Stress Plays Role in Younger Women with CHD

Chicago—New research found that young women with stable coronary heart disease (CHD) are more likely than men of the same age to develop reduced blood flow to the heart if they are under emotional stress but not physical stress. The findings were presented at the AHA meeting.

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“Women who develop heart disease at a younger age make up a special high-risk group because they are disproportionally vulnerable to emotional stress,” said the study’s lead author, Viola Vaccarino, MD, PhD, chairperson, cardiovascular research and epidemiology, Emory University’s Rollins School of Public Health, Atlanta, Georgia, in a press statement.

Women generally develop heart disease later in life than men; however, younger women who have premature heart attacks are more likely to die than men of a similar age. Risk factors, such as diabetes or high blood pressure (BP), do not explain these mortality differences. Dr. Vaccarino referenced 2 studies she and colleagues conducted that looked at young women with CHD. In a pilot study, the researchers found that women ≤50 years of age had higher rates of ischemia with mental stress than age-matched men [Psychosom Med. 2014;76(3):171-180]. In another study, younger women (<50 years of age) had higher mortality and complication rates after myocardial infarction compared with men of the same age [N Engl J Med. 1999;341(14):217-225].

In the current study, 534 patients (n=151 women) 38 to 78 years of age with a documented history of CHD verified by medical record review underwent 99mTc-sestambi myocardial perfusion imaging at rest and with both mental and physical stress testing. A summed total severity score was computed to quantify hypoperfusion size and severity at rest and under both stressful conditions with observer-independent software. The difference between stress and rest provided a quantitative measure of total ischemic perfusion deficit (IPD). Gender differences in IPD were calculated according to 3 age groups: (1) ≤55 years of age; (2) 56 to 64 years of age; and (3) ≥65 years of age.

The researchers gave a standardized mental stress test and, on a separate day, a traditional physical stress test (exercise treadmill test or pharmacological stress test). For the mental stress protocol, patients were asked to imagine a stressful life situation and deliver a speech about this real-life scenario in front of a small audience. Nuclear imaging was used to take pictures of the heart while undergoing each of the 2 stress tests and while at rest. Patients’ heart rate and BP were monitored during both mental and physical tests. The researchers then analyzed the differences in coronary blood flow based on gender and age.

Women had a more adverse psychosocial profile than men, while there were few gender differences in medical history and CHD risk factors (eg, diabetes, obesity, and smoking). Overall, women had more IPD with mental stress than men (91 vs 55, respectively; P<.001), but not with physical stress (140 vs 131, respectively; P=.63). Women ≤55 years of age exhibited a higher IPD with mental stress than any of the other age groups. Additionally, this same group had >3-fold IPD with mental stress than men of a similar age; the gender difference declined in older age groups (Table). The researchers noted that these results persisted when adjusting for sociodemographic and CHD risk factors, psychosocial factors, and medications.

Young women with stable CHD are vulnerable to ischemia secondary to psychological stress, which could play a role in the prognosis of CHD in this group, the researchers concluded.
Dr. Vaccarino said healthcare providers should be aware of young and middle-age women’s special vulnerability to stress and recommended they “ask questions about psychological stress that often do not get asked.”

“If [healthcare providers] note that their patient is under psychological stress or is depressed, they should advise the [patient] to get relevant help or support from mental health providers, stress
reduction programs, or other means,” she noted.—Eileen Koutnik-Fotopoulos