Stressed Young Women With CAD Susceptible to Heart Ischemia

Marlene Busko

November 16, 2014

CHICAGO, IL — Among patients with stable CAD, women in their 40s and early 50s were three-times more likely than men to exhibit myocardial ischemia after performing a mental stress test in a new study[1]. The reduced blood flow to the heart was not explained by sociodemographic factors, CAD severity, cardiovascular risk factors, or depression.

In a slightly older group, 56- to 64-year-olds, the stress-related myocardial perfusion deficit was twice as large in women as men. But the gender disparity disappeared among men and women age 65 and older. In all three age groups, there were no gender differences in myocardial ischemia after an exercise stress test.

This research shows that "young women with CAD are vulnerable to ischemia secondary to psychological stress, which could play a role in [their] prognosis," Dr Viola Vaccarino (Emory University, Atlanta, GA) said, who presented the findings during a press conference at the American Heart Association (AHA) 2014 Scientific Sessions.

"We've known for a while that women seem to have more detrimental effects from CVD than men, and this shows that maybe [mental-stress–induced myocardial ischemia] is a mediating factor," press conference moderator Dr Donna Arnett (University of Alabama at Birmingham) and past president of the AHA, told heartwire . It will be interesting to see whether further long-term studies show that emotional stress predicts poor outcomes, such as MI, in women, she observed.

In fact, the research group is continuing to follow these patients to study this. In the meantime, "It is important that clinicians realize the vulnerability of this patient population," Vaccarino told heartwire. Women's everyday stressors may include taking care of their children and aging parents. Clinicians should inquire about this in this patient population and possibly recommend exercise as a way to combat stress.

Stressed Women, Hampered Heart Muscle

Vaccarino and colleagues have long studied gender differences in heart disease. Previously they showed that women had higher mortality and complication rates after MI than men of the same age[2].

And in a pilot study, they showed that in 100 CAD patients younger than age 60, women had higher rates of mental-stress–induced ischemia than men[3]. In the current study, they aimed to see whether this effect was specific to younger women. They enrolled 534 patients (151 women) aged 38 to 79 who had a documented history of CAD.

Participants were divided into three age groups: >55 years (25 women, 80 men), 56 to 64 years (49 women, 113 men), and >65 years (77 women, 190 men).

Men and women had a similar prevalence of cardiovascular risk factors (diabetes, hypertension, smoking, abnormal lipids), severity of heart disease, and current medication use. However, women were more likely to be from a minority group and unmarried, have less education, and have depression or anxiety.

Patients underwent a standardized mental stress test during which they were asked to give a speech about a stressful situation to an audience of a few "intimidating" people in white coats. While the patients were doing this, they were injected with a radioactive substance.

Researchers performed a nuclear imaging single-photon emission computerized tomography (SPECT) test in which they quantified myocardial perfusion across 17 myocardial segments at rest and during the stressful situation.

On another day, patients had a physical stress test—during which stress was induced pharmacologically or using an exercise treadmill.

The gender difference was seen only with mental stress and lessened with age. Young women had greater mental-stress–induced ischemia than older women.

"Women did not have higher hemodynamic responses to stress; they didn't have higher increases in blood pressure or heart rate with stress," Vaccarino pointed out.

"It is well known that ischemia with mental stress is often silent, so patients may have it during the day, but they may not realize it." Future research might show that women with chest pain that goes away may have mental-stress–induced myocardial ischemia, she speculated.

Vaccarino reported she had no relevant financial relationships. Disclosures for the coauthors are listed in the abstract.

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