The unique toll of stress and depression on women’s hearts

At the emergency room, doctors quickly discovered that the two-time breast cancer survivor was having a heart attack. Surgery to unblock her arteries saved her life, but for the next four months, her pain continued. “I was feeling worse off after the stent than before,” she said. “I suffered, sometimes silently. My family suffered as well.”

It wasn’t until she visited a women’s heart specialist that she found answers. Her doctor asked questions about her life, family and stress related to her work as the director of alumni relations at a graduate school. Her physician, C. Noel Bairey Merz, director of ​​ the Barbra Streisand Women’s Heart Center in the Smidt Heart Institute at Cedars-Sinai, also explained the link between mental and cardiac health, especially in women.

Bairey Merz prescribed a new blood pressure medication and a lifestyle regimen focused on stress reduction. Travis-Teague was feeling better within a few weeks.

“It was like all of a sudden, somebody could hear me,” Travis-Teague said. “Now I know the importance of work-life balance.”

Why stress affects women’s hearts

A growing body of evidence suggests the effects of mental health has a disproportionate impact on women’s bodies. Recent findings presented at the American College of Cardiology’s Annual Scientific Session in April indicate that depression and anxiety accelerate the development of new cardiovascular disease risk factors, particularly among young and middle-aged women.

The researchers followed 71,214 people participating in the Mass General Brigham Biobank for 10 years. Those with a history of anxiety or depression before the study were about 55 percent more likely to develop high blood pressure, high cholesterol or diabetes compared to those without. The finding was most pronounced among women with anxiety or depression who were under 50, who were nearly twice as likely to develop cardiovascular risk factors compared with any other group.

“The aim of our project is to suggest that if a physician has a patient with anxiety or depression, he or she should also think about screening for cardiovascular risk factors,” said lead author Giovanni Civieri, a cardiologist and research fellow at Massachusetts General Hospital and Harvard Medical School.

Previous studies have also shown that stress and emotional health can have an outsize impact on women’s hearts.

One study of more than 3,600 men and women from Framingham, Mass., looked at married partners who typically bottled up their feelings during a fight with their spouse. Women who “self-silenced” during marital conflict were four times as likely to die during the 10-year study period as women who always spoke their mind. (The effect wasn’t seen in men.) Whether the woman reported being in a happy marriage or an unhappy marriage didn’t change her risk.

An 18-year study of 860 Australian women concluded that having a depressive disorder is a risk factor for coronary heart disease in women. The strength of association between depression and heart disease was of a greater magnitude than any other risk factor.

“The literature supports an even stronger association between depression and heart disease and bad outcomes in women than men,” said Roy Ziegelstein, a cardiologist and professor of medicine at Johns Hopkins.

Ziegelstein pointed to a condition called Takotsubo cardiomyopathy — also known as “stress cardiomyopathy” or broken heart syndrome — that is more common in women. As many as 90 percent of cases occur in women between the ages of 58 and 75. While many people recover, the condition can be life-threatening and is often triggered by intense physical or emotional stress.

Across the spectrum of age, ethnicity and socioeconomic status, there are numerous tales of women whose symptoms are ignored, only to later discover that they have experienced a heart attack or developed cardiovascular disease.

For Marianna Knopov, several New York physicians she saw over three years were unable to pinpoint the cause of her intense heart palpitations and chest tension. In 2013, the then 51-year-old Russian immigrant was a busy mother of two teenage sons steering her own thriving dental clinic. “My life was basically like a roller coaster,” she said.

After years of the same cycle — pain, hospitals and home without relief — Knopov said she was ready to give up on her search for answers. “You go to one after another and they don’t listen to you. They don’t hear you. They just want to dismiss you, and that’s how I felt.”

By the time she met Evelina Grayver in 2016, a cardiologist specializing in women’s heart health who is now at Katz Institute for Women’s Health at Northwell Health in Queens, the vessels in her heart had become constricted and calcified, and there was “absolutely nowhere” to attach a new bypass.

Doctors placed seven stents in all three of her major arteries — and Grayver prescribed a lifestyle regimen to better regulate the anxiety and chronic stress that helped get her there. Knopov said the diagnosis had a “profound” effect on her. “I had to change something,” she said.

She eventually sold her practice, traded in New York’s bustling streets for Florida’s serene beaches, and recently became a grandmother.

“I’m living a totally different life,” she said. Now 62, Knopov has incorporated meditation, yoga and abdominal breathing exercises into her daily routine, and she walks 10,000 steps per day.

Knopov said her doctors’ advice helped her “experience a different state of mind and being.” There is a lot of joy each day,” she said.

In the intricate web of mental health and cardiovascular well-being, there isn’t a clear explanation why the connection is so strong in women.

Studies from Emory University have found that women experiencing acute mental stress are more susceptible than men to constriction of their small peripheral arteries, leading to diminished blood flow. Researchers found that the microvascular response to stress was also associated with adverse outcomes in women but not in men.

One reason for this could be that women’s blood vessels are smaller in caliber and consistency than those found in men. While men are prone to centralized plaque buildup in the largest arteries that supply blood to the heart, women typically have diffused, small blockages throughout their blood vessels, “which is very dangerous” because they can be more difficult to detect and treat, according to Grayver.

Additionally, experts say stress in women appears to disrupt lipid balance, increase platelet aggregation and impair glucose regulation. Chronic stress may further exacerbate coronary heart disease progression by fueling inflammation, a risk factor more pronounced in women. This heightened inflammatory response elevates their chances of major adverse cardiovascular events.

“We know that anxiety and stress and depression are bad. Now, let’s figure out how to best identify and treat people who are 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 so that it improves blood flow to the heart?”

One key area of interest for researchers is whether addressing mental health concerns, using existing medications such as antidepressants or traditional talk therapy could mitigate cardiovascular risk. Others are studying a potential genetic link between depression and heart disease, with the hope of discovering novel drugs capable of treating both conditions simultaneously.

After an attack, lowering future risk

While understanding why women’s hearts are particularly vulnerable to stress is valuable, it’s more important for doctors to acknowledge the connection from the outset.

“What tends to happen is that younger women who have risk factors, for example, may only see their OB/GYN for birth control, and by the time they come to the cardiologist they’ve already developed heart disease or heart failure,” Mehta said. “We have to do a better job of identifying and early prevention.”

Following a heart attack, women face a higher risk of mortality within the five years. While not fully understood, one theory suggests that the increased risk could be attributed to the adverse psychological reactions to the stress of experiencing a heart attack, according to JoAnn E. Manson, chief of preventive medicine at Brigham and Women’s Hospital in Boston.

Research also shows that fewer women than men are referred to cardiac rehabilitation programs, which can help limit the psychological stresses associated with cardiac disease, reduce the risk of associated mortality and improve cardiovascular function to help patients optimize their quality of life. In addition, women are less likely to be put on protective medications, such as cholesterol-lowering statins or beta blockers, to protect against future cardiovascular events.

Experts emphasize that lifestyle interventions are among the most effective and accessible tools for women managing both mental health and cardiovascular conditions. That includes regular exercise, improved diet and sleep patterns, as well as tools to manage stress, such as meditation and deep breathing.

Social support also seems to have a stronger heart benefit for women compared with men. The presence of family members or friends with whom women can maintain regular contact strongly predicts their cardiovascular health, according to Manson.

Travis-Teague has continued to work with her doctors to manage her stress. Her advice to women facing similar challenges: “Understand that you need to listen to your body and be your own advocate. Do not be afraid to ask questions and to find the place where people will care for you.”