Psychosocial stress in patients with coronary heart disease (CHD) poses an additional risk of CV mortality even when the patients are receiving optimal secondary prevention treatment.
Much of the current data is from patients with MI, therefore researchers from Uppsala University, Sweden, focused on psychosocial stressors in patients with stable CHD. 
Here, they analysed data from the Stabilisation of Atherosclerosis plaque By Initiation of darapLadIb TherapY (STABILITY) trial, which was carried out in 39 countries.
During this study a baseline questionnaire reported the presence of, and extent of various psychosocial stressors including marital status, educational level, depressive symptoms, loss of interest, financial stress and home- and work-related control in 14,849 participants with stable CHD. The end points were CV death and a primary composite of CV death, non-fatal myocardial infarction (MI) or non-fatal stroke. 
After a follow-up period of 3.7 years, researchers found that financial stress, depressive symptoms and loss of interest were the factors that were associated with the highest increased risk of CV death and the primary composite endpoint. Living alone was also associated with a higher risk of CV death and primary composite endpoint store, although being married or living with a partner was linked with a lower risk of CV death.
These findings are consistent with previous studies such as the INTERHEART trial that examined modifiable risk factors associated with MI,  and other observational studies that identify marital status as a potential independent risk factor for heart disease or stroke. 
This study does have some limitations. For example, some of the questions were simplified, and researchers did not predefine certain terms such as ‘sense of control’ (at work), which may have resulted in some ambiguity in the answers.
Nonetheless the outcome of this study suggests that ‘an unfavourable milieu could add additional risk beyond established risk factors and physical comorbidities,’ and as such should be considered by clinicians in patients with stable CHD.