‘Emotional stressors’ may play larger role in women’s heart disease

“Women need — and deserve — heart care specific to female hearts.”

— Barbra Streisand to WebMD magazine

Ladies, here’s the upshot: Kick back, relax, chill out, chillax (as the kids say).

Gentlemen, that’s sage advice for you, too, but it’s particularly urgent for women who should take it to heart — for the sake of their hearts.

“If we can effect a change in the way women deal with their stress, the implications are massive in terms of preventing heart attacks in women,” says cardiologist Dr. Kathleen Benson of Sunrise Hospital about a recently released study linking the physiological effect of stress to coronary artery disease in women.

“It’s great that they are doing projects on this because as a medical society we don’t know enough about why they have normal coronary arteries but women are dying: What’s going on?”

Answers to that come slowly and incrementally in the realm of medical research, but a notable step forward was announced in March when a report was released by the Barbra Streisand Women’s Heart Center at the Cedars Sinai Heart Institute in Los Angeles. (The center was named for Streisand in 2012, after she raised more than $22 million for research into women’s heart disease, and donated $10 million herself.)

Researchers there say they have found that what they call “emotional stressors” — particularly those triggering anger — may cause changes in the nervous system that controls heart rate, leading to a type of coronary artery dysfunction that surfaces more frequently in women than in men.

“A huge percentage of cases of emotional, stress-based heart attacks, over 80 percent, are in women,” says Dr. Puja Mehta, director of the Streisand Center’s Non-Invasive Vascular Function Research Lab, and an author of the study that was presented to a meeting of the American Psychosomatic Society.

“One of the common things in cardiology has been described as the broken-heart syndrome. It’s when a woman is exposed to an emotional event — death of a spouse or a pet, a diagnosis of cancer, divorce, gambling or financial loss. They show up at emergency rooms with heart attack symptoms such as shortness or breath, or even going into heart failure. But when you look at their arteries (on a coronary angiogram), they’re open. There’s no blockage. It’s not too many cheeseburgers. It’s the stress response system that is different in women than in men.”

Previous studies established that about half of all women who complain of heart attack symptoms but show no blockage suffered from microvascular coronary dysfunction, in which the large arteries remain clear, but the smaller branches connecting to even-smaller capillaries lose their ability to widen, starving the heart of oxygen. Exploring the role of stress in that dysfunction, the Streisand Center researchers conducted tests with 16 women with the coronary dysfunction, and eight without it as the control group.

“We wanted in this study to see whether women who have this small-vessel dysfunction, how did they respond to this kind of mental stress compared to women who are healthy with no chest pain?” Mehta says.

Subjected to several types of mental stress — recalling upsetting situations, being asked to solve math problems, even having cold compresses against their foreheads — the women were then monitored for heart-rate variability and blood pressure. While both groups responded more or less equally to the stress factors, it was anger that particularly aggravated the autonomic nervous systems of women with the microvascular dysfunction, which can lead to heart attacks and other cardiac problems in women.

“Biologically, we know that the stress response system is different in men than in women. There is a lot of active investigation in this area and we’re trying to figure it out, too,” Mehta says. “During childbearing years, women tend to have stiffer hearts than men, in terms of the squeezing function and relaxation. There are a lot of sex differences. Mental stress can cause a lack of blood flow in both men and women, but the degree to which it affects women seems to be a lot more, and that’s the bottom line.”

These findings were welcomed by Dr. Karen Weihs, a professor of psychiatry at the University of Arizona, and president of the American Psychosomatic Society. “This is quite important because it contributes to a body of knowledge that eventually moves us into clinical applications,” says Weihs, noting that it dovetails with the society’s mission. Even though the word “psychosomatic” is often dismissed by laymen as amounting to a disease being “all in your head,” this data suggests that the link between the psychological and physiological is more concrete than most people realize.

“It’s a prejudicial attitude, so one of our challenges is to redefine ‘psychosomatic’ as a cutting-edge science studying the way the nervous system and the mind are involved in helping people be healthy,” Weihs says.

Statistics put out by the Streisand Center underscore the urgency to unravel the mystery of women’s heart disease: Ten women will die from heart disease for every one who dies from breast cancer. Many doctors, the center claims, are unaware that a woman suffering a heart attack is 50 percent to 100 percent more likely to die from it than a man.

Even so, old perceptions — and people’s response to them — die hard.

“Mom in the household gets chest pain, she gets Mylanta; Dad gets chest pain, he is taken to the ER fearing a heart attack,” says Dr. Keshav Chander, a cardiologist with the Smart Heart Care practice in Las Vegas. “I think this is primarily due to our mistaken belief that heart disease is a disease of older men. … Coronary artery disease behaves differently for women as compared to men. Not understanding these differences can lead to significant, sometimes fatal consequences.”

Sex bias in heart disease treatment was notably addressed back in the early 1990s by Dr. Bernadine Healy, the director of the National Institutes of Health, who died in 2011. In a study published in the New England Journal of Medicine, she stated that it was only when women had coronary heart disease that resembled a male pattern that they were as likely to undergo life-saving treatment such as bypass surgery.

“Once a woman showed that she was just like a man, by having severe coronary artery disease, then she was treated as a man would be,” Healy wrote.

Much of the data collected on heart disease over the years, researchers say, has been based on studies involving only male patients. Now that women are making equal-rights strides on the awareness front in heart disease, is there a difference in treatment or preventive care advice?

Not really.

Medications can improve blood flow in the heart and increase oxygenation, but it still boils down to the basics: eat properly, exercise regularly, get enough sleep, and keep your blood pressure and cholesterol levels under control, Chander says.

“I do not, however, think there is a need for involving mental health professionals or mood drugs in most of the cases,” he adds.

Not surprisingly, a mental health professional disagrees.

“It’s not that a psychiatric physician needs to see each patient,” says Weihs of the Psychosomatic Society. “But the knowledge from psychiatric investigations and people who understand the nervous system, which includes the brain, is crucial for understanding what will be the most effective approach.”

Advice everyone agrees on?

Cut down on stress.

That, of course, is the ultimate definition of “easier said than done.”

Relaxation?

Be sure your method isn’t self-defeating.

“Do not use crutches like smoking or alcohol for relaxation,” Chander says. “Women also tend to be more susceptible than men to the detrimental effects of alcohol.”

Turn, instead, to substance-free alternatives.

“Doing something even five minutes a day that is pleasing is important,” says Benson, who often advocates yoga and meditation. “I suggest my patients go into a room, close the door, turn off the lights, don’t fall asleep and relax. Focus on their breathing, where they are right now, everything else is shut out. It’s very rudimentary and basic, but it’s medication.”

In layman’s terms: Kick back, relax, chill out, chillax (as the kids say).