, age, hypercholesterolemia, alcohol use, Alzheimer disease/dementia, anticoagulant use, body mass index (BMI), sleep apnea, level of education, and insurance status, each stress subtype was significantly associated with ICH risk. Higher levels of each stress subtype (including combined stress score) increased the probability of ICH.

Maximal stress vs no stress increased the risk for ICH for:

• emotional well-being stress (odds ratio [OR], 4.2; 95% CI, 3.0-5.8),
• health-related stress (OR, 3.6; 95% CI, 2.7-4.9),
• family-related stress (OR, 2.6; 95% CI, 2.1-3.2), and
• financial stress (OR, 2.3; 95% CI, 1.9-2.9; P <.0001 for all).

After excluding patients with anticoagulant-associated ICH and those with a prior history of ischemic or hemorrhagic stroke, total stress remained significantly associated with ICH risk.

Stress remained a significant risk factor for both lobar and nonlobar ICH after controlling for covariates. Patients with higher financial stress were more likely to have untreated hypertension (median [interquartile range; (IQR)], 3; 95% CI, 0–6 vs 5; 95% CI, 1–8; P <.0001); however, ICH risk due to financial stress remained independent of untreated hypertension.

A mediation analysis showed that the association between each stress subtype and ICH risk was mediated by hypertension with the strongest mediation observed for health-related stress. When compared with White participants, Black and Hispanic participants in the control group had significantly higher levels of psychosocial stress, particularly with regard to financial stress in Black (OR, 3.9; 95% CI, 2.4-6.2) and Hispanic (OR, 3.0; 95% CI, 1.8-4.9) populations.

After adjusting for differences in maximal stress by race and ethnicity, each stress subtype remained significant for ICH, including:

• emotional well-being stress (OR 3.22; 95% CI, 2.27–4.59; P <.0001),
• health-related stress (OR, 2.49; 95% CI, 1.79–3.45; P <.0001),
• family-related stress (OR, 2.16; 95% CI, 1.70–2.73; P <.0001), and
• financial stress (OR, 1.81; 95% CI, 1.44–2.27); P <.0001).

Study limitations include biases in reported stress between subjects and proxies, subjectivity of the definition of stress, and utilization of a retrospective database rather than another study design.

“Stress as a highly prevalent risk factor with important racial/ethnic differences warrants future studies to delineate the complex mechanisms for this association, which may lead to changes in stroke prevention and management in the future,” the researchers concluded.