The influence of workplace stressors on the risk of cardiovascular diseases among healthcare providers: a systematic review

Background: Cardiovascular diseases (CVDs) are a leading cause of death worldwide. Healthcare workers are at increased risk due to workplace stressors such as long hours, shift work, and high job demands, which may worsen both modifiable and non-modifiable CVD risk factors. This systematic review examines the impact of these workplace stressors on the risk for CVD among healthcare providers.

Methods: We conducted a systematic review of observational studies from inception to January 2024, following PRISMA guidelines. We searched databases including PubMed, Embase, Scopus, Web of Science, and PsycINFO using keywords related to workplace stressors and CVDs among healthcare professionals. The quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS).

Results: Our review included 31 observational studies (15 cohort studies, 13 cross-sectional studies, and three case-control studies) with a total of 323,978 participants from 17 countries. The key stressors identified were long working hours, night shifts, and high job strain. Most studies reported significant associations between these stressors and increased risks of hypertension, ischemic heart disease, and cardiometabolic disorders. The quality of the studies ranged from fair to good, indicating a low risk of bias.

Conclusion: Growing evidence suggests a strong correlation between workplace stressors and an increased risk of cardiovascular disease among healthcare workers. This leads to negative consequences that affect their performance and may extend to the quality of their patients’ care. Addressing these stressors through targeted interventions is crucial for protecting their health and improving patient care outcomes.

1 Introduction

The field of occupational health epidemiology began to investigate psychosocial work exposures in the 1990s (1). Since then, the body of literature has expanded significantly, making a synthesis of the existing research both timely and necessary (2). Healthcare professionals (HCPs) represent a high-risk occupational group due to the nature of their duties, which involve exposure to hazardous environments, rotating shifts, and work-related stress (3).

Work-related stress occurs when HCPs face job demands and pressures that surpass their abilities, leading to challenges in their performance (4). The stress becomes even more pronounced for HCPs when they sense a lack of support from their supervisors and colleagues, coupled with minimal control over their work processes (5). Moreover, various workplace situations can contribute to this stress, including the nature of the job, excessive workload, long working hours, limited opportunities for advancement, unclear or unfair performance reviews, poor communication, weak leadership, strained interpersonal relationships, and an insufficient work-life balance (6, 7).

The complexity between work-related stress and various health outcomes pose significant challenges for synthesizing research (8). Specifically, a substantial portion of the literature on psychosocial work exposures has focused on their associations with mental disorders and cardiovascular diseases (9–12). Cardiovascular diseases are the foremost cause of death worldwide. In 2019, they accounted for an estimated 17.9 million deaths—32% of all global deaths—with heart attacks and strokes responsible for 85% of these fatalities (13). Among HCPs, CVDs pose a significant health burden globally, accounting for approximately 50% of all deaths and 25% of work-related disabilities (14). A survey involving 2,500 physicians found significantly higher rates of cardiovascular disease risk factors, including stress, compared to a comparable sample from the general population (15).

Stress may promote cardiovascular disease by contributing to the development of metabolic syndrome—a cluster of at least three risk factors, including central obesity, hypertension, hyperglycemia, elevated triglycerides, and low HDL cholesterol (16). Metabolic abnormalities, in turn, accelerate atherosclerosis, characterized by the thickening of the arterial wall and the formation of plaques. Carotid intima–media thickness (IMT) serves as a noninvasive marker of early atherosclerotic change and can be measured using external ultrasound in extensive cohort studies (16). In one cross-sectional analysis of young adults, high job strain was linked to greater carotid IMT in men. However, this association was not observed in women, suggesting that occupational stress may differentially influence subclinical atherosclerosis by sex (17). Several lines of evidence support a causal relationship between workplace stressors and cardiovascular disease. First, the temporal sequence is precise, as exposure to work-related stress precedes the development of disease. Second, consistency across multiple studies reinforces this link, while biological plausibility is established by well-understood mechanisms through which stress can harm the cardiovascular system. The association also shows specificity, being most evident in particular heart and vascular conditions. Importantly, reversibility has been demonstrated: interventions that reduce job stress are associated with lower cardiovascular risk. Finally, the strength of the association—often with relative risks exceeding 2.0 for stressed versus unstressed workers—underscores the robustness of this effect (15, 16).

Several systematic reviews and meta-analyses revealed a significant association between work stress and the risk of cardiovascular disease (12, 18, 19). However, there is a scarcity of literature that has studied this association among HCPs. Therefore, this systematic review aimed to address the association between work-related stress and the risk of cardiovascular disease among HCPs.

2 Methods

2.1 Study design

This systematic review aims to investigate the impact of workplace stressors on the risk of cardiovascular diseases among healthcare providers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines were adhered to throughout the study selection and data synthesis processes (11).

2.2 Search strategy

A comprehensive search strategy was developed using relevant keywords and Medical Subject Headings (MeSH) terms. Databases including PubMed, Embase, Scopus, Web of Science, and PsycINFO were systematically searched from inception to January 2024. Additionally, we hand searched the citation lists of the included studies and similar reviews for potentially eligible studies. The search strategy encompassed terms related to workplace stressors and cardiovascular diseases (among healthcare professionals consists of the following: (“Job Strain” OR “Job stress” OR “Work Strain” OR “Workplace Stress” OR “Occupational Stress” OR “Job Demand-Control” OR “Karasek”) AND (“Healthcare professionals” OR “Healthcare Workers” OR “Healthcare practitioners” OR “Physician” OR “Surgeons” OR “Nurses” OR “Medical Staff” OR “Pharmacists” OR “Medical assistants” OR “Healthcare administrators “OR “Health information technologists” OR “Dietitians” OR “Nutritionists” OR “Health educators” OR “Physical therapists” OR “Psychologists” OR “Paramedics” OR “Respiratory therapists” OR “Dentists”) AND (“Cardiovascular disease” OR “Cardiovascular event” OR “Coronary heart disease” OR “Acute Coronary Syndrome” OR “Myocardial Infarction” OR “Myocardial ischemia” OR “Heart Attack” OR “Angina” OR “Stroke” OR “Arrhythmias” OR “Ventricular Tachycardia” OR “Ventricular Fibrillation” OR “Acute Heart Failure” OR “Acute Aortic Dissection”). The search was limited to articles published in English to ensure relevance and comprehensiveness.

2.3 Study selection

The systematic review included observational studies with healthcare professionals as the population and workplace stressors such as job strain, long working hours, shift work, lack of social support, and other relevant factors as the exposure. The outcome evaluated was the risk of cardiovascular diseases, including angina, acute myocardial infarction, transient ischemic attack, and stroke. Studies focusing solely on burnout or job insecurity, including participants with baseline cardiovascular diseases, or not in the English language, were excluded from the review. Two independent reviewers screened the titles and abstracts of identified articles for eligibility based on predefined inclusion and exclusion criteria; a third reviewer was consulted to resolve any conflicts. Furthermore, full-text articles from potentially relevant studies were obtained and subsequently evaluated for eligibility by two independent reviewers. Any disagreement among the reviewers were resolved through discussion or by seeking input from a third independent author.

2.4 Data extraction and synthesis

Two authors independently extracted data using a standardized form. Extracted variables included: first author, year of publication, country, study design, sample size, population characteristics, type of workplace stressor, cardiovascular outcomes assessed, and key findings. Any disagreements were resolved either by reaching a consensus or by consulting a third reviewer. A narrative synthesis approach was employed to summarize the findings of included studies, considering the heterogeneity of study designs and outcomes.

2.5 Quality assessment

The quality of included studies was independently assessed by two reviewers using the Newcastle-Ottawa Scale (NOS) for cohort, cross-sectional, and case-control studies. Each study was rated based on selection, comparability, and outcome domains, with results tabulated in Supplementary Table 2. Disagreements were resolved either through consensus among the parties involved or by using a third-party adjudicator.

2.6 Ethics consideration

Ethical approval was not required for this study since it relied on existing literature.

2.7 Reporting

All methods employed in this systematic review, along with the inclusion criteria and the steps taken for data handling, have been thoroughly documented in accordance with PRISMA standards. This includes a detailed description of how studies were selected, the criteria used to evaluate their quality, and the strategies implemented for data extraction and analysis.

2.8 Definition of variables

Workplace Stressors: This includes any of the following exposures:

● Job strain: High psychological demands combined with low control, typically measured using the Job Content Questionnaire (JCQ) or Demand-Control-Support models.

● Long working hours: Defined as working 48 hours or more per week, or 55 hours or more based on WHO criteria.

● Shift work: Refers to non-standard work hours, including rotating shifts, night shifts, and continuous 24-hour shifts.

● Organizational stress: Includes stressors such as lack of managerial support, inadequate staffing or resources, poor communication, or workplace instability.

● Cardiovascular Disease (CVD) outcomes includes hypertension, ischemic heart disease, stroke or transient ischemic attack (TIA), and cardiometabolic syndrome.

● Hypertension (HTN): Identified through clinical diagnosis or based on blood pressure readings from ambulatory blood pressure monitoring (ABPM) or self-report.

● Ischemic Heart Disease (IHD): Includes angina, acute coronary syndrome, and myocardial infarction as confirmed by diagnostic criteria or medical records.

● Stroke or Transient Ischemic Attack (TIA): Reported based on imaging confirmation or physician diagnosis.

● Cardiometabolic risk factors: Includes obesity (defined as BMI ≥30), dyslipidemia, impaired glucose metabolism, and other indicators of metabolic syndrome.

3 Results

3.1 Search and screening

Our search and final screening process identified 31 observational studies, comprising 15 cohort studies, 13 cross-sectional studies, and three case-control studies, as illustrated in the PRISMA flow diagram (Figure 1). These studies encompassed a total of 323,978 healthcare workers across 17 countries, including the United States, Denmark, Japan, Canada, Serbia, Egypt, the Netherlands, Iran, Italy, Sweden, Taiwan, France, Turkey, India, Brazil, Norway, and Switzerland. The United States contributed the most significant number of studies (n = 6), followed by Brazil (n = 4) and Taiwan (n = 3).

Figure 1

Figure 1. PRISMA flow diagram of the study selection process.

This global distribution underscores both the widespread prevalence of workplace stressors in healthcare settings and the growing research interest in their cardiovascular consequences (Table 1).

Table 1

Table 1. Baseline data of included studies.

3.2 Characteristics of included studies

The included studies varied significantly in design, population demographics, and methodological rigor. Participants primarily consisted of healthcare professionals such as physicians and nurses, nurse assistants, medical technicians, physiotherapists, dentists, social workers, and administrative staff. The most represented medical specialties were emergency physicians, general practitioners, surgeons, and cardiologists.

The age distribution among the study populations varied considerably, reflecting a broad spectrum of healthcare experience levels. Some studies focused on younger cohorts in their twenties, such as those by Adams et al. (12), Fialho et al. (15), Refaat et al. (17), and Ramadan et al. (23). Others included older individuals in their sixties, as seen in Allesøe et al. (18), Landsbergis et al. (27), and Chou et al. (28). The age ranges were extensive; for example, Ezber et al. (29) included participants aged 20–59 years, while Landsbergis et al. (27) had an age range of 23–76 years. Riese et al. (30) studied participants aged 22–55 years, and Vetter et al. (19) included individuals aged 30–55 years (Table 1).

Both genders (male and female participants) were represented across the included studies. Ten studies—such as those by Kubo et al. (16), Lajoie et al. (31), Nedić et al. (22), Ramin et al. (32), and Brown et al. (33)—investigated work strain exclusively among female participants. In contrast, only two studies, by Arnetz et al. (21) and von Känel et al. (25), focused solely on male participants. The remaining studies included both genders, providing a more comprehensive understanding of how work stressors affect male and female healthcare professionals differently (Table 1).

The studies investigated various workplace stressors, including job strain (characterized by high demands and low control), long working hours exceeding 48 hours per week, shift work (including night shifts and 24-hour shifts), heavy workload, organizational stress arising from workplace instability, rapid changes, or unhealthy work environments, and burnout—defined as chronic workplace stress resulting in physical and emotional exhaustion (25). The stressors were assessed using standardized questionnaires, including the Job Content Questionnaire (JCQ), Occupational Stress Index (OSI), and Perceived Stress Scale (PSS), as well as through interviews and workplace assessments.

The cardiovascular outcomes measured included hypertension, Ischemic heart diseases (IHDs), stroke, and cardiometabolic risk factors such as elevated lipid profiles, obesity, impaired glucose metabolism, and abnormal body mass index. Additionally, outcomes encompassed heart rate variability and coronary microcirculation. Assessment methods involved clinical measurements, physiological monitoring (e.g., ambulatory blood pressure monitoring, electrocardiography, echocardiography), and self-reported medical histories.

3.3 Follow-up durations

Regarding follow-up durations among the included studies, there were diverse temporal perspectives based on the outcomes and measurement tools. The follow-up periods vary from a span of 24 hours between the pre- and post-intervals, as seen in (12–16), to long-term follow-ups, such as the 10-year follow-up in (17), and even studies that extend over two decades, as illustrated in (18) and (19). This variability underscores the comprehensive exploration of outcomes across various time horizons, thereby enriching the depth and breadth of the synthesized evidence (Table 1).

3.4 Workplace stressors

Physicians are investigated to various forms of occupational stress, and the definition of work stressors differed across the included studies. Day-to-day work stress was the most commonly assessed type of job strain. Studies by Chen et al. (20), Arnetz et al. (21), and Allese et al. (18) reported additional stressors, including heavy workload, work influence, and occupational physical activity. The impact of long working hours on physicians was evaluated by Nedić et al. (22), while Fialho et al. (15) investigated stress associated with 24-hour shifts. Ramadan et al. (23) and Refaat et al. (17) examined the stressful lifestyle of medical residents over a decade, spanning from medical student level to practicing physicians. Stress related to organizational factors was assessed by Jensen et al. (24), and work-related burnout among physicians was explored by von Känel et al. (25). Additionally, Vitale et al. (26) specifically investigated work stress during afternoon shifts (Table 1).

3.5 Association between workplace stressors and cardiovascular outcomes

3.5.1 Hypertension

Ten studies investigated the association between workplace stressors and HTN among healthcare workers, with most reporting a positive correlation. Adams et al. (12) conducted a cross-sectional study of emergency physicians and found that night shifts were associated with increased diastolic blood pressure (12). Similarly, Fialho et al. (15) reported that 24-hour shifts increased the prevalence of abnormal blood pressure readings among emergency medical residents (15). Nedić et al. (22) observed higher rates of hypertension among female physicians associated with long working hours (22). Arnetz et al. (21) identified a strong link between job stress and cardiovascular risk factors, including HTN, in a cross-sectional study (21). Brown et al. (33) found a significant association between job strain, catecholamine release, and elevated blood pressure among female nurses (33). Coelho et al. (36) reported that 20.3% of nurses had HTN, with work stress contributing to elevated blood pressure levels (36). Cash et al. (34) found that 22% of emergency medical services workers had HTN, with perceived stress being a significant predictor (34). Ulguim et al. (35) observed that work stress was associated with high blood pressure among nurses (35). Lajoie et al. (31) found an association between work stress and HTN in female nurses. However, Riese et al. (38), in a cohort study over a three-year follow-up, reported no significant association between high work strain and HTN among young female nurses (38). These findings suggest that specific stressors like night shifts and long working hours may contribute to elevated blood pressure, especially among female healthcare workers, highlighting the need for tailored interventions based on job role and gender (12, 15, 22, 33) (Table 2).

Table 2

Table 2. Summary of included studies.

3.5.2 Ischemic heart disease

Eight studies explored the link between workplace stressors and IHD. Vetter et al. (19), in a 24-year cohort study of female nurses, found that night shift work was associated with a slight increase in coronary heart disease risk over time. Kubo et al. (16) reported that night shift work increased the risk of coronary heart disease during a 10-year follow-up among female nurses (16). Allesøe et al. (18) found that high job strain was significantly associated with IHD among female healthcare workers over two decades (18). Chen et al. (20) observed that high work stress was linked to an increased risk of IHD among healthcare workers over 8 years (20). Jensen et al. (24) discovered that unstable and continuously changing work environments were associated with a higher incidence of IHD compared to stable workplaces over an average follow-up of 5.5 years (24). Refaat et al. (17) found an increased risk of IHD associated with stressful work conditions among medical residents over 10 years (17). Von Känel et al. (25) identified that high job stress was associated with coronary microvascular dysfunction in male physicians (25). Ramadan et al. (23) reported that 60.3% of Egyptian physicians had experienced a heart attack or stroke, with a high prevalence among anesthesiologists and surgeons, attributing this to stressful lifestyles. Notably, several long-term cohort studies provided more substantial evidence of causality, with consistent findings across diverse populations and stressor types. Specifically, among female nurses exposed to prolonged night shifts or high job strain (16, 18, 19) (Table 2).

3.5.3 Cardiovascular risk factors

Seven studies assessed the relationship between workplace stressors and cardiometabolic risk factors. Refaat et al. (17) observed that stressful lifestyles among medical residents were associated with increased obesity and dyslipidemia over a 10-year follow-up (17). Riese et al. (30) found that high job strain was associated with elevated lipid profiles and a BMI reading indicating overweight and obesity among healthcare workers over three years (30). Saberinia et al. (39) reported a significant correlation between work stress and impaired glucose metabolism among nurses in a cross-sectional study (39). Temporelli et al. (37) found that work stress was linked to increased obesity and components of metabolic syndrome among healthcare professionals (37). Ulguim et al. (35) observed that high work stress correlated with adverse cardiometabolic profiles, including elevated cholesterol levels (35). Chou et al. (28) reported an association between work-related stress and overweight or obesity among healthcare workers (28). Fatima et al. (14) found that job stress was linked to elevated blood glucose levels among healthcare staff. Although methodologies and outcomes varied, a consistent trend emerged linking psychosocial stress to adverse metabolic profiles, reinforcing the hypothesis that chronic occupational stress contributes to CVD development via cardiometabolic pathways (17, 30, 39). (Table 2).

3.5.4 Other outcomes

Additional cardiovascular outcomes were examined in several studies. Dutheil et al. (13) found that 24-hour shifts were associated with increased heart rates and reduced heart rate variability among physicians, indicating heightened sympathetic activity (13). Kubo et al. (16) reported that night shift work adversely affected coronary microcirculation among nurses, as assessed by transthoracic Doppler echocardiography (16). Adams et al. (12) observed that night shifts were associated with increased heart rate and blood pressure variability among emergency physicians (Table 2).

3.6 Outcome differences according to the study design

3.6.1 Results from cross-sectional studies

Thirteen cross-sectional studies evaluated various workplace stressors and their association with cardiovascular outcomes among healthcare professionals. The nature of their study design limits their ability to prove causality.

The primary workplace stressors examined were job strain, long working hours, and organizational stress. For instance, Brown et al. (33) and Nedić et al. (22) used standard tools like the Job Content Questionnaire and the Occupational Stress Index to measure job stress and found strong links between it and high blood pressure and a higher risk of CVD (Table 2). Vitale et al. (26) focused on work-related burnout, specifically investigating the impact of afternoon shift work on physician health. Notably, Ramadan et al. (23) found that 60.3% of Egyptian physicians had experienced a heart attack or stroke, with a higher prevalence among anesthesiologists, surgeons, and cardiologists, attributing this to stressful work environments.

3.6.2 Results from cohort studies

The 15 cohort studies included in this review provide more robust evidence regarding the causal relationship between workplace stressors and the development of CVDs. Workplace stressors included long-term exposure to high job demands, extended working hours, night shifts, and organizational factors. Chen et al. (20) and Allesøe et al. (18), for instance, investigated the impact of prolonged work stress on cardiovascular health. Allesøe et al. (18) reported that female healthcare workers exposed to high job strain over a follow-up period exceeding two decades emphasize a significantly increased risk of IHD (Table 2). Vetter et al. (19) demonstrated that night shift work was associated with a gradual increase in CVD risk among female nurses throughout careers. Similarly, Refaat et al. (17) monitored medical residents over 10 years, with a high incidence of HTN and CVD linked to stressful work conditions.

3.7 Quality and risk of bias assessment

The quality assessment of the three case-control studies reveals that Vitale et al. (26) stands out with a Good quality rating, scoring 8 out of 9. This study met all key selection criteria, including an adequate case definition, representativeness of cases, and proper control selection and definition. It also controlled for confounders and adequately assessed outcomes with sufficient follow-up, indicating a well-designed study with minimal risk of bias. In contrast, von Känel et al. (25) earned a Fair rating with five points (stars), falling short in the selection of controls and in assessing outcomes rigorously. While the study controlled for confounders, incomplete reporting on control selection and outcome assessment may introduce potential biases, limiting the generalizability of its findings. Similarly, Nedić (22), also rated Fair, and received six points (stars). Although the study provided an adequate case definition and outcome assessment, it lacked representativeness in case selection and control selection, which poses a moderate risk of bias. Nonetheless, it adequately follows up with participants and offers valuable insights despite these limitations. (Supplementary Table 3). Regarding cross-sectional studies included in this review, Arnetz et al. (21) and Ramadan (23) both received an eight (Good) rating, excelling across key categories, such as representativeness of the sample, sample size, and exposure ascertainment. These studies also controlled for confounding factors and employed appropriate statistical tests, indicating a high level of methodological rigor. Studies like Cash (34), Chou (41), and Riese (30), scoring seven (Good), maintained solid designs but lacked in areas like sample representativeness or handling of non-respondents. Nonetheless, they ensured robust exposure assessments and conducted thorough statistical analyses. However, some studies, such as Coelho (36) and Lajoie (31), were rated Fair with scores of six due to weaknesses in managing non-respondents or comparability between groups. Both Ezber (29) and Temporelli (37) received Poor ratings with scores of four, suffered from significant issues, including inadequate handling of non-respondents, lack of control for confounders, and limited statistical validation. (Supplementary Table 2).

The cohort studies in this review demonstrate varying levels of methodological rigor, as evaluated by the Newcastle-Ottawa Scale (NOS). Chen (20) and Riese (38) both received 8 (Good) scores, indicating a strong design across selection, comparability, and outcome assessment. These studies controlled for confounders effectively, ensured that the outcome of interest was not present at the study’s start, and had adequate follow-up, making them highly reliable in assessing cohort-related outcomes. Allesøe (18), Fatima (14), and Jensen (24) scored seven (Good), showing good representativeness and robust follow-up procedures, though they had minor limitations in their exposure ascertainment or selection of the non-exposed cohort. On the other hand, several studies, such as Adams (12), Fialho (15), and Vetter (19), received Fair scores, ranging from 5 to 6, due to weaker selection processes or failure to adequately demonstrate that the outcome of interest was absent at the study’s initiation. Brown (33) and Dutheil (13), scoring five (Fair), also faced issues in their assessment of confounders and follow-up adequacy, which could compromise the reliability of their result.] (Supplementary Table 1).

4 Discussion

The systematic review identified 31 observational studies comprising 15 cohorts, 13 cross-sectional, and three case-control studies, illustrating diverse 323,978 healthcare workers with different professions across 17 countries, with follow-up durations varying from 24 hours to multi-year spans. Work stressors among healthcare workers were multifaceted, including job strain, long working hours, night shifts, 24-hour shifts, and organizational stress. Studies have evaluated work strain across different medical professions and age cohorts. Both genders were represented in the studies, although some investigations focused exclusively on either males or females. The methodologies used to assess work strain and cardiovascular diseases varied, showcasing a range of approaches from questionnaires to physiological measurements. Baseline risk factors for cardiovascular diseases, such as smoking and hypertension, were reported across multiple studies. The majority of studies found strong associations between job stress and hypertension, ischemic heart diseases, and cardiometabolic status among healthcare workers.

Cardiovascular diseases (CVDs) are the leading cause of death among the whole population in both developed and developing countries. According to the WHO, CVDs were responsible for approximately 17.9 million deaths during 2019 (40). Several factors can precipitate CVDs; modifiable risks include smoking, alcohol, obesity or dyslipidemia, stressful or sedentary lifestyle, while non-modifiable CVD risks include a family history of CVDs, age, and gender (23).

Healthcare workers, besides being liable to both types of CVD risks, are vulnerable to both stressful lifestyles and stressful working strains, making them more liable to develop CVDs. The included studies have found a significant number of physicians, nurses, and other healthcare employees suffering from CVDs or have a great risk of developing coronary heart disease (16, 19, 25).

Various theories have explained the association between job stressors in medical professions and CVDs. Long working hours, night shifts, work influence, and toxic work environments are significant work stressors that have been shown to induce CVDs (18, 20, 21). The high influence of work stressors leads to constant attention, lifestyle disturbances, and psychological stress (36). Chronic psychological workplace stress is positively correlated with ischemic heart disease (41). Also, the lack of sleep during night shifts is significantly correlated with developing CVDs as a result of circadian rhythms desynchronization and blood pressure variations (36).

Medical specialty among physicians is also a risk factor; emergency physicians (EPs) are frequently liable to physiological stress due to their on-calls and long working hours, which may lead to poor cardiac health and CVDs (34). Adams et al. (12) found that EPs had higher blood pressure during night shifts; furthermore, Dutheil et al. (13) found that EPs experienced higher heart rates, especially in 24-hour shifts; these findings may be explained by sleep deprivation and sympathetic activity. Also, Ramadan et al. (23) found that 78.3% of Anesthesiology specialists were correlated with CVD events, followed by surgery residents who exhibited 62.9%. This result is anticipated, as the extended work hours characteristic of select medical specialties are often associated with significant psychological stress for those practitioners, which can lead to a lack of awareness regarding their physical health and, consequently, an increased incidence of cardiovascular diseases among these populations.

The included studies found a strong association between job stress and hypertension, especially during night shifts (12, 21). Which may be linked to catecholamine release (33). Hypertension was common during 24-hour shifts and among female physicians (15, 22).

One important consideration is the significant heterogeneity among the studies included in this systematic review. The variability in study design, population characteristics, and the tools used to measure both workplace stressors and cardiovascular outcomes may have influenced the overall findings. For instance, the differences in defining and assessing job strain, long working hours, and shift work across studies introduce potential biases that could affect the comparability of the results. Similarly, the range of follow-up durations, from short-term assessments over 24 hours to multi-year longitudinal studies, may lead to inconsistent conclusions regarding the long-term cardiovascular effects of workplace stressors. This diversity across the studies makes it challenging to draw definitive conclusions across all studies, and caution is needed when generalizing the findings to broader populations of healthcare workers.

Ischemic heart diseases were also reported widely in the included studies; in a multi-centric cross-sectional study, Ramadan et al. (23) interestingly found that around 60.3% of Egyptian physicians suffer from a heart attack or stroke, and the included specialties were anesthesiologists, ICU, surgery, rheumatology, internal medicine, cardiology, oncology, pediatrics, obstetrics, and gynecology. Night shifts were associated with a higher risk of coronary heart diseases, especially among female nurses (16, 19) and among male physicians (25). Besides other CVD risks, the unstable work environment might be the key responsible factor, as reported by Jensen et al. (24).

While this review notes that some studies did not find a significant association between work strain and CVDs (42–44), other studies have found the contrast (16, 19, 24, 25). It is essential to examine the underlying reasons for these inconsistencies. Differences in study design, population characteristics, and stress measurement methods are likely contributing factors. For example, Riese et al. (30) included young nurses with age ranges from 25 to 50, meaning that the population may not have been exposed to enough chronic work strain. Another explanation proposed by Allesøe et al. (18) is that women in postmenopausal periods are more likely to be affected by work strain due to the lack of protective effects of estrogen. Hence, younger female physicians may be unlikely to be affected. However, this explanation is arguable, as a study by Laflamme et al. (45) found that older women are unlikely to be associated with a positive correlation between work strain and CVDs.

Additionally, the methods used to assess stress—ranging from self-reported questionnaires to physiological measures, such as heart rate variability—vary widely in their sensitivity and precision. Some studies may have used less reliable or validated tools, potentially underestimating the actual impact of work strain. Furthermore, cultural and healthcare system differences in the studied countries may influence job stress levels and the diagnosis and treatment of CVDs, potentially explaining the variability in the results. These factors highlight the need for more standardized methodologies and extended follow-up periods in future research to better understand the relationship between work strain and CVD among healthcare workers.

According to our findings and the literature, physicians and other healthcare workers are at a considerable risk of CVDs. It is essential to recognize that physicians’ health is closely tied to the quality of patient care. The risk of making medical errors is increasing in their practice due to attention failures (20).

Furthermore, physicians are reluctant to seek medical care, especially from their colleagues. They are afraid to feel weak or compromised, so they tend to continue working despite work strain and ignore potential symptoms, which can later impact their health condition and the quality of care they provide to patients.

Several studies included in our review had relatively small sample sizes, which notably limited the statistical power and generalizability of their findings. For instance, Adams et al. (12) conducted a cohort study in the USA involving only 12 emergency physicians (33% female; ages 28–40 years), assessing blood pressure variability and heart rate over 24 hours. Arnetz et al. (21) performed a cross-sectional study in Sweden with 66 male general surgeons and general practitioners (mean age approximately 44–47 years). Brown et al. (33) studied 59 female nurses and nurse’s aides (ages 33.7–37.9 years) in the USA, focusing on blood pressure variability. They noted that 26.1% of the Euro-American participants were smokers and 56.5% consumed alcohol regularly (33). Similarly, Dutheil et al. (13) investigated tachycardia among 17 emergency physicians in France (63% female; mean age 39.1 years), finding that 29% were smokers. Other studies with small samples include Fialho et al. (15) with 61 medical residents in Brazil (53.6% male; mean age 25.4 years), assessing blood pressure variability and reporting a high prevalence of family history of hypertension and lipid disorders (15); Fatima et al. (14) with 50 female nurses in India (mean age 36.7 years), examining blood pressure variability (14); Kubo et al. (16) studying coronary microcirculation in 36 female nurses in Japan (mean age 32 years); Ulguim et al. (35) assessing cardiometabolic status among 45 healthcare workers in Brazil (57.8% female; ages 30–39 years), with 11.1% being smokers (35); and Vitale et al. (26) examining cardiovascular activity in 60 healthcare workers in Italy (40% female; mean age around 41 years), noting that 18% had a family history of cardiovascular diseases (26).

The review also revealed several methodological gaps across studies. Definitions of exposure (e.g., “long working hours”) and outcomes (e.g., “cardiometabolic risk”) were not always consistent. Follow-up durations varied significantly, and not all studies adequately controlled for confounding factors such as age, baseline comorbidities, and lifestyle behaviors.

Moreover, the impact of gender and profession-based differences (e.g., physicians vs. nurses) have not been sufficiently investigated in numerous studies. We suggest that future research should establish standardized definitions, include the analysis of stress biomarkers, and utilize consistent criteria for cardiovascular outcomes. Additionally, there is an urgent need for interventional studies that evaluate the effectiveness of workplace adjustments, such as changes in schedules and the implementation of support systems, in lowering the risk of cardiovascular disease.

5 Conclusion

Emerging evidence demonstrates an association between occupational stress in healthcare professionals and elevated cardiovascular risk. Contributing factors include extended working hours, night and 24-hour shift schedules, high job strain, and adverse workplace environments. These factors have been linked to increased risk of hypertension, ischemic heart disease, and other cardiometabolic disorders. Beyond the direct impact on physical health, these stressors may also compromise clinical performance and patient safety. Targeted interventions and sustained research efforts are critical to mitigate these risks, promote the well-being of healthcare workers, and maintain the quality and resilience of healthcare systems.

6 Limitations and recommendations

Despite the importance of CHDs among healthcare workers, it was inapplicable to pool the studies and perform a meta-analysis due to the majority of the included studies have included mixed samples of healthcare workers from different professions (Physicians, nurses nurse assistants, etc.) and, the measurement tools and questionnaires were different among studies, and the lack of CHDs specifications among studies. Hence, we recommend a future organized study investigating profession-specific studies on physicians, nurses, and medical technicians, with medical specialty subgroup analyses (e.g., emergency medicine, surgery, anesthesiology). Furthermore, we should utilize standardized and validated questionnaires to gauge the impact of job stress on the cardiovascular system. Future research should identify the categories of diseases under study to accurately link workplace stressors to cardiovascular disorders such as hypertension, ischemic heart disease, and arrhythmias. Additionally, we require multicenter, cross-cultural, and longitudinal studies with extended follow-up periods. Longitudinal research can determine how job stressors affect cardiovascular health over time.

Furthermore, future studies should incorporate a comprehensive stressor assessment to ascertain the impact of specific work stressors, such as long hours, night shifts, shift rotations, workload, and organizational challenges, on cardiovascular health. This also involves examining the relationships between psychological stress, burnout, job satisfaction, and work-life balance, and their impact on physical stressors and cardiovascular health, as well as implementing a study comparing stress biomarkers. Additional research on cost-benefit analyses aiming to assess the effectiveness of the possible interventions to reduce work-related stress and prevent CVDs is recommended, targeting the underrepresented healthcare workers, including allied health professionals, support staff, and those in low- and middle-income countries.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.

Author contributions

RA: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing. MA: Methodology, Writing – original draft. SA: Data curation, Writing – original draft. AF: Writing – original draft. SF: Writing – original draft. SA: Writing – original draft. MA: Formal analysis, Methodology, Writing – original draft, Writing – review & editing. MA: Supervision, Writing – original draft, Writing – review & editing. IK: Investigation, Supervision, Validation, Writing – original draft. HA: Formal analysis, Methodology, Writing – original draft. KA: Conceptualization, Data curation, Investigation, Project administration, Supervision, Validation, Writing – review & editing.

Author’s note

Protocol registration: The protocol for this review has not been recorded in PROSPERO or any other registries.

Funding

The author(s) declare that no financial support was received for the research, and/or publication of this article.

Acknowledgments

We would like to thank all the investigators who participated in this project from the Saudi Critical Care Pharmacy Research (SCAPE) platform and the Saudi Society for Multidisciplinary Research Development and Education.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2025.1461698/full#supplementary-material

Glossary

ABEP: Associação Brasileira de Empresas de Pesquisa

AMI: Acute Myocardial Infarction

BMI: Body Mass Index

BP: Blood Pressure

CHD: Coronary Heart Disease

CI: Confidence Interval

CVD: Cardiovascular Disease

CVDs: Cardiovascular Diseases

DCSQ: Demand-Control-Support Questionnaire

DM: Diabetes Mellitus

ECG: Electrocardiogram

EMS: Emergency Medical Services

EP: Emergency Physician(s)

GP: General Practitioner(s)

HCWs: Healthcare Workers

HR: Heart Rate

HTN: Hypertension

ICU: Intensive Care Unit

IHD: Ischemic Heart Disease

IHDs: Ischemic Heart Diseases

JCQ: Job Content Questionnaire

JSS: Job Strain Scale

MeSH: Medical Subject Headings

MetS: Metabolic Syndrome

NHS: National Health Service

NHS2: Nurses’Health Study II

NOS: Newcastle–Ottawa Scale

OSI: Occupational Stress Index

PICO: Population, Intervention, Comparator, Outcome

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PROSPERO: International Prospective Register of Systematic Reviews

ProQOL: Professional Quality of Life Scale

PSS: Perceived Stress Scale

QRISK3: Cardiovascular Disease Risk Assessment Tool

RR: Relative Risk

SCORE: Systematic Coronary Risk Evaluation

SD: Standard Deviation

SSPCS: Social Stigma towards Patients due to COVID Scale

USA: United States of America

WHO: World Health Organization

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