Are There Sex Differences in Mental Stress-Induced Myocardial Ischemia?

Men and women have different cardiovascular and psychological reactions to mental stress, according to a study published Oct. 13 in the Journal of the American College of Cardiology.

Over the years mental stress has steadily grown greater traction as a potentially modifiable nontraditional risk factor of cardiovascular disease. However, the sex-specific differences in the psychobiologic response to mental stress have not been clearly identified, potentially providing valuable clues towards understanding overall cardiovascular disease between men and women.

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To assess the sex-specific differences across multiple important domains in cardiovascular disease pathophysiology and prognosis, including cardiovascular reactivity, platelet aggregation and cardiovascular ischemic responses, the study looked at 56 women and 254 men diagnosed with heart disease enrolled in a larger REMIT study of the impact of the medication escitalopram on heart disease induced by mental stress.  The study’s patients underwent psychometric assessments, transthoracic echocardiography (TTE), and platelet aggregation studies at baseline and after three mental stress tasks.

With mental stress-induced myocardial ischemia defined as the development or worsening of regional wall motion abnormality, a reduction of left ventricular ejection fraction (LVEF) ≥8 percent by TTE, and/or ischemic ST-segment change on electrocardiogram during one or more of the three mental stress tasks, results showed that in the 310 participants, most baseline characteristics were similar between women and men, including heart rate, blood pressure, and LVEF. Women did have a higher baseline of depression and anxiety (p < 0.05), and at rest, women had heightened platelet aggregation responses to serotonin (p = 0.007) and epinephrine (p = 0.004) compared with men.

Following mental stress, women had more mental stress-induced myocardial ischemia (57 percent vs. 41 percent; p < 0.04), expressed more negative (p = 0.02) and less positive emotion (p < 0.001), as well as demonstrated higher collagen-stimulated platelet aggregation responses (p = 0.04) than men. Men meanwhile were more likely than women to display changes in traditional physiologic measures like blood pressure (p < 0.05) and double product.

“This study revealed that mental stress affects the cardiovascular health of men and women differently,” said Zainab Samad, MD, MHS, FACC, lead author of the study and assistant professor of medicine at Duke University Medical Center, Durham, NC. “We need to recognize this difference when evaluating and treating patients for cardiovascular disease.”

He adds that the study “underscores the inadequacy of available risk prediction tools, which currently fail to measure an entire facet of risk, i.e. the impact of negative physiological responses to psychological stress in both sexes, and especially so among women,” and that moving forward, “further studies are needed to test the association of sex differences in the heart’s responses to mental stress and long term outcomes.”

“In his 1992 book, Men Are From Mars, Women Are From Venus, author John Gray argues that women and men have such fundamental psychological differences in their responses to mental stress that they can be thought of as though they came from different planets,” write Ibhar Al Mheid, MD, and Arshed Quyyumi, MD, FACC, in a coinciding editorial. External Link “The provocative findings of Samad et al. certainly provide impetus for further research in understanding the influence of sex on mental stress-mediated cardiovascular responses including myocardial ischemia and leaves unanswered the question of whether women are really from Venus.”

Clinical Topics: Noninvasive Imaging, Prevention, Statins, Echocardiography/Ultrasound, Stress

Keywords: Depression, Myocardial Ischemia, Anxiety, Risk Factors, Blood Pressure, Citalopram, Electrocardiography, Heart Rate, Stress, Psychological, Academic Medical Centers, Psychometrics, Epinephrine, Platelet Aggregation, Serotonin, Stroke Volume, Collagen, Echocardiography

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