Does increased stress lead to heart attack?

Men’s Health Mythbuster is a new section on UrologyTimes.com that explores common statements and beliefs about men’s health and evaluates whether these statements are false. To leave feedback or suggest future myths, send an email to UT@advanstar.com or post a comment below.

Dr. Pollard is a urology resident and Dr. Mills is associate clinical professor of urology at the University of California, Los Angeles.

Does stress kill the heart? Probably, but let’s explore why.

Several high-quality studies have attempted to draw a link between stress and cardiac health. Since stress is a difficult concept to define and reproduce across study subjects, clinical trials have struggled to qualify the relationship between heart disease and stress. But, there certainly appears to be a link between psychological stress and both incidence of acute myocardial infarction (MI) and incidence of risk factors associated with MI.

The largest study to examine stress and cardiac disease was the INTERHEART study, a case-control study from 52 countries that examined over 11,000 cases of acute MI and 13,000 controls. Based on a simplified scale for stress at work or home and financial stress, the study found that over one-third more MI sufferers than controls experienced several periods of stress at home or work, and twice as many cases than controls experienced permanent stress at work or home (OR: 1.38, CI: 1.3-1.61 and 2.17, CI: 1.84-2.55, respectively) (Lancet 2004; 364:953-62). This work reinforces smaller studies performed in single countries among smaller cohorts of patients (BMJ 2002; 325:857, Int J Epidemiol 2003; 6:990-7).

Several disease processes that are significant risk factors for coronary artery disease and MI are also more common among patients with chronic stress. The metabolic syndrome is a cluster of risk factors that includes three of the following: abdominal obesity, elevated triglycerides, suppressed HDL cholesterol, elevated blood pressure, and elevated fasting glucose. A prospective study of over 10,000 English patients found the metabolic syndrome to be twice as common among those who reported higher exposure to work-related stress (OR: 2.29, 1.27-4.12) (BMJ 2006 332:521-5). Similarly, multiple studies have found that chronic stressors at work or panic disorder can lead to increased rates of hypertension (J Psychosom Res 1999; 46:215-27, Am J Med 1999; 107:310-6).

Next: Myth debunked?

Chronic and acute stress-induced endothelial dysfunction plays a big role in stress-related cardiac disease. Studies on the effect of mental stress on flow-mediated brachial artery pressure suggest that stress interferes with physiologic arterial dilation (Am J Cardiol 2003; 92:687-91). Administering metyrapone before exposing subjects to mental stress can prevent this change in flow-mediated dilation by blocking production of cortisol (Am J Cardiol 2005; 46:344-50). This relationship between endothelial dysfunction and stress-induced cortisol production suggests a causal relationship and evidence of the important role mental stress plays in development and progression of cardiac disease.

The Journal of the American College of Cardiology released a state-of-the-art paper discussing psychosocial risk factors in cardiology and the “emerging field of behavioral cardiology” in 2005 (J Am Coll Cardiol 2005; 45:637-51). Since that time, the concept of behavioral cardiology has become an important focus in the management of cardiac risk factors. The American College of Cardiology published an update in 2014 that further discusses the evidence relating health behaviors and emotional states to heart disease (J Am Coll Cardiol 2014; 64:100-10).

Myth debunked? The abundance of evidence examining the relationship between stress, MI, and heart disease suggest that this is not a myth. Stress is an important modifiable risk factor for both men and women at risk for MI. Men’s health specialists should therefore incorporate questions about stress levels in their patient interview.

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