European Journal of Cardiovascular Medicine

Atherosclerosis, a chronic inflammatory condition of the arterial wall, is traditionally associated with older age groups; however, evidence indicates its early onset in young adults, often progressing silently until clinical manifestations emerge later in life (1). This early vascular involvement is particularly concerning, given the rising burden of cardiovascular diseases globally and their increasing incidence in younger populations (2). Among the numerous contributing factors, psychosocial stress and sedentary behavior have garnered significant attention for their independent and synergistic roles in the pathogenesis of atherosclerosis.

Psychosocial stress influences vascular health through neuroendocrine and inflammatory pathways, leading to endothelial dysfunction, oxidative stress, and increased arterial stiffness (3). Chronic stress activates the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system, resulting in elevated cortisol levels, hypertension, and metabolic alterations that promote atherogenesis (4). Additionally, stress has been linked to unhealthy coping behaviors such as smoking, poor diet, and physical inactivity, further compounding cardiovascular risk (5).

A sedentary lifestyle, defined by prolonged sitting or low energy expenditure activities, is another major modifiable risk factor. Physical inactivity contributes to dyslipidemia, insulin resistance, and systemic inflammation, all of which accelerate arterial plaque development (6). With the advent of digital technology and urbanization, young adults are increasingly exposed to sedentary routines, amplifying their vulnerability to early atherosclerotic changes (7).

Despite these known associations, limited data exist on the combined impact of psychosocial stress and sedentary lifestyle on subclinical atherosclerosis among young adults. Therefore, this study aims to evaluate the role of these factors in early vascular changes, using carotid intima-media thickness (CIMT) as a surrogate marker for atherosclerosis.

Study Design and Participants
This cross-sectional observational study was conducted between January and June 2025 in a tertiary care hospital located in an urban metropolitan area. A total of 200 young adults aged 20 to 35 years were enrolled using a stratified random sampling method. Participants were recruited from general outpatient clinics and community wellness programs.

Inclusion and Exclusion Criteria
Inclusion criteria included adults aged 20–35 years with no known history of cardiovascular disease, diabetes, or chronic inflammatory conditions. Exclusion criteria were current use of lipid-lowering or antihypertensive medications, recent infections (within 1 month), pregnancy, or diagnosed psychiatric illness.

Assessment of Psychosocial Stress
Psychosocial stress was evaluated using the Perceived Stress Scale (PSS-10), a validated self-administered questionnaire. Scores were classified as low (0–13), moderate (14–19), or high (≥20). Participants were further grouped into low and high stress categories for analysis.

Assessment of Physical Activity
Physical activity levels were measured using the International Physical Activity Questionnaire–Short Form (IPAQ-SF). Based on metabolic equivalent task (MET) scores, participants were categorized into physically active (≥600 MET-min/week) and sedentary (<600 MET-min/week) groups.

Measurement of Carotid Intima-Media Thickness (CIMT)
Carotid intima-media thickness was assessed using high-resolution B-mode ultrasonography (7.5 MHz linear transducer). Measurements were taken at 1 cm proximal to the carotid bifurcation on both sides, and the mean of three readings from each side was recorded. The sonographer was blinded to participant groupings.

Biochemical Analysis
Fasting blood samples were collected to assess lipid profile (total cholesterol, LDL, HDL, triglycerides) and high-sensitivity C-reactive protein (hs-CRP). Analyses were performed using standardized automated laboratory methods.

Statistical Analysis
Data were analyzed using SPSS version 25. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as percentages. Group comparisons were performed using independent t-tests and chi-square tests. Multiple linear regression was applied to determine the independent association of stress and sedentary lifestyle with CIMT. A p-value <0.05 was considered statistically significant.

A total of 200 participants (112 males and 88 females; mean age: 28.6 ± 3.9 years) were included in the final analysis. The demographic and clinical characteristics are summarized in Table 1. Participants were categorized into high-stress (PSS ≥ 20, n = 96) and low-stress (PSS < 20, n = 104) groups, as well as sedentary (IPAQ < 600 MET-min/week, n = 89) and physically active groups (n = 111).

Table 1 shows that individuals in the high-stress group had significantly higher body mass index (BMI), systolic blood pressure, and hs-CRP levels compared to those in the low-stress group (p < 0.05). Similarly, sedentary individuals exhibited higher mean CIMT, total cholesterol, LDL, and hs-CRP levels than their active counterparts (p < 0.01), as detailed in Table 2.

Carotid intima-media thickness (CIMT) was notably elevated in the high-stress group (0.72 ± 0.12 mm) compared to the low-stress group (0.61 ± 0.09 mm; p < 0.01). Sedentary partcipants also showed increased CIMT (0.75 ± 0.11 mm) relative to active individuals (0.60 ± 0.08 mm; p < 0.001) (Table 3).

Multiple linear regression analysis demonstrated that both psychosocial stress (β = 0.31, p = 0.002) and sedentary lifestyle (β = 0.29, p = 0.004) were independent predictors of increased CIMT after adjusting for age, sex, BMI, and lipid levels (Table 4).

Table 1: Baseline Characteristics of Study Participants

*Significant at p < 0.05

Table 2: Lipid Profile and Physical Activity Status

Table 3: Comparison of CIMT Between Study Groups

Table 4: Multiple Linear Regression Analysis for Predictors of CIMT

These findings indicate a significant association between psychosocial stress, sedentary behavior, and early atherosclerotic changes as measured by CIMT (Tables 1–4).

The present study evaluated the impact of psychosocial stress and sedentary lifestyle on subclinical atherosclerosis in young adults, using carotid intima-media thickness (CIMT) as a surrogate marker. Our findings revealed that both elevated stress levels and low physical activity were significantly associated with increased CIMT, independent of traditional cardiovascular risk factors such as BMI and lipid profile.

Several studies have previously highlighted the role of psychosocial stress in promoting vascular dysfunction and atherosclerosis. Chronic stress induces sustained activation of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system, resulting in elevated cortisol and catecholamine levels that contribute to endothelial dysfunction, systemic inflammation, and vascular remodeling (1,2). In our study, individuals with high perceived stress scores had significantly higher CIMT values, corroborating earlier reports linking psychological distress to early arterial changes (3,4). This association persisted even after adjusting for confounding factors, supporting the hypothesis that stress has a direct pathophysiological role in atherogenesis (5).

Similarly, physical inactivity has been identified as an independent risk factor for cardiovascular morbidity. Prolonged sedentary behavior contributes to obesity, insulin resistance, and dyslipidemia, all of which are known promoters of atherosclerotic plaque formation (6,7). Our results are consistent with previous investigations that demonstrated increased CIMT among individuals with low physical activity levels (8,9). Moreover, sedentary participants in our study exhibited higher serum LDL and hs-CRP levels, suggesting a pro-inflammatory and atherogenic metabolic profile.

The interplay between stress and sedentary behavior is also noteworthy. Stress has been associated with reduced motivation for physical activity and poor lifestyle choices such as unhealthy eating and smoking, thereby creating a vicious cycle of cardiovascular risk accumulation (10,11). Furthermore, stress-related neuroendocrine disturbances can enhance lipid peroxidation and oxidative stress, promoting vascular injury and thickening of the intima-media layer (12). This may explain the synergistic effect observed in individuals exposed to both stress and inactivity in our cohort.

Carotid intima-media thickness has been widely validated as a non-invasive marker of subclinical atherosclerosis and a predictor of future cardiovascular events (13). Its sensitivity in detecting early structural changes makes it a valuable tool for assessing vascular health, particularly in young populations where overt symptoms are often absent. The elevated CIMT values in our study reflect the early vascular consequences of lifestyle and psychological factors, even in the absence of overt clinical disease.

Our findings align with population-based studies such as the Bogalusa Heart Study and the CARDIA study, which documented the initiation of atherosclerotic changes in adolescence and their progression into adulthood in the presence of modifiable risk factors (14,15). These data highlight the urgent need for early screening and lifestyle interventions focused on mental health and physical activity promotion in young adults.

Despite the strength of using objective vascular imaging and standardized questionnaires, the study has some limitations. Its cross-sectional nature precludes establishing causality, and residual confounding factors such as diet, sleep, and socioeconomic status could influence the results. Longitudinal studies are needed to validate the temporal relationship between stress, sedentary behavior, and atherosclerotic progression.

In conclusion, this study reinforces the significant association of psychosocial stress and sedentary lifestyle with early atherosclerotic changes in young adults. These findings emphasize the need for integrated cardiovascular prevention strategies that address both psychological well-being and physical activity.

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