Stress-Related Methylation Risk Scores Predict Coronary Heart Disease

Background Psychosocial stress is a key risk factor for coronary heart disease (CHD), particularly in postmenopausal women who face both a high stress burden and elevated cardiovascular risk. DNA methylation (DNAm) – a critical epigenetic modification bridging environment and health – remains understudied as a contributor to stress- related CHD. Methods We conducted an epigenome-wide association study (EWAS) of stress in the Women’s Health Initiative (WHI), an ancestrally diverse cohort of postmenopausal women (n=3,857). At screening visit, participants completed a questionnaire assessing stressful life events and provided whole blood for DNAm. Incident CHD was then longitudinally ascertained (follow-up mean/SD: 16.7/8.4 years), and DNAm signatures were evaluated as CHD predictors using Cox regression. Predictive models were independently validated in the Jackson Heart Study (JHS; n=3,053) and Multi-Ethnic Study of Atherosclerosis (MESA; n=870). The bulk-level DNAm associations were computationally deconvolved at the cell-type-specific level using tensor composition analysis (TCA). Results The EWAS in WHI identified 841 stress-related DNAm sites (99 hypermethylated, 742 hypomethylated with stress) after FDR correction, with 13 significant after Bonferroni correction, including sites located on immune and CHD- related genes (e.g., TNF , ALDH2 ). Methylation risk scores (MRSs) integrating the 841 FDR-significant sites (MRS 841 ) and 13 Bonferroni-significant sites (MRS 13 ) predicted incident CHD (HR=1.33-1.37; p≤0.0008) and mediated 16.5-17.7% of the association between stress and CHD. In JHS and MESA, MRS 13 independently predicted CHD (HR=1.34; p=0.036), whereas MRS 841 was suggestively associated with CHD (HR=1.27; p=0.087). TCA indicated that the greatest number of stress-related sites predictive of CHD was specifically in monocytes (133 total), with directions consistent with bulk-level associations (9 hypermethylated, 124 hypomethylated with stress). Conclusion Our study supports methylation risk scores as novel biomarkers of stress- related CHD and uncovers epigenetic regulation in monocytes as a potential underlying mechanism. These findings highlight biological pathways linking stress and disease and may promote personalized interventions in high-risk populations.