Background: Exacerbations in heart failure (HF) symptoms and severity occur frequently in HF patients, and often result in repeated hospitalizations in this population. B-type natriuretic peptide (BNP) is a biomarker of ventricular wall stretch, a key pathophysiologic process in HF. Stress can trigger acute cardiovascular events, yet little is known about emotional stress as a precipitating factor for worsened HF biomarkers or hospitalizations.
Objective: This study sought to determine the relationship of changes in perceived stress to HF exacerbations as measured by changes in BNP and the prospective relationship of perceived stress to HF hospitalizations.
Method: Sixty-three patients (mean = 54.4 + 11.5 years) with HF (mean ejection fraction = 22.6 + 7.2) were examined at baseline and again 3 months later. Physiological measurements and clinical information were recorded; at both assessments, plasma BNP (ng/mL) was determined and the Perceived Stress Scale (PSS) was administered. BNP data were log transformed. Hospitalizations were recorded for 12 months following baseline visit. Patients and clinicians were blinded to PSS scores and BNP levels.
Results: No change was found in BNP from baseline (mean = 0.479 ± 0.83) to 3 months (mean = 0.567 ± 1.31). PSS scores significantly decreased (change = -2.85, p = .01). BNP changes from baseline to follow-up were associated with changes in PSS score (r = 0.61, p < .001) over the 3-month period. After controlling for the same variables along with baseline BNP, only age (beta = -0.52) and increases in PSS scores (beta = 0.82) remained significant predictors of increases in plasma BNP (F = 2.58, p = .044, overall model R² = .62). Hospitalizations occurred in 19 of 63 patients (28.8%) over a one year period. After controlling for age, gender, body mass index, smoking status, atrial fibrillation, diabetic status, creatinine, and prior myocardial infarction, baseline PSS score was found to be the only significant predictor of hospitalizations occurring within 12 months of initial assessment (OR = 1.12, p = .05); each 1-point increment in PSS score resulted in an 12% increased risk of hospitalization.
Conclusions: In HF patients studied prospectively, baseline perceived stress levels predicted hospitalizations in the subsequent year and increases in PSS scores were associated with increases in BNP, an objective physiologic marker of HF exacerbation. Psychological distress may be a mechanism associated with increased risk of heart failure exacerbations and hospitalizations in HF patients.