Surprise Attack

Kindrea Holman knew something was wrong when she became too winded to climb a second set of steps up to the check-out office at the local high school. She was there to pick up her daughter, who had phoned earlier to say that she didn’t feel well. Holman wasn’t feeling very well herself, having experienced fatigue and shortness of breath during the previous two days.

At the school, “I broke out in a cold sweat,” she recalls. “I wasn’t feeling good, but I was going to take my daughter to the doctor anyway, and while I was there, have them check me out, too.” Holman ended up spending the next ten days in the hospital.

The forty-two-year-old mother of three was having a heart attack.

According to Viola Vaccarino, professor and chair of the Department of Epidemiology at Emory’s Rollins School of Public Health, research has shown that women in their forties and early fifties with early onset heart disease are particularly susceptible to the damaging effects of psychological stress on the heart. Young women with heart disease tend to fare worse than men of the same age, especially after a heart attack; they suffer a higher mortality rate, more disability, and more medical complications.

The phenomenon “is not explained by the severity of the disease itself, preexisting risk factors, or other diseases they may have. If anything, women have less severe disease,” says Vaccarino, who also has a joint appointment in the Department of Medicine, Division of Cardiology, at Emory School of Medicine. Her hypothesis is that psychological stress may be the key differentiating factor.

“Women, particularly those in this younger age group, tend to have more stresses in their lives,” she notes. “Many of them work outside the home and at the same time have lots of responsibilities at home—caring for children or elderly parents, to name just a couple—and many of them don’t take good care of themselves and don’t find the time to exercise or relax because of all of the demands on their time and attention.”

But for some young women at risk, an important source of stress is financial hardship and all the tension and struggle it brings to everyday life.

Holman is a case in point. A single parent raising two teenagers and an eight-year-old, she is always on the go, trying her best to be a dutiful mom by supporting her kids’ various activities and helping out at their schools. Financially, the family struggles to get by on a fixed income. They’ve faced homelessness more than once, and there’s a seemingly insurmountable mountain of debt—and relentless pressure from bill collectors. In addition, Holman admits that her eating habits “weren’t all that great.”

“There were a lot of things I was stressed out about,” she says, “and one thing led to another. It was just too much.”

Holman was one of 534 men and women with stable coronary heart disease who were recruited for an experimental protocol designed by Vaccarino and her team to provoke mental stress in a clinical setting while measuring the heart’s response.

Each participant was asked to think about how he or she would handle a hypothetical scenario—an aging parent had been abused in the nursing home, for example, and the staff must be confronted about the situation. Then, participants were asked to deliver a brief speech about the given scenario before a small audience of grim-faced Emory staffers dressed in white lab coats.

During the test, nuclear imaging was performed on the volunteers to measure blood flow to their hearts. “We focused on abnormalities called ischemia, which is basically a deficit of blood flow to the heart,” Vaccarino explains. “It’s the basis of heart attacks and other acute coronary events.”

The results, presented by Vaccarino at the annual meeting of the American Heart Association in November, showed that women under age fifty-five exhibited ischemia three times greater than that of men under fifty-five. Women between fifty-six and sixty-four exhibited a blood-flow reduction twice that of men the same age. But differences between women and men disappeared among participants aged sixty-five and older.

On a separate day, members of the group were given a standard physical stress test, which showed no differences in blood flow to the heart between men and women of all ages.

“Although stress was artificially induced for the study,” Vaccarino says, “past research indicates that the physiological reactions we observed in the clinical setting closely correlate to how people would’ve responded had the scenario been real.”

Vaccarino says that physicians should be made aware of the extra risk that stress poses for young women with early onset heart disease, and pursue the matter with them by offering advice on ways to get help.

“Some women may need referrals for psychological counseling, so that should be kept in mind,” she says. “In some cases, just finding a little time every day for herself would be sufficient, maybe by taking regular long walks. If they have the time and resources to go to a gym every other day, that would be an excellent way to decrease stress levels and also decrease depression levels—which is very pronounced in this group as well—and at the same time help to improve their cardiovascular health.”

Holman says she has good days and bad days health-wise, but of late the good ones outweigh the bad. “I’m taking my medicine, and I’m eating the right things,” she says. “If I can’t fix it, I don’t worry about it. I don’t let as much get to me now, because life is too short for me to worry about the little things. So I feel like I’m headed in a positive direction rather than a negative one.”