Psychological distress and estimated ASCVD risk in primary prevention: evidence from a large community-based cohort

This study evaluates whether psychological distress is independently associated with estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk and whether it explains variation in estimated risk beyond conventional predictors. A cross-sectional analysis was performed in 6184 adults aged 40–75 years from the Shiraz Cohort Heart Study who had no prior cardiovascular or diagnosed psychiatric disorders. Psychological distress was assessed using the 28-item General Health Questionnaire (GHQ-28), and 10-year ASCVD risk was estimated using guideline-based equations. Associations were examined using multivariable regression and random forest modeling. Among 6184 participants, ASCVD risk increased progressively from Low- to High-risk groups (3.30 ± 1.01 vs. 28.47 ± 8.08), accompanied by higher age (45.93 ± 5.58 vs. 59.54 ± 6.12 years), male prevalence (9.7% vs. 94.4%), and smoking rates (5.4% vs. 54.4%). Psychological distress showed an inverse gradient across ASCVD risk categories, with mean GHQ scores decreasing from 15.87 ± 8.46 in Low-risk to 11.61 ± 7.28 in High-risk participants. In multivariable linear regression, psychological distress was positively associated with estimated ASCVD risk (B = 0.30; 95% confidence interval [CI] 0.01–0.59; standardized β = 0.01), although the magnitude of this association was clinically negligible. Random forest analysis identified age, sex, smoking status, and systolic blood pressure as the strongest contributors to ASCVD classification, with relative importance values of 29.34%, 25.90%, 14.22%, and 11.35%, respectively. Psychological distress demonstrated limited relative importance (2.20%) compared with traditional cardiovascular risk factors. Therefore, our findings indicate that psychological distress demonstrated a statistically significant but clinically modest association beyond established cardiometabolic factors. These findings suggest that psychological distress may represent a complementary clinical domain rather than a major additive determinant within current ASCVD risk stratification.