STRESS PASS

Stress and the heart: Why the hype doesn’t match the facts

“Ashok was working too hard. All that stress must have caused his heart attack,” declared a colleague to the anxious relatives as they waited outside the ICU. At only 47, Ashok was a successful entrepreneur. The relatives were impressed at the confidence and apparent wisdom of Ashok’s colleague. “I heard someone at my cousin’s office also had a similar problem,” a bystander added.

However, after the evaluation, the doctor explained that Ashok’s heart attack resulted from years of neglecting his health. He had been gaining weight around his middle, his metabolic parameters were abnormal, and he had a history of high blood pressure but refused medication. Citing work pressure, Ashok didn’t exercise or get enough sleep, and he had taken up smoking in an attempt to relieve his tension.

“A lie can travel halfway around the world, while truth is still putting on its shoes,” says a quote attributed to Mark Twain. Many of the things we believe about health are myths, but they circulate widely because they are not only convincing, but also convenient. The more the number of people who share them, the more cemented these beliefs become.

Stress and heart health is one such topic. When young adults die unexpectedly, stress is often blamed — even before the cause of death is determined. To be clear, stress does not directly cause heart attacks; however, it can worsen other known risk factors.

What is a heart attack?
A heart attack occurs when one of the coronary arteries supplying blood to the heart muscle becomes suddenly blocked, depriving the heart muscle of oxygen. This can lead to symptoms such as severe chest pain, sweating, shortness of breath and nausea.

If the blockage is not relieved through treatments like a clot-busting injection (thrombolysis) or primary angioplasty, a portion of the heart muscle may die, resulting in a condition known as myocardial infarction. While many patients recover fully, some may experience complications or may not survive.

How does it occur?
A critical event in a heart attack is the rupture of a plaque on the wall of a coronary artery. When the plaque ruptures, its inner material gets exposed, attracting platelets and clotting factors that contribute to the formation of a blood clot. This clot can obstruct blood flow, leading to a heart attack.

Is a heart attack the same as cardiac arrest?
No. A cardiac arrest refers to any situation where the heart stops beating effectively. This can occur due to many reasons, one of which is a myocardial infarction or heart attack.
Other causes include rhythm disturbances (arrhythmias), cardiomyopathy, electrolyte abnormalities, drug overdose and severe breathing difficulty of any cause. It requires immediate CPR, which has been described in an earlier article.

What are the risk factors for a heart attack?
Unlike tuberculosis, that has a single causative agent (bacteria), many conditions such as cancer, heart disease and diabetes are multifactorial. Rather than a single cause, they have associated risk factors. The greater the number of risk factors, the higher the likelihood of a heart attack. The ten established risk factors are:
1) Age
2) Gender
3) Diabetes
4) High blood pressure
5) Smoking
6) High LDL Cholesterol
7) Harmful use of alcohol
8) Obesity
9) Lack of exercise
10) Family history of early onset heart disease

Importantly, these risk factors are additive. For example, smoking poses a greater cardiovascular risk for a person with diabetes, compared to someone without diabetes.

What about stress? Is it not a risk factor?
Stress is not recognized as a direct risk factor for heart attacks by major professional societies. It is not included in coronary risk calculators, including AHA/ACC, PREVENT or QRISK3.

Although it is widely believed that stress causes heart attacks, it is what some indivuduals do (or fail to do) in response to stress that often causes trouble. For example, they might smoke or drink heavily, binge eat, skip medical checkups, refuse or stop essential medications and follow shortcuts from social media for significant conditions like hypertension. Besides, chronic stress raises blood pressure. Sedentary lifestyle, alcohol use and high-salt diet also aggravate hypertension. Cumulatively, these behaviours negatively impact cardiovascular health.

What do professional societies say about stress and heart attacks?
Professional societies indicate that while stress does not directly cause heart attacks, it can contribute by interacting with other well-established risk factors such as high blood pressure, high cholesterol, smoking, obesity, diabetes and lack of exercise.

A detailed Cochrane review of 35 randomised controlled trials found that stress reduction interventions did not significantly reduce mortality or prevent major cardiovascular events.

What about Takotsubo syndrome?
It is a rare condition often heard in the context, dramatically referred to as “broken heart syndrome.” It typically occurs in older women after sudden and intense emotional trauma. A portion of the heart wall weakens temporarily, and this is reversible. It is not a heart attack because there is no blockage in the coronary arteries.

Is there anything good about stress?
Unlike smoking or blood pressure, stress lacks a clear definition; what one person finds stressful may not affect another in the same way. Almost everyone encounters stressful situations, many of which they use constructively.

In fact, moderate stress can enhance work efficiency. For instance, the day before an exam, many students find they can focus better and study more effectively in a limited time. Similarly, the threat of unexpected guests visiting can motivate a quick house cleanup. Athletes often perform at their best under pressure, channelling stress to drive their performance.

While these examples reflect manageable stress, toxic work environments or unhealthy relationships can lead to feelings of dejection, also reducing productivity in the process. This leads to more stress, setting off a vicious circle.

Are all sudden deaths due to heart attacks?
Although heart attacks are a major cause of sudden deaths, there are several other possible reasons, especially among younger adults. Brain haemorrhage (bleed), pneumonia, meningitis, malaria, suicide, heart rhythm abnormalities, heart muscle disorders, COVID-19 and drug abuse are a few. A post-mortem can reveal the cause on most occasions.

Social media claims vaccines cause sudden deaths. Is it true?
False. There is no scientific proof that COVID vaccination causes sudden deaths. This was addressed in an earlier article, which also discusses heart attacks in young adults in detail.

In fact, severe COVID-19 is associated with cardiovascular events due to its impact on the endothelium (the inner lining of blood vessels). A recent study from England revealed that individuals who survived severe COVID-19 in 2020 (prior to the availability of vaccines) experienced higher cardiovascular mortality in the following three years.

How important is sleep in heart health?
Poor sleep quality is linked to atherosclerosis, or the hardening of coronary arteries. It can indirectly impact heart health by increasing blood pressure and cortisol levels. Inadequate sleep contributes to insulin resistance, a key factor in metabolic syndrome, which includes hypertension, diabetes, and high cholesterol.

Research indicates that not only insufficient sleep but also excessive sleep and disordered sleep from obstructive sleep apnea can be detrimental to heart health. Ongoing sleep problems require medical attention as they may indicate declining mental health.

Although 7 hours is often cited as the optimal sleep duration, individual requirements vary. Sleep hygiene and restorative sleep are themes to explore and follow.

What can a person do to reduce stress level and improve heart health?
Finding the work setting that suits our own style and temperament is key, although it is not always possible at the start of our career.

Rather than working harder, working smarter is the key. For instance, a person could spend all day cleaning a table fan, or spend five minutes of the day doing it and quickly move on to more important tasks. Unnecessary distractions such as social media scrolling can be avoided. Delegating less important tasks allows us to remain focused on our primary responsibilities.

For long-term health, work-life balance is required, and an important aspect of that is to learn time-management and people skills. By prioritising tasks, eliminating distractions and utilising the available time more effectively, work can be made more efficient. This alsoreduces workplace stress.

To a large extent, health is the outcome of what we do every day. Finding time to sleep, exercise, eat and connect with family and friends is essential, as is avoiding harmful health behaviours. Knowing our numbers is important. This includes weight, blood pressure, sugar and cholesterol levels. Maintaining a healthy lifestyle in the earlier years reduces the risk of chronic diseases in later life.

What we perceive as stress may also be the symptoms of conditions such as diabetes, Long COVID, tuberculosis, thyroid problems or depression. Both physical and mental health require attention. Seeking professional help early should not carry stigma, as discussed earlier.

Unlike machines, not every human being has the same temperament or personality. Learning to say no, and where to draw the line are essential life skills. Unfortunately, some work settings are not optimised for employee well-being, or may even foster toxic work cultures. In such cases, it is advisable to look out for other job opportunities and move on at the earliest - even if it means taking a pay-cut.

Summary
Out of the ten established cardiovascular risk factors mentioned above, seven can be modified through early lifestyle changes. Although stress is not officially recognized as a risk factor, it can exacerbate existing conditions and should be managed proactively. Whether it is in a relationship or at the workplace, it is important not to give the key to our happiness to other people. It is a fact that when we die, we get immediately replaced at the workplace - and it is business as usual from the next day. However, for our family, the loss is permanent. It is therefore crucial to take responsibility for our own health, regardless of the work setting. As in Ashok’s case, workplace stress should never become an excuse to neglect one’s own health.

References
1. AHA/ACC ASCVD coronary risk calculator
2. QRISK3 calculator, UK (NICE guideline)
3. AHA’s updated PREVENT prediction model
4. NEJM report on the new PREVENT risk calculator
5. COVID vaccine is not the reason for sudden deaths
6. Heart attacks in young adults
7. How to do CPR and be a life-saver
8. Psychiatric illness is more common than we think
9. COVID increases long-term risk of death on follow up
10. Study from UK about higher mortality long after COVID
11. Long COVID: the symptoms are vague but the suffering is real
12. Inadequate sleep could raise risk of coronary atherosclerosis
13. Inadequate as well as excessive sleep could affect cardiovascular mortality
14. Risk factors are additive: smoking causes greater cardiovascular risk when combined with diabetes, compared to people without diabetes
15. Alcohol increases blood pressure
16. Smoking causes diabetes
(Dr Rajeev Jayadevan MD, DNB, MRCP, ABIM(Med), ABIM(GE)
Chairman, Research Cell, Kerala State IMA)