In the emergency room, doctors quickly discovered the two-time breast cancer survivor had suffered a heart attack. Surgery to unblock an artery saved her life, but the pain continued for four months after. “After the stent was put in, I felt worse than I had ever felt before,” she says. “I suffered, and sometimes suffered silently. And my family suffered as well.”
It wasn’t until she visited a female cardiologist that she found the answer. Her doctor asked her questions about the stresses related to her life, her family and her job as alumni relations director at her graduate school. Her doctor, C. Noelle Bailee Mertz, director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai’s Smit Heart Institute, also explained the connection between mental health and heart health, especially in women.
Dr. Bayley Mertz prescribed new blood pressure medication and a lifestyle change that focused on reducing stress, and within a few weeks, Travis Teague was feeling better.
“Suddenly, I felt like someone was listening to me,” Travis Teague said. “Now I know the importance of work-life balance.”
Why stress affects a woman’s heart
Growing evidence suggests that mental health disproportionately impacts women’s bodies: Recent findings presented at the American College of Cardiology’s annual scientific meeting in April suggest that depression and anxiety accelerate the development of new cardiovascular disease risk factors, especially among younger and middle-aged women.
The researchers followed 71,214 participants from the Massachusetts General Brigham Biobank for 10 years. Those who had a history of anxiety or depression before the study were about 55% more likely to develop high blood pressure, high cholesterol, and diabetes than those without. The results were most pronounced in women under 50 with anxiety or depression, who were nearly twice as likely to develop risk factors for cardiovascular disease than other groups.
“The goal of our project is to suggest that physicians who treat patients with anxiety and depression should also consider screening for cardiovascular risk factors,” said lead author Giovanni Civvieri, a cardiologist and research fellow at Massachusetts General Hospital and Harvard Medical School.
Previous studies have also shown that stress and mental health can have a significant impact on a woman’s heart.
A study of more than 3,600 men and women in Framingham, Massachusetts looked at couples who tended to bottle up their emotions during arguments with their spouse. Women who “silenced themselves” during marital disputes were four times more likely to die over the 10-year study period than women who always spoke up. (Men were not affected.) The risk of death did not vary whether the women reported being in a happy or unhappy marriage.
An 18-year study of 860 Australian women concluded that depression is a risk factor for coronary heart disease in women. The association between depression and heart disease was stronger than any other risk factor.
“The literature supports that the association between depression and heart disease and poor prognosis is even stronger in women than in men,” said Roy Ziegelstein, a cardiologist and professor of medicine at Johns Hopkins University.
Siegelstein pointed to a condition called takotsubo cardiomyopathy (also known as “stress cardiomyopathy” or broken heart syndrome), which is more prevalent in women. 90 percent of cases occur in women between the ages of 58 and 75. Although many people recover, the disease can be life-threatening and is often brought on by intense physical or emotional stress.
There are numerous stories of women of all ages, ethnicities and socioeconomic status whose symptoms were ignored only to find out later that they had suffered a heart attack or developed cardiovascular disease.
Marianna Nopov had seen several New York doctors for three years, but no one could find the cause of her racing heartbeat and chest tightness. In 2013, the 51-year-old Russian immigrant was the mother of two teenage boys and ran a thriving dental practice. “My life had basically been a roller coaster,” she says.
After years of repeating the same cycle of pain, hospitals and a restless home, Nopov said she was ready to give up looking for answers. “You go from hospital to hospital, and they don’t listen to you. They don’t listen to you. They just want to ignore you. That’s how I felt.”
When she met Evelina Graber, a cardiologist specializing in women’s heart health, now at the Katz Institute for Women’s Health at Northwell Health in Queens, in 2016, the blood vessels in her heart had become so narrowed and calcified that there was “just no place” to install a new bypass.
Doctors placed seven stents in all three of her major arteries, and Dr. Graeber prescribed lifestyle changes to help her better manage the anxiety and chronic stress that contributed to her condition. Nopov said the diagnosis had a “huge” impact on her. “Something had to change,” she said.
She eventually sold her practice, left the bustling city of New York for the quiet beaches of Florida, and recently became a grandmother.
“I’m living a totally different life,” she said. Now 62, Nopov incorporates meditation, yoga and abdominal breathing into her daily routine, and walks 10,000 steps a day.
Nopov said her doctor’s advice has helped her “experience a different state of mind and way of life.” “There’s a lot of joy in every day,” she said.
Mental health and cardiovascular health are intricately intertwined, but there’s no clear explanation for why the connection is so strong in women.
A study from Emory University found that women who experience acute psychological stress tend to be more susceptible than men to constriction of peripheral small arteries, resulting in reduced blood flow. The researchers found that microvascular responses to stress were also associated with adverse outcomes in women, but not men.
One reason is that women’s blood vessels are smaller and less stiff than men’s: While men tend to have concentrated plaque buildup in the largest arteries that supply blood to the heart, women typically develop small blockages that are spread throughout their vessels and that Graeber says are “much more dangerous” because they can be harder to find and treat.
Moreover, experts say that stress in women appears to disrupt lipid balance, increase platelet aggregation, and impair glucose regulation. Chronic stress may further exacerbate the progression of coronary heart disease by promoting inflammation, a prominent risk factor in women. This heightened inflammatory response increases the likelihood of experiencing serious adverse cardiovascular events.
“We know that anxiety, stress, and depression are bad, so let’s think about how to best identify and treat those at risk,” said Puja Mehta, director of women’s translational cardiovascular research at the Emory Women’s Heart Center. “How do we help them manage stress to improve blood flow to the heart?”
One key area of interest for researchers is whether using existing medicines, such as antidepressants or traditional talking therapies, to address mental health concerns could reduce the risk of cardiovascular disease. Others are studying potential genetic links between depression and heart disease in the hope of finding new drugs that could treat both conditions simultaneously.
After an attack, reduce future risk
While it’s useful to understand why women’s hearts are particularly vulnerable to stress, it’s even more important for doctors to acknowledge the connection from the start.
“For example, young women with risk factors often only see their obstetrician-gynecologist for birth control, and by the time they go to a cardiologist, they’ve already developed heart disease or heart failure,” Mehta said. “We need to do a much stronger job of early detection and prevention.”
Women who have a heart attack are at higher risk of dying within the next five years, and while the reasons for this increased risk aren’t fully understood, one theory is that it could be due to the negative psychological effects of the stress of experiencing a heart attack, says Joan E. Munson, chief of preventive medicine at Brigham and Women’s Hospital in Boston.
Studies have shown that fewer women than men are referred to cardiac rehabilitation programs, which can help limit the mental stress associated with heart disease, reduce the associated risk of mortality, and improve cardiovascular function to optimize patients’ quality of life. Additionally, women are less likely to take protective medications such as cholesterol-lowering medications. Use statins or beta-blockers to prevent future cardiovascular events.
Experts stress that lifestyle interventions are among the most effective and accessible tools for women to manage both their mental health and cardiovascular disease. These include regular exercise, improving diet and sleep patterns, and stress management tools such as meditation and deep breathing.
Social support also appears to have a more beneficial effect on women’s hearts than men’s: Having family and friends that women can check in with regularly is a strong predictor of women’s cardiovascular health, according to Manson.
Travis Teague continues to work with her doctor to manage her stress, and her advice to women facing similar issues is, “Listen to your body and understand that you need to be your own advocate. Don’t be afraid to ask questions and find a place where you’re cared for.”
