Mental Stress and Myocardial Ischemia: Young Women at Risk

W omen with obstructive coronary artery disease (CAD) have poor outcomes relative to otherwise comparable men. More women than men die after a first myocardial infarction. Younger women (<55 years) have a particularly unfavorable prognosis after myocardial infarction relative to male counterparts. Mechanisms for these differential outcomes are unclear, but since younger women have worse preevent health status versus men, including lower overall and mental health qualities of life, it is likely that the adverse condition begins long before the acute event. Attention has increasingly focused on psychosocial or mental stressors as potential nontraditional CAD risk conditions. In the Psychophysiological Investigations of Myocardial Ischemia Study, we found that mental stress– induced ischemia predicted increased risk for all-cause mortality in patients with obstructive CAD and exerciseinduced ischemia. In a cohort of women with symptoms and signs of ischemic heart disease (mean age 58 years) from the Women’s Ischemia Syndrome Evaluation, mostly without obstructive CAD, we found associations between psychosocial factors and premature mortality. Over 9.3 years, the Spielberger Trait Anxiety Index and Beck Depression Inventory scores (hazard ratio 1.09, 95% CI 1.02–1.15, and hazard ratio 0.86, CI 0.78–0.93, respectively) and very good self-rated health (versus poor self-rated health, hazard ratio 0.33, CI 0.12–0.96) each independently predicted mortality risk. These results extend prior knowledge in female ischemic heart disease /CAD populations. Clearly, psychosocial factors link with adverse outcomes among women with ischemic heart disease, but how mental stress uniquely modulates the course of younger women remains unclear.