***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    Input: BACKGROUND Vital exhaustion , a psychological measure characterized by fatigue and depressive symptoms , has been suggested to be an independent risk factor for ischaemic heart disease ( IHD ) but the generality of the phenomenon remains in question . The aim of this study is to describe prevalence of these symptoms in a community sample and determine whether they prospect ively predict increased risk of IHD and all-cause mortality in men and women . METHODS The study base was 4084 men and 5479 women aged 20 - 98 free of IHD examined in 1991 - 1993 in the Copenhagen City Heart Study . Events were ascertained through record linkage until 1998 for IHD and September 2000 for all-cause mortality . There were 483 first hospital admissions and deaths caused by IHD and 1559 deaths from all causes during follow-up . RESULTS The 17 items on the vital exhaustion question naire were frequently endorsed with prevalence ranging from 6 to 47 per cent , higher in women . All but 4 of the 17 items were significantly associated with IHD with significant relative risks ( RR ) ranging between 1.36 ( 95 % CI : 1.08 , 1.72 ) and 2.10 ( 95 % CI : 1.63 , 2.71 ) . Associations with all-cause mortality were also observed , but were weaker . RR of both IHD and all-cause mortality increased with increasing item sum score and were similar in men and women . For IHD , RR reached a maximum of 2.57 ( 95 % CI : 1.65 , 4.00 ) for subjects endorsing > 9 items . The similar RR for all-cause mortality was 2.50 ( 95 % CI : 2.09 , 2.99 ) . Multivariate adjustment for biological , behavioural , and socioeconomic risk factors did not substantially affect the association for IHD but attenuated the association with all-cause mortality . CONCLUSIONS Measures of fatigue and depression were common symptoms in this population sample and convey increased risk of IHD and of all-cause mortality . We propose this knowledge begin to be implemented in risk assessment in clinical practice In this prospect i ve study a psychological test ( the " Maastricht Question naire ' ) was constructed which measures feelings of vital exhaustion and depression . It is shown that those subjects who have elevated scores on this test have more chance to get a new coronary event within a period of 10 months than those who have low scores on this test Vital exhaustion , defined as a combination of fatigue , lack of energy , feelings of hopelessness , loss of libido , and increased irritability , has been proposed as a risk indicator for the development of coronary heart disease ( CHD ) . It is unclear if the association between vital exhaustion and CHD is independent of sleep behavior , depression , and physical activity . We ascertained sense of exhaustion among 5,053 male college alumni who were free of cardiovascular disease , cancer , and chronic obstructive pulmonary disease by asking , " How often do you experience  sense  of exhaustion ( except after exercise ) ? " on a health survey in 1980 . Eight hundred fifteen men died during 12 years of follow-up , 25 % due to CHD . After adjustment for age , body mass index , smoking status , and history of physician-diagnosed diabetes and hypertension , frequent sense of exhaustion was associated with a twofold increase in CHD mortality ( rate ratio 2.07 ; 95 % confidence interval 1.08 to 3.96 ) . After additional adjustment for insomnia , sleep duration , use of sleeping pills and tranquilizers , physical activity , history of physician-diagnosed depression , and alcohol intake , the rate ratio was not appreciably altered ; however , the association now was of borderline significance ( rate ratio 2.06 ; 95 % confidence interval : 0.98 to 4.36 ) because there were only 10 deaths from CHD among men who were frequently exhausted . In a prospect i ve observational study , frequent sense of exhaustion appeared to be independently associated with increased risk of CHD mortality in men Prospect i ve studies on the role of psychosocial factors in heart failure development are virtually nonexistent . The authors aim ed to address the effect of psychosocial factors on the risk of heart failure hospitalization in men and women free of cardiovascular disease . In 1991 - 1993 , the 8,670 participants of the Copenhagen City Heart Study ( Denmark ) were asked comprehensive questions on major life events , work-related stress , social network , vital exhaustion , and sleep medication and were followed in nationwide registries until 2007 , with less than 0.2 % loss to follow-up . Almost one-fourth of the population reported some degree of vital exhaustion . The vital exhaustion score was associated with a higher risk of heart failure in a dose-response manner ( P < 0.002 ) , with high vital exhaustion being associated with a 2-fold higher risk of heart failure in both men ( hazard ratio = 1.93 , 95 % confidence interval : 1.20 , 3.10 ) and women ( hazard ratio = 2.56 , 95 % confidence interval : 1.80 , 3.65 ) . Contrary to expectation , major life events , social network , and sleeping medication did not play an individual role for heart failure hospitalization . Because of the high prevalence of vital exhaustion in the population , even a modestly higher risk of heart failure associated with vital exhaustion may be of importance in the planning of future preventive strategies for heart failure In order to study the association between vital exhaustion and different manifestations of coronary heart disease , a prospect i ve study was conducted among 3877 males , aged 39 - 65 . This group was studied during a mean period of 4.2 years . Vital exhaustion , a mental state characterized by unusual fatigue , a feeling of being dejected or defeated , and increased irritability , were assessed by means of the Maastricht Question naire . Subjects who scored in the upper third were labelled as exhausted and were compared with those who scored in the lower or middle third . The age-adjusted relative risk of angina pectoris at screening that was associated with vital exhaustion was 4.17 ( p less than 0.01 ) ; that of unstable angina pectoris at screening was 17.21 ( p less than 0.001 ) . No association was observed between vital exhaustion and past myocardial infa rct ion , except in the youngest age group ( OR = 3.76 ; p = 0.05 ) . Among the subjects free from coronary heart disease at screening , 54 cases of angina pectoris , 38 cases of non-fatal myocardial infa rct ion , and 21 cases of fatal myocardial infa rct ion were observed during follow-up . The age-adjusted relative risk of angina pectoris at follow-up was found to be 1.86 ( p less than 0.03 ) and that of non-fatal myocardial infa rct ion was found to be 2.28 ( p less than 0.001 ) . No association was found between vital exhaustion and fatal events To test the hypothesis that feelings of exhaustion are predictive of future coronary heart disease , a prospect i ve study was done among 3877 males , aged 39 - 65 .  Feelings of exhaustion were assessed by the Maastricht Question naire . Among those who were free of coronary heart disease at screening , 59 subjects experienced a fatal or non-fatal myocardial infa rct ion during the 4.2 year follow-up period . A multiple logistic regression analysis revealed that feelings of exhaustion were predictive of future myocardial infa rct ion when controlling simultaneously for blood pressure , smoking , cholesterol , age and the use of antihypertensive drugs Vital exhaustion , defined as excessive fatigue , feelings of demoralization , and increased irritability , has been identified as a risk factor for incident and recurrent cardiac events , but there are no population -based prospect i ve studies of this association in US sample s. We examined the predictive value of vital exhaustion for incident myocardial infa rct ion or fatal coronary heart disease in middle-aged men and women in 4 US communities . Participants were 12,895 black or white men and women enrolled in the Atherosclerosis Risk In Communities ( ARIC ) study cohort and followed for the occurrence of cardiac morbidity and mortality from 1990 through 2002 ( maximum follow-up 13.0 years ) . Vital exhaustion was assessed using the 21-item Maastricht Question naire and scores were partitioned into approximate quartiles for statistical analyses . High vital exhaustion ( fourth quartile ) predicted adverse cardiac events in age- , gender- , and race-center-adjusted analyses ( 1.69 , 95 % confidence interval 1.40 to 2.05 ) and in analyses further adjusted for educational level , body mass index , plasma low-density lipoprotein and high-density lipoprotein cholesterol levels , systolic and diastolic blood pressure levels , diabetes mellitus , cigarette smoking status , and pack-years of cigarette smoking ( 1.46 , 95 % confidence interval 1.20 to 1.79 ) . Risk for adverse cardiac events increased monotonically from the first through the fourth quartile of vital exhaustion . Probabilities of adverse cardiac events over time were significantly higher in people with high vital exhaustion compared to those with low exhaustion ( p = 0.002 ) . In conclusion , vital exhaustion predicts long-term risk for adverse cardiac events in men and women , independent of established biomedical risk factors BACKGROUND Stress is a consequence of different types of external dem and s , most of which have been shown to be associated with increased risk of ischaemic heart disease ( IHD ) , but whether accumulation of stressors over a life-course results in additional risk of IHD remains unknown . This study investigates the impact of major life events ( MLE ) in childhood , adulthood and at work , singly and accumulated , on incident IHD in men and women and examines vital exhaustion ( VE ) and use of tranquillizers as potential mediators . Material and methods The study includes 8738 participants , 57 % women , from the third wave of the Copenhagen City Heart Study , who in 1991 - 93 answered a range of questions on MLE , VE and use of tranquillizers .  The participants were followed in a nationwide hospital discharge register until 2007 . RESULTS During follow-up , 653 experienced a first-time incident of IHD . In general , there were no associations between MLE and incidence of IHD . However , being placed in care during childhood was associated with a higher risk of IHD among women [ hazard ratio ( HR ) = 1.36 ; 95 % confidence interval ( 95 % CI ) 0.97 - 1.89 ] , but a lower risk of IHD among men ( HR = 0.72 ; 95 % CI 0.51 - 1.03 ) . MLE showed a dose-response association with psychological risk factors with highest estimates for those exposed to MLE in all three life domains : VE [ odds ratio ( OR ) = 15.07 ; 95 % CI 8.97 - 25.31 ] and use of tranquillizers ( OR = 4.41 ; 95 % CI 3.10 - 6.26 ) . CONCLUSION This prospect i ve study finds no associations between accumulated MLE and IHD . MLE is , however , strongly associated with VE and use of tranquillizers . The results underscore the problems in conceptualizing and measuring MLE & NA ; Excessive tiredness is one of the most prevalent premonitory symptoms of myocardial infa rct ion and sudden cardiac death . This state is labelled as vital exhaustion and consists of three components : fatigue , increased irritability , and demoralization . Vital exhaustion has been found to be an independent risk‐indicator of myocardial infa rct ion in one prospect i ve study and several case‐control studies . It is as yet unclear whether the association between vital exhaustion and future myocardial infa rct ion can be explained by confounding of ( sub clinical ) coronary artery disease . Therefore , the present study investigates the predictive value of vital exhaustion for the occurrence of new cardiac events after  percutaneous transluminal coronary angioplasty ( PTCA )  , while explicitly controlling for the severity of coronary artery disease . Patients with a successful PTCA were followed during 1.5 years . A new cardiac event was defined as present if one of the following end points occurred : cardiac death , myocardial infa rct ion , coronary bypass surgery , repeat‐PTCA , increase of coronary atherosclerosis , or new anginal complaints with documented ischemia . Vital exhaustion was assessed using the Maastricht Question naire two weeks after hospital discharge . Participants of the present study were 127 patients ( mean age 55.6 + /‐ 9.1 ; 105 men , 22 women ) . Fifteen ( 35 % ) of the 43 exhausted patients experienced a new cardiac event , whereas 14 ( 17 % ) of the 84 not exhausted patients had a new cardiac event ( OR = 2.7 ; CI = 1.1–6.3 ; p = .02 ) . Multiple logistic regression analysis revealed that vital exhaustion continued to be of predictive value when other significant risk factors for new cardiac events were controlled for ( i.e. , severity of coronary artery disease and hypercholesterolemia ) . ( ABSTRACT TRUNCATED AT 250 WORDS During the preparation of a prospect i ve study of exhaustion as a precursor of myocardial infa rct ion ( MI ) , the authors found that many coronary patients said that they had been burned out at some time in their lives . Therefore , the question , " Have you ever been burned out ? " 
    Output:
    
Conclusions Vital exhaustion is associated with increased risk of incident and recurrent CHD