Mental stress: A novel cardiovascular risk factor

Table 6 Key points

Topic	Summary
Changing paradigm	Atherosclerosis is now viewed as an “inflammatory/immune-driven” disease, not just passive lipid buildup
Residual risk	Many acute coronary syndromes or strokes occur without classic risk factors (arterial hypertension, diabetes, dyslipidaemia, smoking)
Psychosocial factors	Stress, negative affect, and psychosocial context are independent cardiovascular risk contributors
Stress syndromes	Modern stress-related disorders include acute stress reactions, adjustment disorders, and PTSD
Guidelines positioning	ESC guidance recognizes psychosocial factors as risk modifiers to refine cardiovascular risk assessment, encouraging clinicians to incorporate psychosocial evaluation into care decisions
What stress is	Stress occurs when perceived demands exceed coping resources/homeostatic reserve; this explains inter-individual variability in cardiovascular impact and vulnerability
Main stressor domains	Major life events, adverse work conditions, and family conflict are repeatedly linked to higher cardiovascular risk. This identifies “high-yield” psychosocial exposures relevant for clinical history-taking
High risk populations	Type D personality, individuals with elevated neuroticism polygenic risk scores, women, Black and Hispanic people show a greater cardiovascular risk
Social inequities	Socioeconomic/structural factors and inequities (unsafe environments, limited healthy options) create chronic stress burdens, hitting disadvantaged groups harder
Neuro-cardiac axis	Stress responses are regulated by corticolimbic regions influencing autonomic outputs (“brain-to-heart” pathways with feedback loops)
Acute stress outcomes	Acute triggers (anger/fear, bereavement, disasters, noise, temperature shifts, sports, traffic) can precipitate myocardial infarction, arrhythmia, stroke/TIA, and transient left ventricle dysfunction in predisposed individuals
Takotsubo syndrome	Stress cardiomyopathy accounts for approximately 2%-3% of suspected acute coronary syndromes, often in post-menopausal women; it is linked to catecholamine surge, microvascular spasm, and myocardial stunning
Arrhythmias	Acute stress can destabilize repolarization via autonomic activation; anxiety may increase sudden cardiac risk directly/indirectly
PTSD & cardiovascular risk	PTSD a major, clinically meaningful risk state, is associated with approximately 25%-50% higher cardiovascular risk, including coronary heart disease, heart failure, stroke and mortality; mechanisms include inflammation, unhealthy behaviors, autonomic imbalance, and microvascular dysfunction
Chronic stress & prevention	Chronic stress correlates with poorer cardiovascular health metrics and recurrent events; interventions integrating mental well-being into cardiovascular care (mindfulness, cognitive behavioural therapy, breathing techniques, exercise/cardiac rehabilitation, etc.) show promise, but hard-outcome evidence remains limited and structured assessment is underused

PTSD: Post-traumatic stress disorder; ESC: European Society of Cardiology; TIA: Transient ischemic attack.