Outcomes, statistical models and confounders such as biological and behavioural risk factors were also heterogeneous. Thus, a meta-analysis was not conducted. Findings The presented systematic review affirms the first GSK872 research question, since the collected studies revealed moderate evidence that stress at work is related to cardiovascular morbidity and mortality. The strength of association depended on the stress model employed and the population or subgroups examined. All studies based on the effort–reward imbalance model, and about half of the studies with the job strain model revealed

an impact Torin 1 manufacturer of work stress on cardiovascular disease. So far, the ERI model seems to be a more consistent predictor of cardiovascular diseases. However, the

ERI approach was used in only three studies. Thus, the answer to the question which stress model has the strongest evidence for an association with cardiovascular diseases is not unambiguous. With one exception (Lee et al. 2002), all risk estimates showed a positive association between psychosocial stress at the workplace and cardiovascular disease. However, statistically significant results were described for only 13 CYC202 out of the 20 cohorts investigated (Tables 1, 2, 3). Some issues may explain the non-significant results. Most of the included studies assessed job strain at one point in time only. Three analyses (Chandola et al. 2005, 2008; Markovitz et al. 2004) that measured either temporal changes in job stress or cumulative stress reported statistically significant associations with disease. However, more studies with sophisticated assessment of the development of job stress over time and its impact on health are desirable. Another aspect is the long follow-up duration in some of the studies. As a consequence, information bias might be introduced unless job strain is stable for a long time and workers do not change and leave their job or experience times of unemployment. Paclitaxel Job change due to stress will underestimate the effect, in case vulnerable individuals may have already left work. In the Whitehall

study, the effect of effort–reward imbalance on cardiovascular health indicated higher risk estimates after an average follow-up time of 5.3 years (Bosma et al. 1998) than after a follow-up time of 11 years (Kuper et al. 2002). However, the outcome in the two analyses differed. Bosma et al. (1998) considered cardiovascular morbidity and mortality and Kuper et al. (2002) only cardiovascular morbidity. The possible conclusion of an underestimation of true effect estimates in long-term studies needs further investigations. In some studies included in our review, only few events occurred. Thus, the statistical power was probably not strong enough to observe significant results (e.g. Tsutsumi et al. 2006).