Sex Differences in Platelet Reactivity, Cardiovascular and Psychological Response to Mental Stress in Patients With Stable Ischemic Heart Disease: Insights From the Responses of Mental Stress-Induced Myocardial Ischemia to Escitalopram (REMIT) Study

Study Questions:

Are psychological and cardiovascular responses to mental stress different among men and women with stable heart disease?


Data from the REMIT (Responses of Mental Stress–Induced Myocardial Ischemia to Escitalopram) study were used for the present analysis. Participants completed psychometric assessments, transthoracic echocardiography (TTE), and platelet aggregation studies at baseline, and after completion of three mental stress tasks. Mental stress-induced myocardial ischemia was defined as the development or worsening of regional wall motion abnormality, reduction of left ventricular ejection fraction (LVEF) ≥8% by TTE, and/or ischemic ST-segment change on electrocardiogram during one or more of the three mental stress tasks.


A total of 310 participants with known ischemic heart disease (18% women, 82% men) were included. Most baseline characteristics were similar between women and men (including heart rate, blood pressure, and LVEF), although women were more likely to be nonwhite, living alone (p < 0.001), and unmarried (p < 0.001). Women also had higher baseline depression and anxiety (p < 0.05). 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% vs. 41%, p < 0.04), expressed more negative (p = 0.02) and less positive emotion (p < 0.001), and demonstrated higher collagen-stimulated platelet aggregation responses (p = 0.04) than men. Men were more likely than women to show changes in traditional physiologic measures, such as blood pressure (p < 0.05) and double product.


The investigators concluded that in this exploratory analysis, clear, measurable, and differential responses to mental stress in women and men were identified. Further studies should test the association of sex differences in cardiovascular and platelet reactivity in response to mental stress and long-term outcomes.


These data support the hypothesis that women and men experience stress differently. Given the difference in physiologic responses, interventions that reduce stress should be examined for gender differences.

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

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