Mental Stress in Women With CAD Has Different Impact From That in Men

Marlene Busko

October 13, 2014

DURHAM, NC — New preliminary research has identified psychological and physiological differences in how men and women with stable CAD respond to mental stress. If confirmed, the findings may help explain why women with CAD fare worse than men and provide insights into how to improve their risk assessment and treatment[1].

After performing three stressful tasks, men with CAD were more likely than women with CAD to have changes in blood pressure and other traditional CVD risk factors.

However, women were more likely to have decreased blood flow to the heart (ie, mental-stress–induced myocardial ischemia). The women also had a greater increase in collagen-stimulated platelet aggregation, and they were more likely to report negative emotions.

These findings from more than 300 patients who were screened for the Responses of Mental Stress–Induced Myocardial Ischemia to Escitalopram (REMIT) study were published October 13, 2014 in the Journal of the American College of Cardiology.

"In this exploratory analysis, we identified clear, measurable, and differential responses to mental stress in women and men" with CAD, Dr Zainab Samad (Duke University Medical Center, Durham, NC) and colleagues summarize.

"In the context of its known poorer prognosis, the higher rate of mental-stress–induced myocardial ischemia in women observed in our study requires further investigation, because it may provide a potential explanation for the 'ischemic paradox' " in people with CAD—where women may have less severe symptoms but a worse prognosis, they note.

Clinicians should be aware of these sex differences when assessing a patient's CVD risk. "This study revealed that mental stress affects the cardiovascular health of men and women differently; we need to recognize this difference when evaluating and treating patients for cardiovascular disease," Samad said in a statement[2].

More research is needed to determine the impact of stress on long-term outcomes and to come up with a better screening tool. "At this point, further studies are needed to test the association of sex differences in the heart's responses to mental stress and long-term outcomes," Samad said.

High CVD Mortality in Women: Is Mental Stress a Factor?

Although CVD mortality in women is decreasing, "it is important to emphasize that the number of cardiovascular deaths for women has exceeded men for the past 20 years," the authors write.

The researchers analyzed data from 56 women and 250 men who were screened for REMIT, which compared the selective serotonin reuptake inhibitor escitalopram with placebo.

The participants had a mean age of 63 and a mean body-mass index (BMI) of 29. At baseline, women were more likely than men to have a history of depression (31% vs 10%).

The participants performed three mental-stress tasks—mental arithmetic, mirror trace, and anger recall—followed by a treadmill-exercise stress test.

Mental- or exercise-stress–induced myocardial ischemia was defined as the development or a worsening of an echocardiographically detected wall-motion abnormality; a reduction of LVEF >8%; and/or ischemic ST-segment change during the stress tasks compared with rest.

The patients replied to questionnaires that assessed depression, hostility, anxiety, and perceived social stress. Blood samples were collected at rest and at the end of the mental stress tests to measure platelet aggregation.

Following the mental stress tasks, more women than men had mental-stress–induced myocardial ischemia (57% vs 41%; P<0.04), but there were no significant sex differences in myocardial ischemia after the exercise stress test.

According to Samad, "This study also underscores the inadequacy of available risk prediction tools, which currently fail to measure an entire facet of risk (ie, the impact of negative physiological responses to psychological stress) in both sexes and especially so among women."

Samad has received research funding from Boston Scientific–Duke University Strategic Alliance for Research and the American Society of Echocardiography. Disclosures for the coauthors are listed in the article.

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