Home Am I at Risk? Stress and Heart Risk

Stress and Heart Risk

What is stress?

Stress is a mentally or emotionally disruptive condition that occurs in response to outside influences. It is usually characterized by a faster heart rate, a rise in blood pressure, tensing of the muscles, irritability, and depression.

Can stress affect my risk of heart disease?

Yes. However, when researchers talk about the effects of stress, they speak specifically to the kinds of events that trigger this response. Many of these triggers are short term, such as experiencing a death in the family or surviving a car crash. However, stressors that are likely to affect your risk of heart disease are more long term. They are often called chronic stressors. Chronic stressors include those discussed below.

Lack of social support

Social support is the friendship, encouragement, and companionship that family and friends provide. People with fewer connections to friends and family have a higher risk of heart disease and heart attack.41-45 In a review of 15 studies that examined the effects of social factors on heart disease, having a relatively small network of family and friends increased a person’s risk of having heart disease 2- to 3-fold over time, compared with people who have larger social support groups.7

In a study of over 500 women who likely had heart disease, those who had larger, more supportive social networks had fewer risk factors including lower blood sugar levels, lower rates of smoking, and lower rates of high blood pressure and diabetes, and were slimmer than those with smaller social circles.46

While living alone has been shown to increase the risk of heart disease in men,47 the same has not been seen in women because women are more likely than men to develop close friendships outside of marriage.48


Not earning much money increases the risk of heart attacks in both healthy people and those with heart disease. This may be due, in part, to both the stress of poverty and reduced access to healthcare. Poverty has also been linked to poorer health habits, higher rates of heart disease risk factors, increased levels of high-risk behaviors such as smoking and drinking alcohol, and other psychosocial risk factors such as chronic stress.49-52 Researchers also think that much of the risk associated with smaller social circles could be explained by income level.46 A large, all-female study showed that women with the fewest social ties were much more likely to have an annual income below $20,000 and a low income level was significantly associated with an increased risk of death.46 Your income level is also related to the type of work you do, which may influence your stress level.

Work-related stress

The relationship between work stress and heart disease is still up for discussion. Data from a study of more than 3,000 people (44% were women) show that over 10 years, women in high-powered jobs with high degrees of authority and control had almost 3 times the risk of developing heart disease than women in high-demand jobs who had little control over the work they do, such as factory workers.53 This is different than the findings in men, where those with lots of control over their work are less likely to have heart disease than those with busy jobs but little control .54 In another large study of over 10,000 people, being stressed at work was significantly related to heart disease risk in men and women, regardless of job type.54

In a study of more than 1,300 women, having a “high pressure deadline at work” made both men and woman 6 times more likely to have a heart attack within the next 24 hours. A change in financial circumstances tripled a woman’s risk of heart attack. Women were also 3 times more likely to experience a heart attack if they had recently taken on more responsibilities at work, particularly if they were unhappy about these new responsibilities.55

However, the Nurses’ Health Study of more than 35,000 women found that job strain was not related to an increased risk of heart disease. Women in this study were between the ages of 46 and 71 and were followed for an average of 4 years. Though they were all registered nurses, they performed different jobs, some of which were more stressful than others. After adjusting for other risk factors including age and smoking, women in high-strain jobs did not have a higher incidence of heart disease compared with those in low-strain jobs, and neither women in active or passive jobs showed an increased risk of heart disease.56

Marital stress

Marital stress may be a greater risk for women who already have some form of heart disease than for those with healthy hearts. One all-female report found that severe stress in a marriage or live-in relationship can triple a woman’s risk of a second heart attack or angina.57 Marital stress may also affect risk factors. Women in the Pittsburgh Healthy Women Study who were either dissatisfied with their marriage, were divorced, or widowed were significantly more likely to develop metabolic syndrome after nearly 12 years. Single women, however, showed no significant difference from happily married women.58

Caregiver stress

Caring for people who are elderly, ill, or disabled is burdensome and stressful for many families and may lead to depression.59 Studies have shown that female caregivers are less likely to take care of their own health, and their blood pressure tends to rise when they are in the presence of the person they care for.60, 61

In the Nurses Health Study, of more than 54,000 women, those who cared for a disabled or ill spouse for 9 hours or more per week were about twice as likely to develop heart disease in the next 4 years.62 However, caring for disabled or ill parents, children, or friends did not significantly increase a woman’s risk. Other results from the Nurses’ Health Study also showed that being under strain from caregiving could increase your risk of death from any cause.59

Caring for a family member or spouse isn’t always bad for your health. The risks are not due to the act of caregiving alone, but occur only when the act is viewed as stressful.59

How can depression or stress be treated?

There are many things you can do to combat depression and stress. Finding social support either from friends and family or through a support group can be helpful. Managing your stress can also help treat depression.

There are also several different types of treatments available for women who are under a lot of stress—the key is to find the method that is right for you. Many women find that relaxation exercises and meditation help alleviate stress. Relaxation exercises involve the flexing and releasing of major muscle groups. Breathing exercises also help to reduce stress. Exercise has also been shown to be a very effective way of reducing stress because it reduces the amount of stress hormones that your body releases.63 Many cardiac rehabilitation programs also teach stress management techniques.

If you can't lower stress or depression by yourself, you may want professional help. Licensed therapists, psychologists, marriage and family therapists, pastoral counselors, clinical social workers, and psychiatrists offer short-term psychotherapy.63 A psychiatrist may also help a person overcome their depression. Talk to your doctor. There are medications that he or she can prescribe to help treat depression called selective serotonin reuptake inhibitors such as Zoloft and Paxil. Though these medications do have serious side effects, most studies show that they are safe and effective for people with heart disease.64-66 Your doctor can help you weigh the risks and benefits of using these medications.

For more information:

The National Institute of Mental Health

The American Psychological Association

The Depression and Bipolar Support Alliance


1. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. Mar 1 2005;45(5):637-651.
2. Ferketich AK, Binkley PF. Psychological distress and cardiovascular disease: results from the 2002 National Health Interview Survey. Eur Heart J. September 2005;26(18):1923-1929.
3. McCrone S, Lenz E, Tarzian A, Perkins S. Anxiety and depression: incidence and patterns in patients after coronary artery bypass graft surgery. Appl Nurs Res. Aug 2001;14(3):155-164.
4. Con AH, Linden W, Thompson JM, Ignaszewski A. The psychology of men and women recovering from coronary artery bypass surgery. J Cardiopulm Rehabil. May-Jun 1999;19(3):152-161.
5. Wassertheil-Smoller S, Shumaker S, Ockene J, et al. Depression and Cardiovascular Sequelae in Postmenopausal Women: The Women's Health Initiative (WHI). Arch Intern Med. Feb 9 2004;164(3):289-298.
6. Depression: National Institutes of Health; 2000.
7. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation. Apr 27 1999;99(16):2192-2217.
8. Zellweger MJ, Osterwalder RH, Langewitz W, Pfisterer ME. Coronary artery disease and depression. Eur Heart J. 2003;25:3-9.
9. The Numbers Count: Mental Disorders In America: National Institute of Health; 2001.
10. Blazer DG, Kessler RC, McGonagle KA, Swartz M. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry. 1994;151(7):979-986.
11. Carroll BJ, Curtis GC, Davies BM, Mendels J, Sugerman AA. Urinary free cortisol excretion in depression. Psychol Med. Feb 1976;6(1):43-50.
12. Gold PW, Loriaux DL, Roy A, et al. Responses to corticotropin-releasing hormone in the hypercortisolism of depression and Cushing's disease. Pathophysiologic and diagnostic implications. N Engl J Med. May 22 1986;314(21):1329-1335.
13. Veith RC, Lewis N, Linares OA, et al. Sympathetic nervous system activity in major depression. Basal and desipramine-induced alterations in plasma norepinephrine kinetics. Arch Gen Psychiatry. May 1994;51(5):411-422.
14. Owens MJ, Nemeroff CB. The role of corticotropin-releasing factor in the pathophysiology of affective and anxiety disorders: laboratory and clinical studies. Ciba Found Symp. 1993;172:296-308; discussion 308-216.
15. Harris KF, Matthews KA, Sutton-Tyrrell K, Kuller LH. Associations between psychological traits and endothelial function in postmenopausal women. Psychosom Med. May-Jun 2003;65(3):402-409.
16. Hemingway H, Marmot MG. Evidence based cardiology: Psychologocal factors in the aetiology and progosis of coronary heart disease: systematic review of prospective cohort studies. BMJ. 1999;318:1460-1467.
17. Grace SL, Abbey SE, Kapral MK, Fang J, Nolan RP, Stewart DE. Effect of depression on five-year mortality after an acute coronary syndrome. Am J Cardiol. 2005;96:1179-1185.
18. Lane D, Carroll D, Ring C, Beevers DG, Lip GY. Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety. Psychosom Med. Mar-Apr 2001;63(2):221-230.
19. Mayou RA, Gill D, Thompson DR, et al. Depression and anxiety as predictors of outcome after myocardial infarction. Psychosom Med. Mar-Apr 2000;62(2):212-219.
20. Anxiety Disorders. Bethesda, Maryland: National Institue of Health; 2002. 02-3879.
21. Haines AP, Imeson JD, Meade TW. Phobic anxiety and ischaemic heart disease. Br Med J (Clin Res Ed). Aug 1 1987;295(6593):297-299.
22. Kawachi I, Colditz GA, Ascherio A, et al. Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation. May 1994;89(5):1992-1997.
23. Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation. Nov 1994;90(5):2225-2229.
24. Albert CM, Chae CU, Rexrode KM, Manson JE, Kawachi I. Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women. Circulation. Feb 1 2005;111(4):480-487.
25. The American Heritage Stedman's Medical Dictionary: Houghton Mifflin Company; 2002.
26. Rosenman RH, Brand RJ, Jenkins CD, Friedman M, Straus R, Wurm M. Coronary heart disease in the Western Collaborative Group Study: final follow-up experience of 8 1/2 years. JAMA. 1975;233:872-877.
27. Dimsdale JE, Hackett TP, Hutter AM, Jr., Block PC, Catanzano DM, White PJ. Type A behavior and angiographic findings. J Psychosom Res. 1979;23(4):273-276.
28. Shekelle RB, Hulley SB, Neaton JD, et al. The MRFIT behavior pattern study. II. Type A behavior and incidence of coronary heart disease. Am J Epidemiol. Oct 1985;122(4):559-570.
29. Case RB, Heller SS, Case NB, Moss AJ. Type A behavior and survival after acute myocardial infarction. N Engl J Med. Mar 21 1985;312(12):737-741.
30. Ragland DR, Brand RJ. Type A behavior and mortality from coronary heart disease. N Engl J Med. Jan 14 1988;318(2):65-69.
31. Shekelle RB, Gale M, Norusis M. Type A score (Jenkins Activity Survey) and risk of recurrent coronary heart disease in the aspirin myocardial infarction study. Am J Cardiol. Aug 1 1985;56(4):221-225.
32. Knox SS, Weidner G, Adelman A, Stoney CM, Ellison RC. Hostility and psychological risk in the National Heart, Lung, and Blood Institute Family Study. Arch Intern Med. Dec 13-27 2004;164:2442-2448.
33. Sloan RP, Shapiro PA, Bagiella E, Myers MM, Gorman JM. Cardiac autonomic control buffers blood pressure variability response to challenge: A psychophysiological model of coronary artery disease. Psychosomatic Medicine. 1999;61:58-68.
34. Chaput LA, Adams SH, Simon JA, et al. Hostility predicts recurrent events among postmenopausal women with coronary heart disease. Am J Epidemiol. Dec 15 2002;156(12):1092-1099.
35. Matthews KA, Owens JF, Kuller LH, Sutton-Tyrrell K, Jansen-McWilliams L. Are hostility and anxiety associated with carotid atherosclerosis in healthy postmenopausal women? Psychosom Med. Sep-Oct 1998;60(5):633-638.
36. Matsumoto Y, Uyama O, Shimizu S, et al. Do anger and aggression affect carotid atherosclerosis? Stroke. Jul 1993;24(7):983-986.
37. Knox SS, Adelman A, Ellison RC, et al. Hostility, social support, and carotid artery atherosclerosis in the National Heart, Lung, and Blood Institute Family Heart Study. Am J Cardiol. Nov 15 2000;86(10):1086-1089.
38. Julkunen J, Salonen R, Kaplan GA, Chesney MA, Salonen JT. Hostility and the progression of carotid atherosclerosis. Psychosom Med. Nov-Dec 1994;56(6):519-525.
39. Surtees P, Wainwright N, Luben R, Day N, Khaw K. Prospective cohort study of hostility and the risk of cardiovascular disease mortality. Int J Cardiol. Apr 8 2005;100(1):155-162.
40. Haas DC, Chaplin WF, Shimbo D, Pickering TG, Burg M, Davidson KW. Hostility is an independant predictor of recurrent coronary heart disease events in men but not women: results from a population based study. Heart. Nov 23 2005;91:1609-1610.
41. House JS, Robbins C, Metzner HL. The association of social relationships and activities with mortality: prospective evidence from the Tecumseh Community Health Study. Am J Epidemiol. Jul 1982;116(1):123-140.
42. Berkman LF, Syme SL. Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. Am J Epidemiol. Feb 1979;109(2):186-204.
43. Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction. A prospective, population-based study of the elderly. Ann Intern Med. Dec 15 1992;117(12):1003-1009.
44. Orth-Gomer K, Rosengren A, Wilhelmsen L. Lack of social support and incidence of coronary heart disease in middle-aged Swedish men. Psychosom Med. Jan-Feb 1993;55(1):37-43.
45. Welin L, Tibblin G, Svardsudd K, et al. Prospective study of social influences on mortality. The study of men born in 1913 and 1923. Lancet. Apr 20 1985;1(8434):915-918.
46. Rutledge T, Reis SE, Olson M, et al. Social networks are associated with lower mortality rates among women with suspected coronary disease: The National Heart, Lung and Blood Institute-sponsored Women's Ischemic Syndrome Evaluation Study. Psychosomatic Medicine. Nov-Dec 2004;66(6):882-888.
47. Nakatani D, Sato H, Sakata Y, et al. Living alone is an independent predictor of future cardiac events not in female but in male elderly patients after acute myocardial infarction. J Am Coll Cardiol. Feb 1, 2005 2005;45(3):Suplement A.
48. Frasure-Smith N, Lesperance F, Juneau M, Talajic M, Bourassa MG. Gender, depression, and one-year prognosis after myocardial infarction. Psychosom Med. Jan-Feb 1999;61(1):26-37.
49. Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet. Jul 26 1997;350(9073):235-239.
50. Winkleby MA, Fortmann SP, Barrett DC. Social class disparities in risk factors for disease: eight-year prevalence patterns by level of education. Prev Med. Jan 1990;19(1):1-12.
51. Barefoot JC, Peterson BL, Dahlstrom WG, Siegler IC, Anderson NB, Williams RB, Jr. Hostility patterns and health implications: correlates of Cook-Medley Hostility Scale scores in a national survey. Health Psychol. 1991;10(1):18-24.
52. Baum A, Garofalo JP, Yali AM. Socioeconomic status and chronic stress: Does stress account for SES effects on Health? Annals of the New YorkAcademy of Sciences. 1999;896:131-144.
53. Eaker ED, Sullivan LM, Kelly-Hayes M, D'Agostino RB, Sr., Benjamin EJ. Does job strain increase the risk for coronary heart disease or death in men and women? The Framingham Offspring Study. Am J Epidemiol. May 15 2004;159(10):950-958.
54. Kuper H, Marmot M. Job strain, job demands, decision latitude, and risk of coronary heart disease within the Whitehall II study. J Epidemiol Community Health. Feb 2003;57(2):147-153.
55. Moller J, Theorell T, de Faire U, Ahlbom A, Hallqvist J. Work related stressful life events and the risk of myocardial infarction. Case-control and case-crossover analyses within the Stockholm heart epidemiology programme (SHEEP). J Epidemiol Community Health. Jan 2005;59(1):23-30.
56. Lee S, Colditz G, Berkman L, Kawachi I. A prospective study of job strain and coronary heart disease in US women. Int J Epidemiol. Dec 2002;31(6):1147-1153; discussion 1154.
57. Orth-Gomer K, Wamala SP, Horsten M, Schenck-Gustafsson K, Schneiderman N, Mittleman MA. Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. Jama. Dec 20 2000;284(23):3008-3014.
58. Troxel WM, Mathews KA, Gallo LC, Kuller LH. Marital quality and occurence of the metabolic syndrome in women. Arch Intern Med. 2005;165:1022-1027.
59. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. Jama. Dec 15 1999;282(23):2215-2219.
60. Schulz R, Newsom J, Mittelmark M, Burton L, Hirsch C, Jackson S. Health effects of caregiving: the caregiver health effects study: an ancillary study of the Cardiovascular Health Study. Ann Behav Med. Spring 1997;19(2):110-116.
61. King AC, Oka RK, Young DR. Ambulatory blood pressure and heart rate responses to the stress of work and caregiving in older women. J Gerontol. Nov 1994;49(6):M239-245.
62. Lee S, Colditz GA, Berkman LF, Kawachi I. Caregiving and risk of coronary heart disease in U.S. women: a prospective study. Am J Prev Med. Feb 2003;24(2):113-119.
63. Health NIoM. Depression. National Institutes of Mental Health. Available at: http://www.nimh.nih.gov/publicat/depression.cfm#ptdep7. Accessed 1/20/05, 2005.
64. Glassman AH, O'Connor CM, Califf RM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. Jama. Sep 14 2002;288(6):701-709.
65. Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. Jama. Jun 18 2003;289(23):3106-3116.
66. Sauer WH, Berlin JA, Kimmel SE. Selective serotonin reuptake inhibitors and myocardial infarction. Circulation. Nov 16 2001;104(16):1894-1898
67. Whang W, Kubzansky LD, et al. Depression and Risk of Sudden Cardiac Death and Coronary Heart Disease in Women. J Am Coll Cardiol. 2009;53:950-8.


Subscribe to our
monthly newsletter