PracticeUpdate Cardiology March 2019

EDITOR’S PICKS 15

Workplace Bullying andWorkplace Violence as Risk Factors for Cardiovascular Disease European Heart Journal

[95% confidence interval (CI) 1.28-1.98] for CVD. Experiencing workplace violence vs. not was associated with a HR of 1.25 (95% CI 1.12-1.40) for CVD. The population attributable risk was 5.0% for workplace bullying and 3.1% for workplace violence. The excess risk remained similar in analyses with different follow-up lengths, cardi- ovascular risk stratifications, and after additional adjustments. Dose-response relations were observed for both workplace bullying and vio- lence (Ptrend < 0.001). There was only negligible heterogeneity in study-specific estimates. CONCLUSION Bullying and violence are com- mon at workplaces and those exposed to these stressors are at higher risk of CVD. Workplace Bullying and Workplace Violence as Risk Factors for Cardiovascular Disease: A Mul- ti-Cohort Study. Eur Heart J 2018 Nov 19;[EPub Ahead of Print], T Xu, LL Magnusson Hanson, T Lange, et al. www.practiceupdate.com/c/76659 has been understudied in relation to cardiovascular disease. " " …this report brings attention to a dimension of stress, which

Take-home message • Adults without known cardiovascular disease (CVD) were followed for a mean of 12.4 years to evaluate the association between the risk of CVD and exposure to bullying or violence in the workplace. Bullying at work was reported by 9% of the almost 80,000 participants, while 13% reported exposure to workplace violence in the previous year. The hazard ratio for CVD was 1.59 for those who reported bullying compared with those unexposed to bullying. Similarly, the hazard ratio for CVD was 1.25 for those exposed to workplace violence versus those with no exposure. Both bullying and violence appeared to have a dose–response relationship with the risk of CVD. • The prevalence of workplace bullying and violence is high, and exposure results in an increased CVD risk. Abstract

AIMS To assess the associations between bul- lying and violence at work and cardiovascular disease (CVD). METHODS AND RESULTS Participants were 79 201 working men and women, aged 18-65years and free of CVD and were sourced from three cohort studies from Sweden and Denmark. Exposure to workplace bullying and violence was meas- ured at baseline using self-reports. Participants were linked to nationwide health and death registers to ascertain incident CVD, including

coronary heart disease and cerebrovascular disease. Study-specific results were estimated by marginal structural Cox regression and were combined using fixed-effect meta-analysis. Nine percent reported being bullied at work and 13% recorded exposure to workplace violence dur- ing the past year. We recorded 3229 incident CVD cases with a mean follow-up of 12.4years (765 in the first 4 years). After adjustment for age, sex, country of birth, marital status, and educational level, being bullied at work vs. not was associated with a hazard ratio (HR) of 1.59

COMMENT By Viola Vaccarino MD, PhD E pidemiological, physiological, and experimental data support the notion that stressful exposures contribute to cardiovascular risk. Work-related stress is one of the “chronic stressors” most extensively studied, in part because people spend so many hours of their day in the work environ- ment, making it a meaningful source of chronic stress, and in part because the different types of job grades provide an oppor- tunity to examine specific dimensions of psychological stress. Dimensions like job demand, job control, and support at work, independently or in combination, have all been related to cardio- vascular risk. Clearly, however, there are other types of stressful exposures that may occur at work but may not be directly related to the type of job. Xu et al used data from a number of population surveys fromSwe- den and Denmark to examine whether exposure to self-reported workplace bullying and violence is related to the incidence of cardiovascular events. The population surveys were linked to nationwide inpatient, outpatient, and mortality registries, allow- ing the authors to examine cardiovascular events by means of diagnostic codes. This provided the investigators with a sample of more than 79,000 individuals between the age of 18 and 65 years, approximately 50% female. The prevalence of bullying and violence in the workplace was fairly common, on average 9% and 13%, respectively. After a follow-up of about 4 years, and after adjusting for demographic factors (age, gender, country of

birth, marital status, and education), being bullied at work was associated with a 59% increased risk for cardiovascular disease. Experiencing workplace violence showed weaker but still signif- icant associations (an overall increased risk for cardiovascular disease of 25%). Results were robust in subgroup analyses by a variety of participant characteristics and after further adjusting for health behaviors and mental disorders. These results by no means imply causation. For example, very limited information was available on other stressors at work or in private life, which may be related to workplace bullying/violence (or the propensity to self-report these events). Nonetheless, this report brings attention to a dimension of stress, which has been understudied in relation to cardiovascular disease. These kinds of exposures appear quite prevalent in the working population. If the association were causal, removing workplace bullying would prevent 5% of cardiovascular disease. This is clinically significant given the relatively young population, and not much different from some traditional cardiovascular risk factors like diabetes.

Dr. Vaccarino is the Wilton Looney Chair of Cardiovascular Research and Professor and Chair of the Department of Epidemiology at Rollins School of Public Health, Emory University, and Joint Appointment, Department of Medicine, Division of Cardiology at Emory University School of Medicine in Atlanta, Georgia.

VOL. 4 • NO. 1 • 2019