Stress, anxiety and menopause can take a hard toll on women's cardiac health

That hospital might have been in a different country but the response was similarly dismissive. “They looked at my age and health history and assumed I’d recover without much intervention,” she says.

“I spent four days on the ward before I begged a student nurse to ask another consultant to take a look at me.” Six days after the onset of symptoms, Reeves was diagnosed with a rare condition called streptococcus pneumoniae bloodstream infection with purulent pericarditis.

“Basically, infectious fluid had built up around my heart, constraining its function,” she says.

In hindsight, Reeves’ GP identified stress as a contributory factor to her becoming so ill. “I’d been under stress at work for five years at that point,” she says.

“I’d spoken out about workplace bullying and suffered retaliation as a result. I’d been following an internal complaints process against my employer and was so worried about it. My entire career, finances and dignity rested on the outcome.” The situation had affected her mental health and she’d sought help with anxiety and low mood. “I didn’t realise that my physical health had suffered too,” says Reeves. “My GP has since said that they think stress obliterated my immunity. When I got the flu, my body couldn’t take anymore and my heart took the toll.”

One of the reasons why it took medics so long to realise that something might be wrong with Reeves’ heart could be because women have historically been thought to have a lower risk of cardiovascular issues than men.

Yet statistics disprove this. In 2022, 4,656 women died from cardiovascular disease (CVD) in Ireland, only slightly less than the 4,996 men who died of the same condition.

Dr Angie Brown, a consultant cardiologist and the medical director of the Irish Heart Foundation, believes the misapprehension persists because women tend to develop cardiovascular problems at a later age, following menopause.

“Menopause causes a drop in oestrogen and lower oestrogen has been shown to lead to higher LDL, or bad cholesterol,” she says. “So when women reach menopause, they catch up to men in terms of their cardiovascular risk.” Reeves wasn’t menopausal when she developed her heart problem. But a study presented at the American College of Cardiology’s Annual Scientific Session this April [exa.mn/14h] placed her slap bang in the middle of another at-risk group, young and middle-aged women who have depression or anxiety.

“In general terms, younger women are at low risk of CVD due to the protective effects of oestrogen,” says Dr Giovanni Civieri, a cardiologist, research fellow at Harvard Medical School and lead author of this study. “However, previous research had shown that the association between certain mental health conditions and CVD was stronger in young women.” This research included an 18-year-long study of 860 Australian women [exa.mn/1w8] which concluded that having a depressive disorder was the biggest risk factor for coronary heart disease in women.

Civieri’s team wanted to find out what was behind this. They tracked 71,214 people over 10 years and found that those with a history of anxiety or depression were 55% more likely to develop high blood pressure, cholesterol and diabetes, which are all risk factors for CVD, than those without this history. This finding was most pronounced in women under 50.

With rates of anxiety and depression on the increase in young people, Civieri thinks doctors should be aware of the ramifications of this on women’s cardiovascular health.

“Younger women are still the safest group when it comes to the development of cardiovascular risk factors,” he says. “But once a younger woman has anxiety or depression, screening for those risk factors might be warranted.” Reeves wasn’t just experiencing anxiety and low mood. As her GP pointed out, her stress was also chronic.

Brown explains how stress can affect heart health by causing elevated levels of adrenaline and cortisol in the body: “These hormones raise the heart rate and blood pressure and release more glucose into the bloodstream. Over time, this can have a detrimental impact by increasing the risk of high blood pressure and weight gain. Stress can also increase levels of inflammation in the arteries. All of this heightens cardiovascular risk.”

Emotional distress can take a toll on the heart too. Dr Róisín Colleran, a consultant cardiologist with the Mater Private Network in Dublin, points to broken heart syndrome, which is also known as stress cardiomyopathy.

“It’s a sudden, usually temporary, weakness of the heart muscle that typically occurs after an emotionally stressful event and about 90% of those who suffer from it are women, usually postmenopausal,” she says.

Colleran has seen it in bereaved patients and in those who have had upsetting arguments. “They experience a surge of stress hormones which somehow interferes with their heart muscle. They present with all of the symptoms of a heart attack but as they don’t have the blocked arteries that typically cause heart attacks, most will find that their heart function returns to normal with time and the right medications. A minority though can become very unwell and may even die.

 Spontaneous coronary artery dissection, where the lining of a coronary artery tears, leading to a heart attack, is another condition that mostly affects women. “Again, it’s about 90% women and it’s triggered by emotional or physical stress such as strenuous exercise,” says Colleran.

While the reasons for women’s susceptibility to those conditions is still unknown, it’s becoming clear that emotional stress has unique consequences for women’s heart health. Take the findings of a 2007 American study of 3,600 men and women for example. It showed that when women bottled up their feelings during fights with their spouse, they were four times more likely to die within the following 10 years than women who spoke their minds. No such effect was seen in men.

Another disparity between the sexes is that men and women can present with different cardiovascular symptoms. “The most common complaint in both men and women is chest discomfort,” says Colleran. “But in those who do not experience that, atypical symptoms such as nausea, vomiting, shortness of breath or a pain in the neck or jaw are more common in women. This helps to explain why there can sometimes be a delay in diagnosing women.” The gender bias that exists when it comes to researching CVD could explain this delay too. To date, most trials investigating the effects of drugs and interventions have predominantly focused on men. A case in point is the Harvard Physicians’ Health Study of the 1980s. Of its 22,000 participants, there wasn’t a single woman.

This has led to a lack of understanding of women’s heart health. That lack could be why a 2016 University of Leeds study found that women presenting with a heart attack were 50% more likely to be misdiagnosed than men. Or why an international study published in 2020 revealed that women were less likely to be prescribed protective medications such as cholesterol-lowering statins to protect against future cardiovascular events.

Rather than frightening women, Colleran thinks that research like this should motivate them to be more proactive about their health.

She’s already seeing this in her clinic. “I see women in their 40s and 50s who don’t necessarily have symptoms but are getting themselves checked rather than waiting for problems to arise,” she says. “That allows for potential problems to be identified and addressed before they escalate.”

She would like the latest finding regarding anxiety and depression to have a similar effect by raising awareness among women and their doctors. “As doctors, we want to identify and treat people who are at risk,” she says. “If women are more aware of their individual risk factors, they can then ask their doctors to check them accordingly.” Civieri’s team is now planning to investigate whether the treatment of anxiety and depression could reduce the development of CVD risk factors. While we await their conclusions, Brown’s advice to women who are currently feeling anxious and depressed is to get their health checked.

“Ask your doctor to test your blood pressure, cholesterol and blood glucose levels,” she says. “And try to eat a healthy diet.”

As for Reeves, she is taking steps to manage her stress. 

“I ended up having surgery to drain the fluid from around my heart and spent six weeks in hospital recovering,” she says.

“I’m so aware of the role stress played in that happening to me so I make sure to minimise it where possible.” This has meant leaving her old job. “I now work remotely for an autism mentoring agency and it’s a world away from what I experienced previously.” It has also meant responding to cues from her body. “I listen to its demands for rest and sleep,” she says. “I eat healthily and I get enough exercise.” She finds journalling useful too. “It’s a great way of letting go of things that might be worrying me,” she says.

Her advice to other women is to always reach out for help when they need it. “And be insistent if people try to downplay what you’re experiencing,” she says. “Your life is in your hands. I don’t think I’d be alive today if I hadn’t pleaded to be heard.”

What to do:

Emerging research shows that women who are diagnosed with anxiety or depression have a higher risk of developing CVD. However, Dr Angie Brown, a consultant cardiologist and the medical director of the Irish Heart Foundation, points out that it might not be anxiety or depression in themselves that elevate women’s risk. It could be the poor health conditions associated with these conditions.

Whether they have anxiety or depression or not, what are the positive health behaviours that women can follow to reduce their cardiovascular risk?

• Stop smoking.
• Reduce your alcohol intake.
• Try to move more and to exercise regularly.
• Spend less time sitting. Sedentary behaviour is recognised as a risk factor all of its own.
• Eat a balanced diet that is low in processed foods, cakes and sweets and high in fresh fruit and vegetables, lean meats and fish.
• Prioritise your sleep.
• Get yourself checked regularly. After menopause, blood pressure, cholesterol and blood glucose levels should be checked annually.
• Know your risk factors. These include high blood pressure, high cholesterol levels, a family history of heart disease and diabetes, and according to this new research, a diagnosis of anxiety or depression.
• Follow your doctor’s advice on how to manage these risk factors.
• Prioritise your sleep.
• Manage your stress by exercising, spending time with family and friends or practicing stress-reduction techniques such as mindfulness, meditation or a hobby that you enjoy.
• If you experience any discomfort in your chest or any other worrying symptoms, seek medical help immediately.