A study of stressful life events in patients with first episode acute coronary syndrome (ACS) - A hospital based case control study Running Title: Stressful Life Events in First Episode Acute Coronary Syndrome Patients: A Case-Control Study

A study of stressful life events in patients with first episode acute coronary syndrome (ACS) - A hospital based case control study Running Title: Stressful Life Events in First Episode Acute Coronary Syndrome Patients: A Case-Control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A study of stressful life events in patients with first episode acute coronary syndrome (ACS) - A hospital based case control study Running Title: Stressful Life Events in First Episode Acute Coronary Syndrome Patients: A Case-Control Study Muntaqueem Ul Kousar, Shaheena Parveen, Masood Maqbool, Yasir Hassan Rather, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4941610/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Dec, 2024 Read the published version in Middle East Current Psychiatry → Version 1 posted 9 You are reading this latest preprint version Abstract Background There is a considerable evidence in the literature highlighting the impact of psychological factors on the development of coronary heart disease. In India, there's a rising incidence of traumatic life events alongside coronary heart disease, yet the connection between them remains relatively understudied. Therefore, this study aims to investigate the occurrence of stressful life events among patients experiencing their first episode of acute coronary syndrome (ACS) and to compare this with controls. Results The mean number of stressful life events (SLEs) observed was 5.07 ± 2.04 in cases and 4.35 ± 1.88 in controls, with a p-value of < 0.05. The median number of SLEs in cases was nine, compared to eight in controls. Additionally, cases experienced a higher number of SLEs compared to controls with adjusted Z scores of 2.01 for 9 events, 2.74 for 8 events and 3.46 for five events with p-value < 0.01 for all. Significant differences for various types of SLEs were observed between cases and controls. Conclusion The number for SLEs was significantly higher in cases than in controls. There is a need for further research to ascertain and quantify the role of stressful events and risk of a cardiac event. Stressful life events Acute Coronary Syndrome Case-Control Key Message Significant number of Stressful life events in the participants. Significantly higher mean, median and total number of SLEs in cases than controls. Significant difference in the pattern of exposure between cases and controls. Introduction Stressful life events refer to occurrences or events experienced by people during their lives that are not congenial with their current abilities and facilities resulting in increased psychological demands and causing such changes in body that increase the risk for illness. 1 , 2 Everyone experiences stress in their lifetime, irrespective of age, sex, social class, in every form and size. Coronary heart disease is a type of heart disease that develops when the arteries of the heart cannot deliver enough oxygen-rich blood to the heart. 3 Its clinical spectrum varies from silent angina to sudden cardiac death. American Heart Association explains that Acute Coronary syndrome is an umbrella term that includes Unstable Angina (UA), Non-ST elevation Myocardial infarction (NSTEMI) and ST-elevation Myocardial infarction (STEMI) for situations where the blood supply to the heart muscle is suddenly blocked resulting in myocardial injury detected by cardiac biomarkers. 4 The prevalence of UA is decreasing because more cases are now diagnosed as NSTEMI with the help of highly sensitive cardiac biomarkers. Coronary Artery Disease (CAD) is considered as a psycho-somatic illness, as psychological factors have a very important role in their existence and formation. 5 Both acute and chronic stress have harmful effects on the cardiac health. Acute stress, though is adaptive and necessary, may have detrimental effects as it may trigger cardiac events or lead to sudden death. It has been associated with more than two-fold risk of precipitating a cardiac event. 6 Chronic stress influences three main regulatory systems of the body; the autonomic , the endocrine and the immune system. The sympathetic-adrenal-medullary (SAM) axis and the hypothalamic-pituitary-adrenal (HPA) axis are continuously over-activated or in imbalance, and overcompensation of these systems leaves the individual susceptible to stress-related diseases including psychiatric problems like depression and anxiety, metabolic disorders, immunosuppression and cardiovascular problems like hypertension, cardiomyopathy and coronary heart disease. 7 , 8 , 9 Chronic stress has also been linked to endothelial dysfunction as measured by brachial artery flow-mediated dilation (FMD). Evidence suggests chronic stress inversely impacts FMD, reflecting diminished endothelial function and heightened atherosclerotic risk. 10 Also, vital exhaustion and major stressful life events, the indices of chronic stress, have been seen to be associated with arrhythmic events. 11 The secondary outcomes of the chronic stress-related dysfunctions are the metabolic abnormalities characteristic of the metabolic syndrome. It exerts a patho-physiological effect on waist-hip –ratio (WHR), causes alterations in insulin and lipid metabolism, fibrinolysis, and blood pressure – the metabolic parameters of insulin resistance. 12 The registrar general of India reported that in India cardiac deaths increased from 17–23% over only a decade, which increased the total adult deaths by a 6%. India has witnessed a steep rise in heart deaths over the past three years with a rise of > 12% in 2022 according to National Crime Records Bureau (NCRB) attributed majorly to Covid. 13 In an epidemiological study carried in 2005, the overall prevalence of CAD in the Kashmir valley was seen to be 7.54%. 14 Recently Kashmir has seen a rise in heart attacks particularly in men in the age group of 23s to 30s, the common causes include excessive phone use, smoking, drug use behaviours, stress and emotional pain. 15 National Sample Survey Office (NSSO) survey found that an adult in the Kashmir valley witnessed or experienced an average of 7.7 traumatic events during their lifetime and that this unusual stress and emotional strain arising from perturbed conditions in the territory. 14 The deleterious effects of the chronic traumatic situation on cardiac health, nevertheless very relevant, have not been well studied in Kashmiri population so far, our study seeks to identify and compare various SLEs in first episode ACS patients. Methodology Study Aims To determine the socio-demographic and clinical profile of patients with first episode ACS. To assess the number and pattern of stressful life events in patients with first episode ACS and compare with controls. Study Design The study was a case-control study, cross-sectional in design, conducted in the Department of cardiology of Govt. Medical College Srinagar spanning a period of 18 months. Study Sample The calculated sample size of the study was 139, using a formula with a confidence interval of 95%, a margin of error of 5%, and an anticipated prevalence of coronary artery disease from previous studies. Study Population Participants were divided into cases and controls: cases, consisted of 150 patients with first episode of acute coronary syndrome (ACS) taken consecutively from OPD/IPD, and controls, comprising 150 individuals without ACS. Controls mainly comprised of attendants of the patients who mostly are the close relatives of the patients. The cases and controls were matched for socio-demographic and conventional coronary artery disease (CAD) risk factors. Interview Process Interviews took place in a single setting, at the time of discharge from the hospital when their condition had stabilized. Written consent, provided in the local language for clarity, was obtained. Participants were informed about the interview's purpose, and incomplete interviews were excluded from the analysis. Operational Definitions ACS was diagnosed by the detection of abnormal cardiac biomarkers, along with evidence of myocardial ischemia, caused due to sudden blockage of the blood supply. 16 The diagnosis was made and confirmed by the consultant in-charge OPD/IPD. The study was initiated after approval of the institutional Ethical Committee and BORS (Board of Research Studies). Inclusion criteria included, i) Individuals who experienced their first episode of ACS, either admitted to the hospital or receiving outpatient care, ii) Both males and females aged 18 and above, and those willing to participate in the study by providing written informed consent, iii) Age- and gender-matched non-patients agreeing to participate as controls. The following participants were excluded; i) Those with severe or terminal medical conditions, ii) Those with a history of structural heart disease. Measures The following instruments were utilized in the study: A semi-structured proforma was prepared that recorded the socio-demographic variables: age, gender, educational status, marital status, family type, employment status, residence, medical illness and family history of psychiatric illness of cases s well as controls. Kuppuswamys Socio-demographic Scale: It is a measurement tool that calculates a composite score and categorizes patients five categories based on the education and occupation of the head of the family, and monthly income of the household. The five categories are Upper (I), Upper Middle (II), Lower Middle (III), Upper Lower (IV), and Lower (V) socio-economic status. 17 The Mini-International Neuropsychiatric Interview v.7.0.2 (M.I.N.I.) is a structured diagnostic interview, for DSM-5 and ICD-10 psychiatric disorders. It has a high reliability and validity for various psychiatric illnesses. It has been designed to meet the need for a short and accurate interview schedule, and thus was used for the assessment of psychiatric illnesses. 18 Life Event Checklist (LEC) for DSM-5 was used to assess exposure to stressful life events during life time. Participants were assessed for the presence of any life event using the Life Event Checklist. This is a self-report measure designed to screen for potentially traumatic events in a person’s life. It assesses the exposure to 16 potentially distressing events and includes one additional item assessing any other extraordinarily stressful event not captured in the first 16. LEC has adequate psychometric properties as a stand-alone assessment of traumatic exposure, particularly when evaluating the consistency of events that happened to a respondent. Though psychometrics for the LEC-5 is not currently available; only a few psychometric differences are expected as there are minimal revisions from the original version of the LEC. 19 Statistical Analysis Data was entered in Statistical Package for Social Sciences (SPSS) V27. 20 Descriptive statistics was used for continuous variables and the Chi-square test was applied for categorical variables. Group differences in scores were compared on the chi-square test, student’s t -test and Cochrane Armitage trend test. Adjusted Residual (Z-score) was used for comparison of individual items. All p-values were two-sided and p-value 1.96 was considered as statistically significant. Results Participants’ Socio-demographic characteristics The mean age of cases and controls was 56.55 + 13.1 years and 55.04 + 12.9 years respectively, with 112 (74.6%) males and a male to female ratio of 2.95:1. 120 (80%) cases and 125 (83.3%) controls were married, and majority hailed from rural areas (cases 64%; controls 72%). 99 (66%) cases and 120 (72%) controls had received some amount of formal education and most were self-employed (cases 58.7%; controls 64.0%). The majority of participants belonged to lower-middle and upper-lower socioeconomic status. As can be seen in table I, majority of participants lived in nuclear families (cases 46.7%; controls 44%). Participants’ Clinical Characteristics A history of medical illness was present in 134 (89.3%) cases and 103 (69.6%) controls with majority having multiple co-morbidities including hypertension, diabetes and smoking. Only hypertension and only diabetes were identified in 20 (13.33%) and 04 (2.67%) cases and 22 (14.67%) and 03 (2.0%) controls respectively. Table II shows that the type of ACS diagnosed was IWMI in 66 (44.0%), AWMI in 33 (22.0%) and NSTEMI in 33 (22.0%) of cases. Psychiatric morbidity was seen in 85 (56.7%) cases and 36 (24.0%) controls with MDD as the major diagnosis in both. Stressful life events between cases and controls The median number of SLEs was 09 in cases and 08 in controls and the mean number of events to which participants were directly exposed (witnessed by me and happened to me) was 5.07 ± 2.04 in cases and 4.35 ± 1.88 in controls with a significant difference. The number of events directly exposed to, as reported was significantly more by cases, with adjusted Z-score of 2.01 for nine events, 2.74 for eight events and 3.76 for five events, with p-value of < 0.01. Table V shows the pattern of stressful life events in cases and controls, with significant difference between the two. As can be seen, the Z-score for "Natural disaster" and "Assault with a weapon" was significant for the response "happened to me", being higher among cases. With "Fire explosion", the Z score was significant for the "witnessed” response. For traumatic events including transportation accident, serious accident at work, and captivity, the response 'doesn't apply' was significantly higher in control group. Discussion The development of coronary heart disease involves a complex interplay of various factors, some of which can be modified while others cannot. Among these factors, psychosocial elements such as stress and psychiatric conditions play a significant role. 5 Stressors can manifest in different forms, either as acute events with clear beginnings and endings, or as chronic stressors that persist over time. Chronic life difficulties represent ongoing challenges that may endure for a lifetime, such as persistent poverty, unresolved marital conflicts, daily struggles that undermine one's well-being, feelings of unfair treatment, the loss of loved ones, or permanent physical disabilities like vision impairment. However, the distinction between acute and chronic stress can sometimes blur, as the impact of acute sorrow may resonate for years to come. 21 Our study revealed a) a significant psychiatric morbidity in cases than controls, b) significantly more number of SLEs in cases than controls c) significant responses of witnessed by me and happened to me in natural disaster and assault by a weapon in cases than controls d) Different patterns of exposure in cases and controls. The mean age of our study sample was 55.70 ± 13.30 years, similar to past studies. 22 The majority of the sample belonged to male gender which is expected as male gender is an established risk factor for developing CAD because of more chances of being a smoker and more exposure to stressful life events. The majority of participants in our study were literate, belonged to rural areas, from middle SES, self-employed and living in nuclear and extended nuclear families. This may be because of the decreased opportunity of the people living in rural areas to acquire higher education and hence lesser chances of employment, increasing the chances of people reacting adversely to situations thereby creating more stressors. 23 Poor coping mechanisms also increase the adverse effects of day to day stressors. 24 The Median, Mean and Total No. of events exposed to was more in cases than controls. This result in our study is in line with findings from many studies which also reported significantly higher numbers of stressful life events in ACS patients than non-patients. 25 , 26 There was a significant difference between the two groups considering the mean number of SLEs with cases having experienced higher number than controls, pointing towards the association of stress and cardiac events. Stress can dysregulate physiological processes, leading to elevated levels of stress hormones, increased inflammation, and endothelial dysfunction, all of which contribute to the development as well as progression of cardiovascular disease. 27 In addition to this, stress can cause changes in behaviour, such as unhealthy coping and poor adherence to medications that further exacerbates the risk. It may be pertinent to mention here that stress can be viewed as a modifiable risk factor, can be assessed for and strategies aimed at its reduction to improve the burden of cardiovascular disease. 28 With respect to the number of SLEs, significant differences were seen for nine, eight and five events. The most common SLE directly experienced by the participants was natural disaster, could be because the region suffered earthquake in 2005, heavy floods in 2014 and snowstorm in 2019 and most of the population of the region was affected and exposed to these. 29 , 30 Studies have shown that acute stressors such as earthquakes may trigger cardiac events due to a sudden sympathetic surge and Renin-angiotensin-aldosterone system (RAAS) activation, leading to hypertension, heart failure and coronary events. 31 , 32 Moreover, it has been shown that earthquake experiences in the early life is linked to long-term effects on adult resting heart rate, total cholesterol, and fasting plasma glucose, especially among men. 33 Other events that were either experienced or witnessed by the study population included Loss of loved one by sudden death or abduction, Fire Explosion, Road Traffic accidents, Captivity, Physical assault and Assault with a weapon (being shot or stabbed). This may be because of perturbed conditions prevailing in Kashmir from last few decades leading to loss of precious lives. 34 , 35 These findings in our study are in line with past studies from the valley which revealed that the lifetime prevalence of exposure to traumatic events was 58.69% with firing and explosion being the commonest. 36 Sudden loss of closed one, physical assault and assault with weapon were also significantly reported by the participants. Moreover, it has been reported that there is an increase in heart rate in the first month after loss, which can lead to acute coronary event. 37 Thus, it calls for public health initiatives aimed at promoting mental well-being and reducing stress at the population level which can have far-reaching implications for cardiovascular disease prevention and policies that target stress reduction. There is a need for further research to establish causality and elucidate the complex relationship between stress and cardiovascular health. Conclusion In summary, our study highlights the significant impact of stressful life events on cardiovascular health, particularly in the context of acute and chronic stressors experienced. The association between stress and cardiac events is underscored by the higher prevalence of stressful life events among individuals with ACS compared to controls, pointing towards stress as a risk factor for cardiovascular disease and initiatives promoting mental well-being and targeting stress reduction are warranted to mitigate the burden of cardiovascular disease. Limitations The retrospective design introduces potential recall bias, and reliance on self-reported measures may lead to inaccuracies in assessing stress exposure. The cross-sectional design also doesn’t establish any causal relationships. The study's generalizability is also limited by its specific geographic and demographic focus. Also, participants were not fully controlled for all confounding factors. Abbreviations ACS Acute Coronary Syndrome AWMI Anterior Wall Myocardial Infarction CAD Coronary Artery Disease FMD Flow Mediated Dilation GMC Government Medical College HPA Hypothalamic Pituitary Axis IPD In-Patient Department LEC Life Event Checklist MDD Major Depressive Disorder NCRB National Crime Record Bureau NSSO National Sample Survey Office NSTEMI Non ST Elevation Myocardial Infarction OPD Out-Patient Department RAAS Renin Angiotensin Aldosterone System SLE Stressful Life Event STEMI ST Elevation Myocardial Infarction SPSS Statistical Package for Social Sciences SAM Sympathetic Adrenal Medullary UA Unstable Angina WHR Waist Hip Ratio Declarations Consent for participation: Only those were taken for the study who gave the informed consent. Consent for publication: Not applicable Ethical Considerations: The research work was initiated only after approval by the Institutional Ethical Committee, GMC Srinagar. Availability of data: The data sets used and analyzed during this study are available from the Corresponding Author upon reasonable request. Declaration of interests: The authors declare that they have no competing interests. Funding: We verify that this research wasn’t funded by any institution or organization. Authors’ contributions: MuK, SP, and NY collected the data and were major contributors in writing the manuscript, FeR, MM and UR reviewed all the relevant research and analyzed and interpreted the data. YHR guided the whole research. All authors read and approved the final manuscript . Acknowledgments: Not applicable References Larzelere MM, Jones GN. Stress and Health. Primary Care: Clinics in Office Practice. 2008;35:839-85. Cohen S, Kessler RC, Gordon LU. Strategies for measuring stress in studies of psychiatric and physical disorders. National Heart, Lung, and Blood Institute. Coronary Heart Disease. [Internet]. Available from: https://www.nhlbi.nih.gov/health-topics/coronary-heart-disease American Heart Association. Acute Coronary Syndrome. [Internet]. Available from: https://www.heart.org/en/health-topics/heart-attack/about-heart-attacks/acute-coronary-syndrome. Modabber Arasteh M. Comparison of the prevalence and intensity of depression in patients admitted after acute coronary syndrome and patient with cataract. J Fundamentals of Mental Health. 2008;10:128–48. Shruthi DR, Kumar SS, Desai N, Raman R, SathyanarayanaRao TS. Psychiatric co-morbidities in acute coronary syndromes: Six-month follow-up study. Indian J Psychiatry. 2018;60(1):60–64. doi:10.4103/psychiatry.IndianJPsychiatry_94_18 Herring N, Paterson DJ, Pickering AE. Setting the tone for the heart: An update on sympathetic nervous system modulation of cardiac function. Physiology. 2019;34(1):33–46. doi:10.1152/physiol.00038.2018 Björntorp P. Do stress reactions cause abdominal obesity and comorbidities? Obesity Reviews. 2001;2(2):73–86. doi:10.1046/j.1467-789x.2001.00027.x Esler M. The 2009 Carl Ludwig Lecture: Pathophysiology of the human sympathetic nervous system in cardiovascular diseases: The transition from mechanisms to medical management. Journal of Applied Physiology. 2010;108(2):227–237. doi:10.1152/japplphysiol.00933.2009 Sara JDS, Toya T, Ahmad A, Clark MM, Gilliam WP, Lerman LO, et al. Mental Stress and Its Effects on Vascular Health. Mayo Clinic Proceedings. 2022;97(5):951–990. doi:10.1016/j.mayocp.2022.02.004 Hintsa, T., Hintsanen, M., Rosenström, T., & Keltikangas-Järvinen, L. (2012). The Role of Stress in a Pathogenesis of CHD. In (Ed.), Cardiovascular Risk Factors. IntechOpen. https://doi.org/10.5772/33184 Kyrou I, Tsigos C. Stress mechanisms and metabolic complications. Hormone and Metabolic Research. 2009;41(10):707–718. doi:10.1055/s-0029-1237374 India Today. Sudden heart attack deaths increased by 12% in 2022: Government data. [Internet]. Available from: https://www.indiatoday.in/health/story/sudden-heart-attack-deaths-increased-by-12-in-2022-government-data-2471760-2023-12-04 Math SB, Srinivasaraju R. Indian Psychiatric epidemiological studies: Learning from the past. Indian J Psychiatry. 2010;52(Suppl 1) Rising Kashmir. Rise of Heart Attacks in Young Adults. [Internet]. Available from: https://risingkashmir.com/home/news_description/370877/Rise-of-Heart-Attacks-in-Young-Adults Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clinic Proceedings. 2009;84(10):917–938. doi:10.4065/84.10.917 Sharma R. Revised Kuppuswamy's Socioeconomic Status Scale: Explained and Updated. Indian Pediatr. 2017;54(10):867-70. MINI International Neuropsychiatric Interview (MINI) 7.0.2. [Internet]. Available from: https://harmresearch.org/product/mini-international-neuropsychiatric-interview-mini-7-0-2/ Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. The Life Events Checklist for DSM-5 (LEC-5). Instrument available from the National Center for PTSD at www.ptsd.va.gov IBM Corp. IBM SPSS statistics for Windows. Armonk: IBM Corp; 2012. Brown GW, Sklair F, Harris TO, Birley JL. Life events and psychiatric disorders. Psychol Med. 1973;3:74-78. Xavier D et al; CREATE registry investigators. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. 2008 Apr van Zon SKR, Reijneveld SA, Mendes de Leon CF, Bültmann U. The impact of low education and poor health on unemployment varies by work life stage. International Journal of Public Health. 2017;62(9):997–1006. doi:10.1007/s00038-017-0972-7 Algorani EB, Gupta V. Coping Mechanisms. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559031/ Rafanelli C, Roncuzzi R, Milaneschi Y, Tomba E, Colistro MC, Pancaldi LG, Di Pasquale G. Stressful life events, depression and demoralization as risk factors for acute coronary heart disease. Psychother Psychosom. 2005;74(3):179-84. Roohafza H, Talaei M, Sadeghi M, Mackie M, Sarafzadegan N. Association between acute and chronic life events on acute coronary syndrome: a case-control study. The Journal of Cardiovascular Nursing. 2010;25(5)–E7. doi:10.1097/JCN.0b013e3181d81799 Sher LD, Geddie H, Olivier L, Cairns M, Truter N, et al. Chronic stress and endothelial dysfunction: mechanisms, experimental challenges, and the way ahead. American Journal of Physiology-Heart and Circulatory Physiology. Advance online publication. doi:10.1152/ajpheart.00244.2020 Satyjeet F, Naz S, Kumar V, Aung NH, Bansari K, Irfan S, Rizwan A. Psychological Stress as a Risk Factor for Cardiovascular Disease: A Case-Control Study. Cureus. 2020;12(10) doi:10.7759/cureus.10757 Margoob MA. One-year longitudinal study of snow storm disaster survivors in Kashmir. JK-Practitioner. 2006;13(Suppl.1) Wikipedia contributors. 2014 India–Pakistan floods. Wikipedia, The Free Encyclopedia. May 25, 2024. Available from: https://en.wikipedia.org/wiki/2014_India%E2%80%93Pakistan_floods Lin LY, Wu CC, Liu YB, Ho YL, Liau CS, Lee YT. Derangement of heart rate variability during a catastrophic earthquake: a possible mechanism for increased heart attacks. Pacing and Clinical Electrophysiology. 2001;24(11):1596-1601. Satoh M, Kikuya M, Ohkubo T, Imai Y. Acute and subacute effects of the Great East Japan earthquake on home blood pressure values. Hypertension. 2011;58: e193-e194. Li Y, Wang L, Yu L, et al. Long-term effects of earthquake experience of young persons on cardiovascular disease risk factors. Arch Med Sci: AMS. 2017;13:75-81. Sayeed K. Kashmir turned into an open-air prison. Jacobin. 2019 Sept. Wallen J. Young boys tortured in Kashmir clampdown as new figures show 13,000 teenagers arrested. The Telegraph. 2019 Sept 25. Housen T, Lenglet A, Shah S, et al. Trauma in the Kashmir Valley and the mediating effect of stressors of daily life on symptoms of posttraumatic stress disorder, depression and anxiety. Confl Health. 2019;13:58. doi:10.1186/s13031-019-0245-6 Li J, Precht DH, Mortensen PB, Olsen J. Mortality in parents after death of a child in Denmark: a nationwide follow-up study. Lancet. 2003;361(9355):363–7. Tables Table I: Socio-demographic characteristics of the sample Variable Cases No. (%) Controls No. (%) X 2 /T-value (p-value) Age Mean Age 56.55±13.1 55.04±12.96 0.39 Gender Male Female 112 (74.6) 38 (25.3) 112 (74.6) 38 (25.3) 0.00 (1.00) Marital Status Unmarried Married Widowed/ Separated 07 (4.6) 120 (80.0) 23 (15.3) 07 (4.67) 125 (83.3) 18 (12.0) 0.72 (0.70) Residence Rural Urban 96 (64.0) 54 (36.0) 108 (72.0) 42 (28.0) 2.21 (0.14) Education Illiterate Literate 51 (34.0) 99 (66.0) 42 (28.0) 108(72.0) 10.39 (0.94) Employment Status Unemployed Self-employed Employed 27 (18.0) 88 (58.7) 35 (23.3) 22 (14.7) 96 (64.0) 32 (21.3) 1.56 (0.98) Socio-economic Status Upper Upper middle Lower middle Upper lower Lower 19 (12.7) 20 (13.3) 54 (36.0) 49 (32.7) 08 (5.3) 17 (11.3) 24 (16.0) 57 (38.0) 45 (30.0) 07 (4.7) 0.79 (0.9) Family Type Nuclear Joint Extended 70 (46.7) 30 (20.0) 50 (33.3) 66 (44.0) 28 (28.7) 56 (37.3) 0.53 (0.8) Smoking Status Smokers Non-smokers Ex-smokers 42 (28.0) 99 (66.0) 09 (6.0) 57 (38.0) 90 (60.0) 03 (2.0) 5.7 (0.06) Medical Illness Present Absent 134 (89.0) 16 (11.0) 103 (68.7) 47 (31.3) 18.1 (0.01) Occupational status Student Unemployed Unskilled work Skilled Professional 01 (0.7) 26 (17.3) 26 (17.3) 79 (52.6) 18 (12.0) 01 (0.7) 21 (14.0) 28 (18.7) 82 (54.6) 18 (12.0) 0.96 ( 0.66) Table II: Clinical Characteristics of the sample Variable Cases No. (%) Controls No. (%) X 2 (p-value) Medical Illness None Hypertension only T2DM only Smoking only Multiple 16 (10. 67) 20 (13.33 ) 04 (2.67) 42 (28.00) 68 (45.3) 47 (31.33) 22 (14.67) 03 (2.0) 57(38.00) 21(14.00) 42.84 (<0.01) Cardiac Diagnoses Unstable angina NSTEMI IWMI AWMI ALMI 07 (4.7) 33 (22.0) 66 (44.0) 34 (22.7) 10 (6.7) __ __ Psychiatric Diagnoses Absent Present 65 (43.3) 85 (56.7) 114 (76.0) 36 (24.0) 33.25 (<0.01) Family History of Psychiatric illness Present Absent 86 (57.4) 64 (42.6) 77 (51.3) 73 (48.7) 0.85 (0.35) Table III: Number of SLE’s among cases and controls Identity Median Mean ± SD t test F value df (P-value) Cases 09 5.07± 2.04 3.171 0.551 298 (0.002) Controls 08 4.35 ±1.88 Table IV: Events of exposure (Happened to me and Witnessed by me only) No. of reported events Identity No. (%age) Adjusted Residual P-value 09 Cases Controls 04 (2.67) 00 (0.00) 2.01 -2.01 0.00 08 Cases Controls 02 (1.33) 01 (0.8) 2.74 -2.74 0.00 07 Cases Controls 09 (6.0) 04 (2.67) 3.67 -3.67 0.56 06 Cases Controls 17 (11.3) 12 (8.0) 1.08 -1.08 3.66 05 Cases Controls 26 (17.3) 09 (6.0) 3.46 -3.46 0.00 Table V: Pattern of exposure of various events Variable Cases No. (%age) Controls No. (%age) Cases (Z scores) Controls (Z scores) Cochran-Armitage trend test value P-Value Natural Disaster Doesn’t apply Learned about it Witnessed Happened to me 01 (0.67) 25 (16.67) 32 (21.33) 92 (61.33) 03 (2.00) 70 (46.67) 22 (14.67) 55 (36.67) - 1.01 - 5.59 1.50 4.27 1.01 5.59 - 1.50 - 4.27 33.48 0.000 Fire Explosion Doesn’t apply Learned about it Witnessed Happened to me 20 (13.33) 49 (32.7) 66 (44.0) 15 (10.0) 62 (41.33) 35 (23.3) 46 (30.7) 07 (4.7) - 5.44 1.80 2.39 1.77 5.44 - 1.80 - 2.39 - 1.77 30.32 0.000 Transportation Accident Doesn’t apply Learned about it Witnessed Happened to me 14 (9.33) 75 (50.00) 44 (29.33) 17 (11.33) 39 (26.00) 65 (43.33) 35 (23.33) 11 (7.33) - 3.78 1.16 1.18 1.19 3.78 - 1.16 - 1.18 - 1.19 14.8178 0.002 Serious accident at work Doesn’t apply Learned about it Witnessed Happened to me 76 (50.67) 47 (31.33) 18 (12.00) 09 (6.00) 99 (66.00) 37 (22.67) 13 (8.67) 04 (2.67) - 2.69 1.69 0.95 1.42 2.69 - 1.69 - 0.95 - 1.42 7.838 0.049 Assault with a weapon Doesn’t apply Learned about it Witnessed Happened to me 39 (26.0) 78 (52.0) 24 (16.0) 09 (6.0) 62 (41.3) 63 (42.0) 23 (15.3) 02 (1.3) - 2.81 1.74 0.16 2.15 2.81 - 1.74 - 0.16 - 2.15 11.303 0.010 Captivity Doesn’t apply Learned about it Witnessed Happened to me 30 (20.00) 87 (58.00) 26 (17.33) 07 (4.67) 56 (37.33) 69 (46.00) 21 (14.00) 04 (2.67) - 3.32 2.08 0. 79 0.92 3. 32 - 2.08 - 0.79 - 0.92 11.287 0.010 Life threatening Illness Doesn’t apply Learned about it Witnessed Happened to me 24 (16.0) 25 (16.7) 88 (58.7) 13 (8.7) 24 (16.0) 29 (19.3) 81 (54.0) 16 (10.7) 1.60 0.25 1.81 -0.33 -1.60 -0.25 -1.81 0.33 0.002 0.826 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Dec, 2024 Read the published version in Middle East Current Psychiatry → Version 1 posted Editorial decision: Revision requested 10 Sep, 2024 Reviews received at journal 08 Sep, 2024 Reviewers agreed at journal 08 Sep, 2024 Reviews received at journal 04 Sep, 2024 Reviewers agreed at journal 28 Aug, 2024 Reviewers invited by journal 28 Aug, 2024 Editor assigned by journal 28 Aug, 2024 Submission checks completed at journal 28 Aug, 2024 First submitted to journal 19 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4941610","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":351902632,"identity":"53641dfe-f0f3-4236-ae9b-b26cd198e8cd","order_by":0,"name":"Muntaqueem Ul Kousar","email":"","orcid":"","institution":"GMC ANANTNAG","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Muntaqueem","middleName":"Ul","lastName":"Kousar","suffix":""},{"id":351902633,"identity":"f05b5523-527b-4c63-b9c0-f609ffc1979a","order_by":1,"name":"Shaheena Parveen","email":"","orcid":"","institution":"GMC SRINAGAR","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shaheena","middleName":"","lastName":"Parveen","suffix":""},{"id":351902634,"identity":"f99f2a9e-497e-467e-b5de-ea65542a81cd","order_by":2,"name":"Masood Maqbool","email":"","orcid":"","institution":"GMC SRINAGAR","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Masood","middleName":"","lastName":"Maqbool","suffix":""},{"id":351902637,"identity":"72d02b48-3728-46ab-ad98-b869b8b1bfad","order_by":3,"name":"Yasir Hassan Rather","email":"","orcid":"","institution":"GMC SRINAGAR","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yasir","middleName":"Hassan","lastName":"Rather","suffix":""},{"id":351902639,"identity":"14d7e23a-8d18-432a-b82f-5160528ecb74","order_by":4,"name":"Fazle Roub Bhat","email":"","orcid":"","institution":"GMC SRINAGAR","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fazle","middleName":"Roub","lastName":"Bhat","suffix":""},{"id":351902640,"identity":"e75010bc-8e50-4e99-9ea6-63d133f50048","order_by":5,"name":"Neelofar Jan","email":"","orcid":"","institution":"GMC SRINAGAR","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Neelofar","middleName":"","lastName":"Jan","suffix":""},{"id":351902644,"identity":"fbb09de6-bab9-4661-9cf8-971d0e800b6d","order_by":6,"name":"Ubaid Rasool","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYDACCcYGEGXAwA6iDSxI0cJzAERJEKMFQhkwSCQgcfEBg9vNzZ8LKuyM5Wc+v7rhR4EEA397dwJ+LXcOtknPOJNsZnA7p+xmD9BhEmfObsCv5UZiGzNvG7ONgXRO2g0eoBYDiVyCWpo/8/6rt5GfeSbt5h8itTRI8zYcNmO4wX7sNlG2SIL9cuy4scGZHLbbMgYSPAT9wne7/fHngppqw/ntx5/dfPPHRo6/vRe/FhBghlA8BmCSoHIkLewPiFI9CkbBKBgFIw8AABAASTlGEr/5AAAAAElFTkSuQmCC","orcid":"","institution":"GMC SRINAGAR","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ubaid","middleName":"","lastName":"Rasool","suffix":""}],"badges":[],"createdAt":"2024-08-20 03:02:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4941610/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4941610/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43045-024-00491-w","type":"published","date":"2024-12-17T15:57:22+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72202020,"identity":"b62d322f-ec70-465c-8b3b-157750d54097","added_by":"auto","created_at":"2024-12-23 16:13:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1110759,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4941610/v1/48f42bef-67e8-443e-a844-c104ed1cc482.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A study of stressful life events in patients with first episode acute coronary syndrome (ACS) - A hospital based case control study Running Title: Stressful Life Events in First Episode Acute Coronary Syndrome Patients: A Case-Control Study","fulltext":[{"header":"Key Message","content":"\u003cul start=\"12\"\u003e\n \u003cli\u003eSignificant number of Stressful life events in the participants.\u003c/li\u003e\n \u003cli\u003eSignificantly higher mean, median and total number of SLEs in cases than controls.\u003c/li\u003e\n \u003cli\u003eSignificant difference in the pattern of exposure between cases and controls.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eStressful life events refer to occurrences or events experienced by people during their lives that are not congenial with their current abilities and facilities resulting in increased psychological demands and causing such changes in body that increase the risk for illness.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Everyone experiences stress in their lifetime, irrespective of age, sex, social class, in every form and size. Coronary heart disease is a type of heart disease that develops when the arteries of the heart cannot deliver enough oxygen-rich blood to the heart.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Its clinical spectrum varies from silent angina to sudden cardiac death. American Heart Association explains that Acute Coronary syndrome is an umbrella term that includes Unstable Angina (UA), Non-ST elevation Myocardial infarction (NSTEMI) and ST-elevation Myocardial infarction (STEMI) for situations where the blood supply to the heart muscle is suddenly blocked resulting in myocardial injury detected by cardiac biomarkers.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The prevalence of UA is decreasing because more cases are now diagnosed as NSTEMI with the help of highly sensitive cardiac biomarkers.\u003c/p\u003e \u003cp\u003eCoronary Artery Disease (CAD) is considered as a psycho-somatic illness, as psychological factors have a very important role in their existence and formation.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Both acute and chronic stress have harmful effects on the cardiac health. Acute stress, though is adaptive and necessary, may have detrimental effects as it may trigger cardiac events or lead to sudden death. It has been associated with more than two-fold risk of precipitating a cardiac event.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Chronic stress influences three main regulatory systems of the body; the \u003cem\u003eautonomic\u003c/em\u003e, the \u003cem\u003eendocrine\u003c/em\u003e and the \u003cem\u003eimmune\u003c/em\u003e system. The sympathetic-adrenal-medullary (SAM) axis and the hypothalamic-pituitary-adrenal (HPA) axis are continuously over-activated or in imbalance, and overcompensation of these systems leaves the individual susceptible to stress-related diseases including psychiatric problems like depression and anxiety, metabolic disorders, immunosuppression and cardiovascular problems like hypertension, cardiomyopathy and coronary heart disease.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Chronic stress has also been linked to endothelial dysfunction as measured by brachial artery flow-mediated dilation (FMD). Evidence suggests chronic stress inversely impacts FMD, reflecting diminished endothelial function and heightened atherosclerotic risk.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Also, vital exhaustion and major stressful life events, the indices of chronic stress, have been seen to be associated with arrhythmic events.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The secondary outcomes of the chronic stress-related dysfunctions are the metabolic abnormalities characteristic of the metabolic syndrome. It exerts a patho-physiological effect on waist-hip \u0026ndash;ratio (WHR), causes alterations in insulin and lipid metabolism, fibrinolysis, and blood pressure \u0026ndash; the metabolic parameters of insulin resistance.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe registrar general of India reported that in India cardiac deaths increased from 17\u0026ndash;23% over only a decade, which increased the total adult deaths by a 6%. India has witnessed a steep rise in heart deaths over the past three years with a rise of \u0026gt;\u0026thinsp;12% in 2022 according to National Crime Records Bureau (NCRB) attributed majorly to Covid.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In an epidemiological study carried in 2005, the overall prevalence of CAD in the Kashmir valley was seen to be 7.54%.\u003csup\u003e14\u003c/sup\u003e Recently Kashmir has seen a rise in heart attacks particularly in men in the age group of 23s to 30s, the common causes include excessive phone use, smoking, drug use behaviours, stress and emotional pain.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e National Sample Survey Office (NSSO) survey found that an adult in the Kashmir valley witnessed or experienced an average of 7.7 traumatic events during their lifetime and that this unusual stress and emotional strain arising from perturbed conditions in the territory.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The deleterious effects of the chronic traumatic situation on cardiac health, nevertheless very relevant, have not been well studied in Kashmiri population so far, our study seeks to identify and compare various SLEs in first episode ACS patients.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy Aims\u003c/strong\u003e\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003eTo determine the socio-demographic and clinical profile of patients with first episode ACS.\u003c/li\u003e\n \u003cli\u003eTo assess the number and pattern of stressful life events in patients with first episode ACS and compare with controls.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was a case-control study, cross-sectional in design, conducted in the Department of cardiology of Govt. Medical College Srinagar spanning a period of 18 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe calculated sample size of the study was 139, using a formula with a confidence interval of 95%, a margin of error of 5%, and an anticipated prevalence of coronary artery disease from previous studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were divided into cases and controls: cases, consisted of 150 patients with first episode of acute coronary syndrome (ACS) taken consecutively from OPD/IPD, and controls, comprising 150 individuals without ACS. Controls mainly comprised of attendants of the patients who mostly are the close relatives of the patients. The cases and controls were matched for socio-demographic and conventional coronary artery disease (CAD) risk factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterview Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews took place in a single setting, at the time of discharge from the hospital when their condition had stabilized. Written consent, provided in the local language for clarity, was obtained. Participants were informed about the interview\u0026apos;s purpose, and incomplete interviews were excluded from the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational Definitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eACS was diagnosed by the detection of abnormal cardiac biomarkers, along with evidence of myocardial ischemia, caused due to sudden blockage of the blood supply.\u003csup\u003e16\u003c/sup\u003e The diagnosis was made and confirmed by the consultant in-charge OPD/IPD.\u003c/p\u003e\n\u003cp\u003eThe study was initiated after approval of the institutional Ethical Committee and BORS (Board of Research Studies). Inclusion criteria\u0026nbsp;included, i)\u0026nbsp;Individuals who experienced their first episode of ACS, either admitted to the hospital or receiving outpatient care,\u0026nbsp;ii)\u0026nbsp;Both males and females aged 18 and above, and those willing to participate in the study by providing written\u0026nbsp;informed consent, iii)\u0026nbsp;Age- and gender-matched non-patients agreeing to participate as controls.\u0026nbsp;The following participants were excluded; i)\u0026nbsp;Those with severe or terminal medical conditions, ii) Those\u0026nbsp;with a history of structural heart disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following instruments were utilized in the study:\u003c/p\u003e\n\u003cp\u003eA \u003cstrong\u003esemi-structured proforma\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewas prepared that recorded the socio-demographic variables:\u0026nbsp;age, gender, educational status, marital status, family type, employment status, residence, medical illness and family history of psychiatric illness of cases s well as controls.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKuppuswamys Socio-demographic Scale:\u0026nbsp;\u003c/strong\u003eIt is a measurement tool that calculates a composite score and categorizes patients five categories based on the education and occupation of the head of the family, and monthly income of the household. The five categories are Upper (I), Upper Middle (II), Lower Middle (III), Upper Lower (IV), and Lower (V) socio-economic status.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eMini-International Neuropsychiatric Interview\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;v.7.0.2\u0026nbsp;\u003c/strong\u003e(M.I.N.I.) is a structured diagnostic interview, for DSM-5 and ICD-10 psychiatric disorders. It has a high reliability and validity for various psychiatric illnesses. It has been designed to meet the need for a short and accurate interview schedule, and thus was used for\u0026nbsp;the\u0026nbsp;assessment of psychiatric illnesses.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLife Event Checklist (LEC)\u0026nbsp;\u003c/strong\u003efor DSM-5\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewas used to assess exposure to stressful life events during life time. Participants were assessed for the presence of any life event using the Life Event Checklist. This is a self-report measure designed to screen for potentially traumatic events in a person\u0026rsquo;s life. It assesses the exposure to 16 potentially distressing events and includes one additional item assessing any other extraordinarily stressful event not captured in the first 16. LEC has adequate psychometric properties as a stand-alone assessment of traumatic exposure, particularly when evaluating the consistency of events that happened to a respondent. Though psychometrics for the LEC-5 is not currently available; only a few psychometric differences are expected as there are minimal revisions from the original version of the LEC.\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was entered in Statistical Package for Social Sciences (SPSS) V27.\u003csup\u003e20\u003c/sup\u003e Descriptive statistics was used for continuous variables and the Chi-square test was applied for categorical variables. Group differences in scores were compared on the chi-square test, student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test and Cochrane Armitage trend test. Adjusted Residual (Z-score) was used for comparison of individual items. All p-values were two-sided and p-value \u0026lt;0.05 and Z-score \u0026gt;1.96 was considered as statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u0026rsquo; Socio-demographic characteristics\u003c/h2\u003e \u003cp\u003eThe mean age of cases and controls was 56.55\u0026thinsp;+\u0026thinsp;13.1 years and 55.04\u0026thinsp;+\u0026thinsp;12.9 years respectively, with 112 (74.6%) males and a male to female ratio of 2.95:1. 120 (80%) cases and 125 (83.3%) controls were married, and majority hailed from rural areas (cases 64%; controls 72%). 99 (66%) cases and 120 (72%) controls had received some amount of formal education and most were self-employed (cases 58.7%; controls 64.0%). The majority of participants belonged to lower-middle and upper-lower socioeconomic status. As can be seen in table I, majority of participants lived in nuclear families (cases 46.7%; controls 44%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u0026rsquo; Clinical Characteristics\u003c/h2\u003e \u003cp\u003eA history of medical illness was present in 134 (89.3%) cases and 103 (69.6%) controls with majority having multiple co-morbidities including hypertension, diabetes and smoking. Only hypertension and only diabetes were identified in 20 (13.33%) and 04 (2.67%) cases and 22 (14.67%) and 03 (2.0%) controls respectively. Table II shows that the type of ACS diagnosed was IWMI in 66 (44.0%), AWMI in 33 (22.0%) and NSTEMI in 33 (22.0%) of cases. Psychiatric morbidity was seen in 85 (56.7%) cases and 36 (24.0%) controls with MDD as the major diagnosis in both.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStressful life events between cases and controls\u003c/h2\u003e \u003cp\u003eThe median number of SLEs was 09 in cases and 08 in controls and the mean number of events to which participants were directly exposed (witnessed by me and happened to me) was 5.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04 in cases and 4.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88 in controls with a significant difference. The number of events directly exposed to, as reported was significantly more by cases, with adjusted Z-score of 2.01 for nine events, 2.74 for eight events and 3.76 for five events, with p-value of \u0026lt;\u0026thinsp;0.01. Table V shows the pattern of stressful life events in cases and controls, with significant difference between the two. As can be seen, the Z-score for \"Natural disaster\" and \"Assault with a weapon\" was significant for the response \"happened to me\", being higher among cases. With \"Fire explosion\", the Z score was significant for the \"witnessed\u0026rdquo; response. For traumatic events including transportation accident, serious accident at work, and captivity, the response 'doesn't apply' was significantly higher in control group.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe development of coronary heart disease involves a complex interplay of various factors, some of which can be modified while others cannot. Among these factors, psychosocial elements such as stress and psychiatric conditions play a significant role.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Stressors can manifest in different forms, either as acute events with clear beginnings and endings, or as chronic stressors that persist over time. Chronic life difficulties represent ongoing challenges that may endure for a lifetime, such as persistent poverty, unresolved marital conflicts, daily struggles that undermine one's well-being, feelings of unfair treatment, the loss of loved ones, or permanent physical disabilities like vision impairment. However, the distinction between acute and chronic stress can sometimes blur, as the impact of acute sorrow may resonate for years to come.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur study revealed a) a significant psychiatric morbidity in cases than controls, b) significantly more number of SLEs in cases than controls c) significant responses of witnessed by me and happened to me in natural disaster and assault by a weapon in cases than controls d) Different patterns of exposure in cases and controls.\u003c/p\u003e \u003cp\u003eThe mean age of our study sample was 55.70\u0026thinsp;\u0026plusmn;\u0026thinsp;13.30 years, similar to past studies.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e The majority of the sample belonged to male gender which is expected as male gender is an established risk factor for developing CAD because of more chances of being a smoker and more exposure to stressful life events. The majority of participants in our study were literate, belonged to rural areas, from middle SES, self-employed and living in nuclear and extended nuclear families. This may be because of the decreased opportunity of the people living in rural areas to acquire higher education and hence lesser chances of employment, increasing the chances of people reacting adversely to situations thereby creating more stressors.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Poor coping mechanisms also increase the adverse effects of day to day stressors.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe Median, Mean and Total No. of events exposed to was more in cases than controls. This result in our study is in line with findings from many studies which also reported significantly higher numbers of stressful life events in ACS patients than non-patients.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e There was a significant difference between the two groups considering the mean number of SLEs with cases having experienced higher number than controls, pointing towards the association of stress and cardiac events. Stress can dysregulate physiological processes, leading to elevated levels of stress hormones, increased inflammation, and endothelial dysfunction, all of which contribute to the development as well as progression of cardiovascular disease.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e In addition to this, stress can cause changes in behaviour, such as unhealthy coping and poor adherence to medications that further exacerbates the risk. It may be pertinent to mention here that stress can be viewed as a modifiable risk factor, can be assessed for and strategies aimed at its reduction to improve the burden of cardiovascular disease.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e With respect to the number of SLEs, significant differences were seen for nine, eight and five events.\u003c/p\u003e \u003cp\u003eThe most common SLE directly experienced by the participants was natural disaster, could be because the region suffered earthquake in 2005, heavy floods in 2014 and snowstorm in 2019 and most of the population of the region was affected and exposed to these.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Studies have shown that acute stressors such as earthquakes may trigger cardiac events due to a sudden sympathetic surge and Renin-angiotensin-aldosterone system (RAAS) activation, leading to hypertension, heart failure and coronary events.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Moreover, it has been shown that earthquake experiences in the early life is linked to long-term effects on adult resting heart rate, total cholesterol, and fasting plasma glucose, especially among men.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOther events that were either experienced or witnessed by the study population included Loss of loved one by sudden death or abduction, Fire Explosion, Road Traffic accidents, Captivity, Physical assault and Assault with a weapon (being shot or stabbed). This may be because of perturbed conditions prevailing in Kashmir from last few decades leading to loss of precious lives.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e These findings in our study are in line with past studies from the valley which revealed that the lifetime prevalence of exposure to traumatic events was 58.69% with firing and explosion being the commonest.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Sudden loss of closed one, physical assault and assault with weapon were also significantly reported by the participants. Moreover, it has been reported that there is an increase in heart rate in the first month after loss, which can lead to acute coronary event.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThus, it calls for public health initiatives aimed at promoting mental well-being and reducing stress at the population level which can have far-reaching implications for cardiovascular disease prevention and policies that target stress reduction. There is a need for further research to establish causality and elucidate the complex relationship between stress and cardiovascular health.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, our study highlights the significant impact of stressful life events on cardiovascular health, particularly in the context of acute and chronic stressors experienced. The association between stress and cardiac events is underscored by the higher prevalence of stressful life events among individuals with ACS compared to controls, pointing towards stress as a risk factor for cardiovascular disease and initiatives promoting mental well-being and targeting stress reduction are warranted to mitigate the burden of cardiovascular disease.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eThe retrospective design introduces potential recall bias, and reliance on self-reported measures may lead to inaccuracies in assessing stress exposure. The cross-sectional design also doesn’t establish any causal relationships. The study's generalizability is also limited by its specific geographic and demographic focus. Also, participants were not fully controlled for all confounding factors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eACS Acute Coronary Syndrome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAWMI Anterior Wall Myocardial Infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCAD Coronary Artery Disease\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFMD Flow Mediated Dilation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGMC Government Medical College\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHPA Hypothalamic Pituitary Axis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIPD In-Patient Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLEC Life Event Checklist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMDD Major Depressive Disorder\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNCRB National Crime Record Bureau\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNSSO National Sample Survey Office\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNSTEMI Non ST Elevation Myocardial Infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOPD Out-Patient Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRAAS Renin Angiotensin Aldosterone System\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSLE Stressful Life Event\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTEMI ST Elevation Myocardial Infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSPSS Statistical Package for Social Sciences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSAM Sympathetic Adrenal Medullary\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUA Unstable Angina\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHR Waist Hip Ratio\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for participation:\u0026nbsp;\u003c/strong\u003eOnly those were taken for the study who gave the informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations:\u0026nbsp;\u003c/strong\u003eThe research work was initiated only after approval by the Institutional Ethical Committee, GMC Srinagar.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data:\u0026nbsp;\u003c/strong\u003eThe data sets used and analyzed during this study are available from the Corresponding Author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eWe verify that this research wasn\u0026rsquo;t funded by any institution or organization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eMuK, SP, and NY collected the data and were major contributors in writing the manuscript, FeR, MM and UR reviewed all the relevant research and analyzed and interpreted the data. YHR guided the whole research. All authors read and approved the final manuscript\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eLarzelere MM, Jones GN. Stress and Health. Primary Care: Clinics in Office Practice. 2008;35:839-85.\u003c/li\u003e\n \u003cli\u003eCohen S, Kessler RC, Gordon LU. Strategies for measuring stress in studies of psychiatric and physical disorders.\u003c/li\u003e\n \u003cli\u003eNational Heart, Lung, and Blood Institute. Coronary Heart Disease. [Internet]. Available from: https://www.nhlbi.nih.gov/health-topics/coronary-heart-disease\u003c/li\u003e\n \u003cli\u003eAmerican Heart Association. Acute Coronary Syndrome. [Internet]. Available from: https://www.heart.org/en/health-topics/heart-attack/about-heart-attacks/acute-coronary-syndrome.\u003c/li\u003e\n \u003cli\u003eModabber Arasteh M. Comparison of the prevalence and intensity of depression in patients admitted after acute coronary syndrome and patient with cataract. J Fundamentals of Mental Health. 2008;10:128\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eShruthi DR, Kumar SS, Desai N, Raman R, SathyanarayanaRao TS. Psychiatric co-morbidities in acute coronary syndromes: Six-month follow-up study. Indian J Psychiatry. 2018;60(1):60\u0026ndash;64. doi:10.4103/psychiatry.IndianJPsychiatry_94_18\u003c/li\u003e\n \u003cli\u003eHerring N, Paterson DJ, Pickering AE. Setting the tone for the heart: An update on sympathetic nervous system modulation of cardiac function. Physiology. 2019;34(1):33\u0026ndash;46. doi:10.1152/physiol.00038.2018\u003c/li\u003e\n \u003cli\u003eBj\u0026ouml;rntorp P. Do stress reactions cause abdominal obesity and comorbidities? Obesity Reviews. 2001;2(2):73\u0026ndash;86. doi:10.1046/j.1467-789x.2001.00027.x\u003c/li\u003e\n \u003cli\u003eEsler M. The 2009 Carl Ludwig Lecture: Pathophysiology of the human sympathetic nervous system in cardiovascular diseases: The transition from mechanisms to medical management. Journal of Applied Physiology. 2010;108(2):227\u0026ndash;237. doi:10.1152/japplphysiol.00933.2009\u003c/li\u003e\n \u003cli\u003eSara JDS, Toya T, Ahmad A, Clark MM, Gilliam WP, Lerman LO, et al. Mental Stress and Its Effects on Vascular Health. Mayo Clinic Proceedings. 2022;97(5):951\u0026ndash;990. doi:10.1016/j.mayocp.2022.02.004\u003c/li\u003e\n \u003cli\u003eHintsa, T., Hintsanen, M., Rosenstr\u0026ouml;m, T., \u0026amp; Keltikangas-J\u0026auml;rvinen, L. (2012). The Role of Stress in a Pathogenesis of CHD. In \u0026nbsp;(Ed.), Cardiovascular Risk Factors. IntechOpen.\u0026nbsp;\u003ca href=\"https://doi.org/10.5772/33184\"\u003ehttps://doi.org/10.5772/33184\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eKyrou I, Tsigos C. Stress mechanisms and metabolic complications. Hormone and Metabolic Research. 2009;41(10):707\u0026ndash;718. doi:10.1055/s-0029-1237374\u003c/li\u003e\n \u003cli\u003eIndia Today. Sudden heart attack deaths increased by 12% in 2022: Government data. [Internet]. Available from: https://www.indiatoday.in/health/story/sudden-heart-attack-deaths-increased-by-12-in-2022-government-data-2471760-2023-12-04\u003c/li\u003e\n \u003cli\u003eMath SB, Srinivasaraju R. Indian Psychiatric epidemiological studies: Learning from the past. Indian J Psychiatry. 2010;52(Suppl 1)\u003c/li\u003e\n \u003cli\u003eRising Kashmir. Rise of Heart Attacks in Young Adults. [Internet]. Available from: https://risingkashmir.com/home/news_description/370877/Rise-of-Heart-Attacks-in-Young-Adults\u003c/li\u003e\n \u003cli\u003eKumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clinic Proceedings. 2009;84(10):917\u0026ndash;938. doi:10.4065/84.10.917\u003c/li\u003e\n \u003cli\u003eSharma R. Revised Kuppuswamy\u0026apos;s Socioeconomic Status Scale: Explained and Updated. Indian Pediatr. 2017;54(10):867-70.\u003c/li\u003e\n \u003cli\u003eMINI International Neuropsychiatric Interview (MINI) 7.0.2. [Internet]. Available from: https://harmresearch.org/product/mini-international-neuropsychiatric-interview-mini-7-0-2/\u003c/li\u003e\n \u003cli\u003eWeathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. The Life Events Checklist for DSM-5 (LEC-5). Instrument available from the National Center for PTSD at www.ptsd.va.gov\u003c/li\u003e\n \u003cli\u003eIBM Corp. IBM SPSS statistics for Windows. Armonk: IBM Corp; 2012.\u003c/li\u003e\n \u003cli\u003eBrown GW, Sklair F, Harris TO, Birley JL. Life events and psychiatric disorders. Psychol Med. 1973;3:74-78.\u003c/li\u003e\n \u003cli\u003eXavier D et al; CREATE registry investigators. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. 2008 Apr\u003c/li\u003e\n \u003cli\u003evan Zon SKR, Reijneveld SA, Mendes de Leon CF, B\u0026uuml;ltmann U. The impact of low education and poor health on unemployment varies by work life stage. International Journal of Public Health. 2017;62(9):997\u0026ndash;1006. doi:10.1007/s00038-017-0972-7\u003c/li\u003e\n \u003cli\u003eAlgorani EB, Gupta V. Coping Mechanisms. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559031/\u003c/li\u003e\n \u003cli\u003eRafanelli C, Roncuzzi R, Milaneschi Y, Tomba E, Colistro MC, Pancaldi LG, Di Pasquale G. Stressful life events, depression and demoralization as risk factors for acute coronary heart disease. Psychother Psychosom. 2005;74(3):179-84.\u003c/li\u003e\n \u003cli\u003eRoohafza H, Talaei M, Sadeghi M, Mackie M, Sarafzadegan N. Association between acute and chronic life events on acute coronary syndrome: a case-control study. The Journal of Cardiovascular Nursing. 2010;25(5)\u0026ndash;E7. doi:10.1097/JCN.0b013e3181d81799\u003c/li\u003e\n \u003cli\u003eSher LD, Geddie H, Olivier L, Cairns M, Truter N, et al. Chronic stress and endothelial dysfunction: mechanisms, experimental challenges, and the way ahead. American Journal of Physiology-Heart and Circulatory Physiology. Advance online publication. doi:10.1152/ajpheart.00244.2020\u003c/li\u003e\n \u003cli\u003eSatyjeet F, Naz S, Kumar V, Aung NH, Bansari K, Irfan S, Rizwan A. Psychological Stress as a Risk Factor for Cardiovascular Disease: A Case-Control Study. Cureus. 2020;12(10) doi:10.7759/cureus.10757\u003c/li\u003e\n \u003cli\u003eMargoob MA. One-year longitudinal study of snow storm disaster survivors in Kashmir. JK-Practitioner. 2006;13(Suppl.1)\u003c/li\u003e\n \u003cli\u003eWikipedia contributors. 2014 India\u0026ndash;Pakistan floods. Wikipedia, The Free Encyclopedia. May 25, 2024. Available from: https://en.wikipedia.org/wiki/2014_India%E2%80%93Pakistan_floods\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"31\"\u003e\n \u003cli\u003eLin LY, Wu CC, Liu YB, Ho YL, Liau CS, Lee YT. Derangement of heart rate variability during a catastrophic earthquake: a possible mechanism for increased heart attacks. Pacing and Clinical Electrophysiology. 2001;24(11):1596-1601.\u003c/li\u003e\n \u003cli\u003eSatoh M, Kikuya M, Ohkubo T, Imai Y. Acute and subacute effects of the Great East Japan earthquake on home blood pressure values. Hypertension. 2011;58: e193-e194.\u003c/li\u003e\n \u003cli\u003eLi Y, Wang L, Yu L, et al. Long-term effects of earthquake experience of young persons on cardiovascular disease risk factors. Arch Med Sci: AMS. 2017;13:75-81.\u003c/li\u003e\n \u003cli\u003eSayeed K. Kashmir turned into an open-air prison. Jacobin. 2019 Sept.\u003c/li\u003e\n \u003cli\u003eWallen J. Young boys tortured in Kashmir clampdown as new figures show 13,000 teenagers arrested. The Telegraph. 2019 Sept 25.\u003c/li\u003e\n \u003cli\u003eHousen T, Lenglet A, Shah S, et al. Trauma in the Kashmir Valley and the mediating effect of stressors of daily life on symptoms of posttraumatic stress disorder, depression and anxiety. Confl Health. 2019;13:58. doi:10.1186/s13031-019-0245-6\u003c/li\u003e\n \u003cli\u003eLi J, Precht DH, Mortensen PB, Olsen J. Mortality in parents after death of a child in Denmark: a nationwide follow-up study. Lancet. 2003;361(9355):363\u0026ndash;7.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable I:\u003c/strong\u003e \u003cstrong\u003eSocio-demographic characteristics of the sample\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003csup\u003e2\u003c/sup\u003e/T-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eMean Age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e56.55\u0026plusmn;13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e55.04\u0026plusmn;12.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e112 (74.6)\u003c/p\u003e\n \u003cp\u003e38 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e112 (74.6)\u003c/p\u003e\n \u003cp\u003e38 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.00 (1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003eWidowed/ Separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e07 (4.6)\u003c/p\u003e\n \u003cp\u003e120 (80.0)\u003c/p\u003e\n \u003cp\u003e23 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e07 (4.67)\u003c/p\u003e\n \u003cp\u003e125 (83.3)\u003c/p\u003e\n \u003cp\u003e18 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e0.72 (0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e96 (64.0)\u003c/p\u003e\n \u003cp\u003e54 (36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e108 (72.0)\u003c/p\u003e\n \u003cp\u003e42 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e2.21 (0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003cp\u003eLiterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e51 (34.0)\u003c/p\u003e\n \u003cp\u003e99 (66.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e42 (28.0)\u003c/p\u003e\n \u003cp\u003e108(72.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e10.39 (0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment Status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003cp\u003eSelf-employed\u003c/p\u003e\n \u003cp\u003eEmployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e27 (18.0)\u003c/p\u003e\n \u003cp\u003e88 (58.7)\u003c/p\u003e\n \u003cp\u003e35 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e22 (14.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;96 (64.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;32 (21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.56 (0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocio-economic Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003cp\u003eUpper middle\u003c/p\u003e\n \u003cp\u003eLower middle\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUpper lower\u003c/p\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e19 (12.7)\u003c/p\u003e\n \u003cp\u003e20 (13.3)\u003c/p\u003e\n \u003cp\u003e54 (36.0)\u003c/p\u003e\n \u003cp\u003e49 (32.7)\u003c/p\u003e\n \u003cp\u003e08 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e17 (11.3)\u003c/p\u003e\n \u003cp\u003e24 (16.0)\u003c/p\u003e\n \u003cp\u003e57 (38.0)\u003c/p\u003e\n \u003cp\u003e45 (30.0)\u003c/p\u003e\n \u003cp\u003e07 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e0.79 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eNuclear\u003c/p\u003e\n \u003cp\u003eJoint\u003c/p\u003e\n \u003cp\u003eExtended\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e70 (46.7)\u003c/p\u003e\n \u003cp\u003e30 (20.0)\u003c/p\u003e\n \u003cp\u003e50 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e66 (44.0)\u003c/p\u003e\n \u003cp\u003e28 (28.7)\u003c/p\u003e\n \u003cp\u003e56 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e0.53 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eSmokers\u003c/p\u003e\n \u003cp\u003eNon-smokers\u003c/p\u003e\n \u003cp\u003eEx-smokers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e42 (28.0)\u003c/p\u003e\n \u003cp\u003e99 (66.0)\u003c/p\u003e\n \u003cp\u003e09 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e57 (38.0)\u003c/p\u003e\n \u003cp\u003e90 (60.0)\u003c/p\u003e\n \u003cp\u003e03 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.7 (0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical Illness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e134 (89.0)\u003c/p\u003e\n \u003cp\u003e16 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e103 (68.7)\u003c/p\u003e\n \u003cp\u003e47 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18.1 (0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupational status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003cp\u003eUnskilled work\u003c/p\u003e\n \u003cp\u003eSkilled\u003c/p\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e01 (0.7)\u003c/p\u003e\n \u003cp\u003e26 (17.3)\u003c/p\u003e\n \u003cp\u003e26 (17.3)\u003c/p\u003e\n \u003cp\u003e79 (52.6)\u003c/p\u003e\n \u003cp\u003e18 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e01 (0.7)\u003c/p\u003e\n \u003cp\u003e21 (14.0)\u003c/p\u003e\n \u003cp\u003e28 (18.7)\u003c/p\u003e\n \u003cp\u003e82 (54.6)\u003c/p\u003e\n \u003cp\u003e18 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.96 ( 0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable II:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eClinical Characteristics of the sample\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5008%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003csup\u003e2\u003c/sup\u003e (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical Illness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eHypertension only\u003c/p\u003e\n \u003cp\u003eT2DM only\u003c/p\u003e\n \u003cp\u003eSmoking only\u003c/p\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e16 (10. 67)\u003c/p\u003e\n \u003cp\u003e20 (13.33 )\u003c/p\u003e\n \u003cp\u003e04 (2.67)\u003c/p\u003e\n \u003cp\u003e42 (28.00)\u003c/p\u003e\n \u003cp\u003e68 (45.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e47 (31.33)\u003c/p\u003e\n \u003cp\u003e22 (14.67) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e03 (2.0)\u003c/p\u003e\n \u003cp\u003e57(38.00)\u003c/p\u003e\n \u003cp\u003e21(14.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5008%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42.84 (\u0026lt;0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac Diagnoses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003eUnstable angina\u003c/p\u003e\n \u003cp\u003eNSTEMI\u003c/p\u003e\n \u003cp\u003eIWMI\u003c/p\u003e\n \u003cp\u003eAWMI\u003c/p\u003e\n \u003cp\u003eALMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e07 (4.7)\u003c/p\u003e\n \u003cp\u003e33 (22.0)\u003c/p\u003e\n \u003cp\u003e66 (44.0)\u003c/p\u003e\n \u003cp\u003e34 (22.7)\u003c/p\u003e\n \u003cp\u003e10 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e__\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5008%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e__\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychiatric Diagnoses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e65 (43.3)\u003c/p\u003e\n \u003cp\u003e85 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e114 (76.0)\u003c/p\u003e\n \u003cp\u003e36 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5008%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.25 (\u0026lt;0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily History of Psychiatric illness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003ePresent\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e86 (57.4)\u003c/p\u003e\n \u003cp\u003e64 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8748%;\"\u003e\n \u003cp\u003e77 (51.3)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e73 (48.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5008%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.85 (0.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable III:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Number of SLE\u0026rsquo;s among cases and controls\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"650\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdentity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf (P-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003eCases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e09\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.07\u0026plusmn; 2.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 109px;\"\u003e\n \u003cp\u003e3.171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.551\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e298 (0.002)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003eControls\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e08\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.35 \u0026plusmn;1.88\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable IV:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Events of exposure (Happened to me and Witnessed by me only)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8464%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of reported events\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4357%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdentity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.1599%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%age)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4953%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted Residual\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.0627%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8464%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4357%;\"\u003e\n \u003cp\u003eCases\u003c/p\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.1599%;\"\u003e\n \u003cp\u003e04 (2.67)\u003c/p\u003e\n \u003cp\u003e00 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4953%;\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003cp\u003e-2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.0627%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8464%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4357%;\"\u003e\n \u003cp\u003eCases\u003c/p\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.1599%;\"\u003e\n \u003cp\u003e02 (1.33)\u003c/p\u003e\n \u003cp\u003e01 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4953%;\"\u003e\n \u003cp\u003e2.74\u003c/p\u003e\n \u003cp\u003e-2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.0627%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8464%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4357%;\"\u003e\n \u003cp\u003eCases\u003c/p\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.1599%;\"\u003e\n \u003cp\u003e09 (6.0)\u003c/p\u003e\n \u003cp\u003e04 (2.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4953%;\"\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003cp\u003e-3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.0627%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8464%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4357%;\"\u003e\n \u003cp\u003eCases\u003c/p\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.1599%;\"\u003e\n \u003cp\u003e17 (11.3)\u003c/p\u003e\n \u003cp\u003e12 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4953%;\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003cp\u003e-1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.0627%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8464%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4357%;\"\u003e\n \u003cp\u003eCases\u003c/p\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.1599%;\"\u003e\n \u003cp\u003e26 (17.3)\u003c/p\u003e\n \u003cp\u003e09 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4953%;\"\u003e\n \u003cp\u003e3.46\u003c/p\u003e\n \u003cp\u003e-3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.0627%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable V:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Pattern of exposure of various events\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"716\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;No. (%age)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%age)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Z scores)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Z scores)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCochran-Armitage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;trend test value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNatural Disaster\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDoesn\u0026rsquo;t apply\u003c/p\u003e\n \u003cp\u003eLearned about it\u003c/p\u003e\n \u003cp\u003eWitnessed\u003c/p\u003e\n \u003cp\u003eHappened to me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e01 (0.67)\u003c/p\u003e\n \u003cp\u003e25 (16.67)\u003c/p\u003e\n \u003cp\u003e32 (21.33)\u003c/p\u003e\n \u003cp\u003e92 (61.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e03 (2.00)\u003c/p\u003e\n \u003cp\u003e70 (46.67)\u003c/p\u003e\n \u003cp\u003e22 (14.67)\u003c/p\u003e\n \u003cp\u003e55 (36.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.01\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e5.59\u003c/p\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003cp\u003e4.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003cp\u003e5.59\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.50\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e4.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e33.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFire \u0026nbsp;Explosion\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDoesn\u0026rsquo;t apply\u003c/p\u003e\n \u003cp\u003eLearned about it\u003c/p\u003e\n \u003cp\u003eWitnessed\u003c/p\u003e\n \u003cp\u003eHappened to me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20\u0026nbsp;(13.33)\u003c/p\u003e\n \u003cp\u003e49\u0026nbsp;(32.7)\u003c/p\u003e\n \u003cp\u003e66\u0026nbsp;(44.0)\u003c/p\u003e\n \u003cp\u003e15\u0026nbsp;(10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62\u0026nbsp;(41.33)\u003c/p\u003e\n \u003cp\u003e35\u0026nbsp;(23.3)\u003c/p\u003e\n \u003cp\u003e46\u0026nbsp;(30.7)\u003c/p\u003e\n \u003cp\u003e07\u0026nbsp;(4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e5.44\u003c/p\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003cp\u003e1.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.44\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.80\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e2.39\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransportation Accident\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDoesn\u0026rsquo;t apply\u003c/p\u003e\n \u003cp\u003eLearned about it\u003c/p\u003e\n \u003cp\u003eWitnessed\u003c/p\u003e\n \u003cp\u003eHappened to me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14\u0026nbsp;(9.33)\u003c/p\u003e\n \u003cp\u003e75\u0026nbsp;(50.00)\u003c/p\u003e\n \u003cp\u003e44\u0026nbsp;(29.33)\u003c/p\u003e\n \u003cp\u003e17\u0026nbsp;(11.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39\u0026nbsp;(26.00)\u003c/p\u003e\n \u003cp\u003e65\u0026nbsp;(43.33)\u003c/p\u003e\n \u003cp\u003e35\u0026nbsp;(23.33)\u003c/p\u003e\n \u003cp\u003e11\u0026nbsp;(7.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e3.78\u003c/p\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.78\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.16\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.18\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14.8178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSerious accident at work\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDoesn\u0026rsquo;t apply\u003c/p\u003e\n \u003cp\u003eLearned about it\u003c/p\u003e\n \u003cp\u003eWitnessed\u003c/p\u003e\n \u003cp\u003eHappened to me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e76\u0026nbsp;(50.67)\u003c/p\u003e\n \u003cp\u003e47\u0026nbsp;(31.33)\u003c/p\u003e\n \u003cp\u003e18\u0026nbsp;(12.00)\u003c/p\u003e\n \u003cp\u003e09\u0026nbsp;(6.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e99\u0026nbsp;(66.00)\u003c/p\u003e\n \u003cp\u003e37\u0026nbsp;(22.67)\u003c/p\u003e\n \u003cp\u003e13\u0026nbsp;(8.67)\u003c/p\u003e\n \u003cp\u003e04\u0026nbsp;(2.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e2.69\u003c/p\u003e\n \u003cp\u003e1.69\u003c/p\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.69\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.69\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e0.95\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.838\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssault with a weapon\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDoesn\u0026rsquo;t apply\u003c/p\u003e\n \u003cp\u003eLearned about it\u003c/p\u003e\n \u003cp\u003eWitnessed\u003c/p\u003e\n \u003cp\u003eHappened to me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39\u0026nbsp;(26.0)\u003c/p\u003e\n \u003cp\u003e78\u0026nbsp;(52.0)\u003c/p\u003e\n \u003cp\u003e24\u0026nbsp;(16.0)\u003c/p\u003e\n \u003cp\u003e09\u0026nbsp;(6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62\u0026nbsp;(41.3)\u003c/p\u003e\n \u003cp\u003e63\u0026nbsp;(42.0)\u003c/p\u003e\n \u003cp\u003e23\u0026nbsp;(15.3)\u003c/p\u003e\n \u003cp\u003e02\u0026nbsp;(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e2.81\u003c/p\u003e\n \u003cp\u003e1.74\u003c/p\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003cp\u003e2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.81\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e1.74\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e0.16\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaptivity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDoesn\u0026rsquo;t apply\u003c/p\u003e\n \u003cp\u003eLearned about it\u003c/p\u003e\n \u003cp\u003eWitnessed\u003c/p\u003e\n \u003cp\u003eHappened to me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30\u0026nbsp;(20.00)\u003c/p\u003e\n \u003cp\u003e87\u0026nbsp;(58.00)\u003c/p\u003e\n \u003cp\u003e26\u0026nbsp;(17.33)\u003c/p\u003e\n \u003cp\u003e07\u0026nbsp;(4.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e56\u0026nbsp;(37.33)\u003c/p\u003e\n \u003cp\u003e69\u0026nbsp;(46.00)\u003c/p\u003e\n \u003cp\u003e21\u0026nbsp;(14.00)\u003c/p\u003e\n \u003cp\u003e04\u0026nbsp;(2.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e3.32\u003c/p\u003e\n \u003cp\u003e2.08\u003c/p\u003e\n \u003cp\u003e0. 79\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.92\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3. 32\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e2.08\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e0.79\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6862%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLife threatening Illness\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDoesn\u0026rsquo;t apply\u003c/p\u003e\n \u003cp\u003eLearned about it\u003c/p\u003e\n \u003cp\u003eWitnessed\u003c/p\u003e\n \u003cp\u003eHappened to me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5049%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (16.0)\u003c/p\u003e\n \u003cp\u003e25 (16.7)\u003c/p\u003e\n \u003cp\u003e88 (58.7)\u003c/p\u003e\n \u003cp\u003e13 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (16.0)\u003c/p\u003e\n \u003cp\u003e29 (19.3)\u003c/p\u003e\n \u003cp\u003e81 (54.0)\u003c/p\u003e\n \u003cp\u003e16 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1.60\u003c/p\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003cp\u003e-0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.855%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-1.60\u003c/p\u003e\n \u003cp\u003e-0.25\u003c/p\u003e\n \u003cp\u003e-1.81\u003c/p\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2497%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5997%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.826\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Stressful life events, Acute Coronary Syndrome, Case-Control","lastPublishedDoi":"10.21203/rs.3.rs-4941610/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4941610/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThere is a considerable evidence in the literature highlighting the impact of psychological factors on the development of coronary heart disease. In India, there's a rising incidence of traumatic life events alongside coronary heart disease, yet the connection between them remains relatively understudied. Therefore, this study aims to investigate the occurrence of stressful life events among patients experiencing their first episode of acute coronary syndrome (ACS) and to compare this with controls.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe mean number of stressful life events (SLEs) observed was \u003cb\u003e5.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/b\u003e in cases and \u003cb\u003e4.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/b\u003e in controls, with a p-value of \u0026lt;\u0026thinsp;0.05. The median number of SLEs in cases was nine, compared to eight in controls. Additionally, cases experienced a higher number of SLEs compared to controls with adjusted Z scores of \u003cb\u003e2.01\u003c/b\u003e for 9 events, \u003cb\u003e2.74\u003c/b\u003e for 8 events and \u003cb\u003e3.46\u003c/b\u003e for five events with p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01 for all. Significant differences for various types of SLEs were observed between cases and controls.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe number for SLEs was significantly higher in cases than in controls. There is a need for further research to ascertain and quantify the role of stressful events and risk of a cardiac event.\u003c/p\u003e","manuscriptTitle":"A study of stressful life events in patients with first episode acute coronary syndrome (ACS) - A hospital based case control study Running Title: Stressful Life Events in First Episode Acute Coronary Syndrome Patients: A Case-Control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-26 11:28:00","doi":"10.21203/rs.3.rs-4941610/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-10T07:35:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-08T11:09:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80866890555920310273692988484773432175","date":"2024-09-08T10:16:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-04T17:41:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196973754274943940552227743213985995725","date":"2024-08-28T08:47:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-28T08:42:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-28T05:20:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-28T05:20:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Middle East Current Psychiatry","date":"2024-08-20T03:01:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9b199508-6e0f-4947-a6d8-17092da2dec3","owner":[],"postedDate":"September 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:06:41+00:00","versionOfRecord":{"articleIdentity":"rs-4941610","link":"https://doi.org/10.1186/s43045-024-00491-w","journal":{"identity":"middle-east-current-psychiatry","isVorOnly":false,"title":"Middle East Current Psychiatry"},"publishedOn":"2024-12-17 15:57:22","publishedOnDateReadable":"December 17th, 2024"},"versionCreatedAt":"2024-09-26 11:28:00","video":"","vorDoi":"10.1186/s43045-024-00491-w","vorDoiUrl":"https://doi.org/10.1186/s43045-024-00491-w","workflowStages":[]},"version":"v1","identity":"rs-4941610","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4941610","identity":"rs-4941610","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}