Future studies should include multiple measurement of work stress to monitor temporal changes. Additionally, questions concerning psychosocial burden at home and information about work–privacy conflict that seems to be especially important in the female participants need to be enclosed (Orth-Gomer et al. 2005). With the inclusion of other work-related factors in the study design such as noise, physical workload and shift work as well as the enquiry of several lifestyle factors, interactions

between risk factors can be analysed, given adequate statistical GDC-0449 purchase power. This will permit new concepts concerning the multifactorial aetiology of cardiovascular diseases and their prevention. Data need to be stratified for potential effect

modifiers such as age groups and gender. There is a clear need for primary interventions examining the effects of lowering work stress by enhancing the ability of coping as well as changes in work organisation (e.g. changes related to demands, Selleck INK-128 decision authority, quality of leadership). Events enhancing stress such as organisational downsizing have already shown to increase the risk of cardiovascular death (Vahtera et al. 2004). Also, individual risk profiles, such as cardiovascular reactivity or inflammatory response following an acute stress situation, need to be investigated and considered, since the same challenges may not induce similar stress responses in all workers. A recent meta-analysis (Chida and Steptoe 2010) showed that a higher cardiovascular response to laboratory mental stress is related to poor cardiovascular status. Also, stress-induced inflammatory responses may have implications for future health (Steptoe et al. 2007). Success of interventions needs to be monitored by measuring subclinical changes rather than long-term outcomes

such as cardiovascular mortality. Candidates for subclinical parameters were discussed in a recent review about the effect of psychosocial working environment on physiological changes in blood and urine (Hansen et al. 2009). Carotid intima media thickness (Tu et al. 2010) and arterial stiffness (Utsugi et al. 2009) are parameters that seem however to be increased following high job strain or effort–reward imbalance. Summary In line with other systematic reviews, this publication provides moderate evidence that psychosocial factors at work are related to cardiovascular diseases. However, none of the stress models used in epidemiological research has so far proven to satisfactorily elucidate the stress–disease relationship. Both the job strain and the effort–reward imbalance model are promising despite the limitation of existing studies. It is not yet clear whether individual factors (e.g. coping, overcommitment) or the objective working conditions (e.g. time pressure, work organisation), which both contribute to the individual perception of work stress, have a stronger impact.