It’s not a coincidence that we associate strong emotions with the heart: wild things make our hearts sing, and our hearts break when we lose a loved one. The connection between the brain’s emotional regulation center, the amygdala, and the cardiovascular system has been the subject of plenty of research, and especially as neuroimaging has advanced, the relationship is undeniable (find more examples here, here, and here).
It’s also not a new idea that stress causes heart disease. Cardiac patients have been told to lower their stress levels for decades by avoiding strenuous activity — but unfortunately, they haven’t been told much more than that. Healthcare providers tend to focus more on things that are easily measurable like medication adherence, blood pressure, smoking, and cholesterol. Stress seems like a slippery, messy, wishy-washy concept that we are not well equipped to address. But some recent science suggests the role of mental stress in cardiovascular disease might be more significant than previously understood. In light of this evidence, a deeper dive into the concept of stress is warranted.
Stress: what it does to the body
Stress is the body’s physical and mental response to changes and challenges (stressors). The stressors themselves can be physical, like hard exercise or injury, or mental, like emotional upset or trauma. Some of the body’s responses are helpful, especially in the short term.
Increased alertness, heightened perception, increased blood flow to muscles, and increased energy availability can help you respond to a stressor. Appropriate levels of stress can also lead to adaptation over time. However, when stress is chronically high, these mechanisms can become maladaptive, and without time to rest and recuperate, adaptation doesn’t occur.
In mental stress, the brain responds to fear (processed in the amygdala) by activating the sympathetic nervous system (that’s the fight-or-flight response). This sets off a cascade of hormones that can serve to protect the body from danger acutely, but chronic activation can result in increased body fat, insulin resistance, hypertension, vascular inflammation, and atherosclerosis.
Chronic systemic inflammation created through these mechanisms is also a potential consequence of ongoing stress. A chronic inflammatory state is associated with a host of chronic illnesses. This is one likely mechanism for how poverty, racism, abuse, and other so-called social determinants of health are major contributors to observed health disparities.
So what does the evidence say?
A large (n=24,767) case-control study published in the journal Lancet in 2004 reported that psychological stress was an independent predictor of later heart attacks. A more recent study published in JAMA late last year (including 918 patients over nine years) reiterates this finding with more specificity. Not only can mental stress lead to cardiac ischemia (reduced blood flow to the heart), but patients who develop mental stress-induced ischemia are more likely to experience heart attacks and to die over the next four to eight years. These findings tell us clearly that in people with any degree of underlying heart disease, mental stress is strongly associated with heart attacks and death. This isn’t a negligible effect or a questionable outcome. These are meaningful, relevant endpoints, and we should care about them.
Is there a prescription for stress?
Perhaps you work in, or get care in, a patient-centered medical home with an integrated behavioral health team that has the training and resources to coach people through long-term, evidence-based stress management programs. But probably not. Absent a perfect solution, what tools do healthcare providers and patients have at their disposal? Physical exercise is one tool that can reliably modulate the body’s stress responses, including inflammation. Others include consistent, high-quality sleep, mindfulness practices, and an anti-inflammatory diet pattern. For some, medication to treat anxiety or depression can lessen activation of the stress response.
Exercise, get good sleep, eat well, meditate, and take your medication? This list reads like a who’s who of behaviors that are hard to change. For people who are used to getting simple prescriptions from their healthcare providers, advice to make changes to their lives and habits is often ineffective. Most people don’t have experience with positive goal setting and behavior change, and most clinicians think they lack the expertise and/or time to counsel them. There are promising models to address these challenges, including group visits, behavior change specialists embedded into primary care, integrative medicine practices, and health coaching. For many, though, these services are not available, too expensive, or otherwise out of reach.
Practical tips for providers & patients to try
So what CAN you do, as a clinician or a patient seeking to encourage stress reduction as a means to reduce cardiac risk? First, acknowledge that this is a different kind of prescription — not everyone will be game for it. Ask your patient (or yourself) if they’re willing to try this approach. If they are, here are some tips to guide you.
- Make it meaningful. Scare tactics don’t work. Tying change to individual values does. Try asking an open-ended question like “what do you want to be in good health for?”.
- Make it personal. Consider offering some possible directions and seeing which one sounds most interesting, doable, or important. For some, increasing physical activity will be appealing; for others, it may seem impossible. Explore what will work best for each individual.
- Make it specific. Trying to make huge, sweeping changes is overwhelming. Advice to “eat better” or “exercise more” doesn’t create a path forward. Offer targeted information and encourage identifying small, manageable actions steps, one at a time.
- Offer affirmation & accountability. Believe in each person’s strengths, acknowledge their skills and successes, and help them stay connected to their intention to change. For some people, a reminder letter or a quick question at a follow-up visit will do the trick. Others might find keeping a log or looping in a loved one helps.
This process, believe it or not, can be accomplished in just a few minutes if that’s all you have. If you don’t believe me, give it a try! With a little practice, I’ve been able to implement this style of counseling into routine primary care visits without getting behind. As an added bonus, most people really value being listened to in this way.
Clearly, brief counseling in medical visits is not a panacea and won’t undo stress, especially chronic stress from poverty or racism. But it is an inexpensive, empowering, and science-based risk reduction strategy that anyone can implement in any setting — and that’s a great place to start. Are you ready to add stress reduction to your cardiac risk management toolkit?
Elizabeth Knight is a scientist, nurse practitioner, educator, and coach. You can find her at www.flowerpower.health.