EDITORIAL Neglecting the subjective relevance of stress

This editorial refers to ‘Increased risk of coronary heart disease among individuals reporting adverse impact of stress on their health: the Whitehall II prospective cohort study’, by H. Nabi et al., doi:10.1093/eurheartj/eht216 The recent study of Nabi et al. introduced a new variable into the set of risk factors that contribute to the development of coronary heart disease (CHD).1 The authors assessed the perception of the impact one’s stress has on health. Therefore, this study goes beyond established risk factors for CHD with established behavioural2 and psychological risk factors such as depression.3 On the other hand, resources such as social support might be beneficial in terms of the onset of CHD2,4 (see the ‘Basic model ’ in Figure 1). Initial health status is associated with CHD incidence and progno-sis. Therefore, an adjustment for health status in longitudinal studies is necessary, and has been included in the study of Nabi et al. (‘Medical model ’ in Figure 1). Furthermore, an impact of stress on CHD inci-dence was confirmed in epidemiological research and also in basic re-search according to aetiological models (‘Stress model ’ in Figure 1). The medical model and the stress model did not assess the belief of the individual that stress affects health. In the model of Nabi et al. now presented, the perceived stress and the perceived health status were combined in a single variable. The perception that Figure 1 Aetiologic models of risk factors and resources of coronary heart disease