Stressors From All Sides Impact Women’s CV Risk, Review Asserts

Women, compared with men, deal with a higher dose of psychosocial stressors: difficult life situations and events that exert pressure on mental and physical health. Addressing these strains could be an important tool for both primary and secondary CVD prevention, a new review article asserts.

Imo A. Ebong, MD (University of California Davis, Sacramento), the review’s lead author, told TCTMD that it’s essential to spread the word on this link.

“There's psychosocial stress everywhere, and women in particular are really being exposed to a lot of stress,” she said. That “adversity” can present itself in many environments, whether at home when caring for loved ones or at work when trying to ensure their own voices are heard, added Ebong. “Sometimes, as women, we don't even know that we are undergoing that stress,” much less that this stress can impact heart health or that that they personally could be affected by CVD.

These knowledge gaps are in fact an opportunity, Ebong stressed. “If we don't make the changes now when we're exposed to these risk factors, then we're definitely going to have to face or deal with the consequences in later life.”

The document, created by members of the American College of Cardiology Cardiovascular Disease in Women Committee, was published online ahead of print earlier this week in the Journal of the American College of Cardiology. “Psychosocial stress is a key modifiable risk factor for women, especially for young and midlife women and those in underrepresented groups,” its authors emphasize.

Nobody's immune to stress, because stress is everywhere in this society. Imo A. Ebong

Evidence continues to grow that “women face unique propensity toward the cardiovascular consequences of psychosocial stress,” the paper notes. Women bear a disproportionate burden of abuse, financial disadvantage, discrimination, and other stressors compared with men and, perhaps as a result, are more likely to have stress-related mood and anxiety disorders.

Importantly, they “are also more susceptible to adverse cardiovascular sequelae from these exposures,” whether that’s development of CVD or events in people who already have CVD, Ebong and colleagues say. The experience of menarche, pregnancy, and menopause can exacerbate stress.

Female patients are twice as likely to experience stress-provoked myocardial ischemia than men, for example, and have a much higher prevalence of conditions like spontaneous coronary artery dissection and Takotsubo cardiomyopathy that can result from intense stress. Potential mechanisms are many, from neurobiology to vascular dysfunction, immune dysfunction, and inflammation. Behavioral pathways include things like disengagement in self-care, lack of physical activity, sleep disturbances, poor dietary quality, and smoking.

On a broader level, too, there are social determinants of health that affect the lives of many women, but especially those of Black and Hispanic women, who are more apt to experience “residential segregation, discrimination, unhealthy environments, financial strain, and poor access to resources,” the review points out.

As an African-American woman, Ebong said, the experience of pulling this review together has inspired her to look at her own stressors and ask, “What am I doing to protect myself?” For example, the concept of the “superwoman,” or being a strong Black woman, hit home. “I think seeing myself in the picture of what I was writing was a surprise. . . . Feeling like you can fix everything, feeling like you can do everything when you're really stressed,” she said.

It will take a multipronged approach to address the manifold sources of psychosocial stress, the review’s authors suggest. They cite individual solutions (eg, cognitive behavioral therapy, biofeedback, stress management and lifestyle coaching, and relationship therapy) as well as those on a community level (eg, neighborhood coalitions to address specific stressors like crime, culturally sensitive community support networks, investment in a community-based health workforce, and geomapping to target resources to disadvantaged areas) and policy level (eg, affordable housing, effective transportation networks, antipoverty programs, and inclusion of women in clinical trials).

Their main goal in writing the review was to create awareness, said Ebong, but there are also lessons that be applied in clinical practice.

“I want us to begin to think about a sex-specific approach when we are performing risk stratification. [Without doing that], we will not be able to address inequities that persist in cardiovascular disease between men and women,” she said. Beyond awareness, “the next step should be to begin to think about how we can incorporate these differences” through things like screening for psychosocial stress and investigating how to incorporate it into risk scores. Clinical trials should be done to inform guidelines for screening and management. Pay-for-performance models could be used to incentivize providers, too.

What’s important to recognize is that this is an issue with broad implications, Ebong commented. “Nobody's immune to stress, because stress is everywhere in this society.”