13-05-2025
Proven Stress Management Techniques to Maintain a Healthy Heart
Heart disease is the leading cause of death for women in the U.S.; more than four million women die from ischemic heart disease (IHD) each year, and cardiovascular disease claims more lives than all cancers, respiratory diseases and infectious diseases combined.
This risk is even more pronounced among women with intersecting identities; Black women, in particular, are more likely to die of heart disease than white women. They also have the highest rates of hypertension, stroke, heart failure and coronary heart disease among all women in the U.S.
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Despite the fact that women suffer from more heart attacks than men as they age—and are more likely to die from cardiac events—heart disease continues to be seen as a 'man's disease,' and women are generally told to monitor heart health symptoms based on men's cardiovascular systems. Because of this, many women don't even understand their risks.
Women are less likely to be referred to cardiac rehabilitation, less likely to be put on statins or beta blockers to pre-empt cardiac events, plus they are more likely to have their symptoms dismissed as a mental health issue.
'Often women don't get screened, not through any fault of their own, but even the medical community often ignores women,' asserted Cedars-Sinai Smidt Heart Institute staff physician and cardiologist Dr. Martha Gulati in an interview with Flow Space.
'Bikini medicine—breast and reproductive health—is the norm for how we care for women,' Gulati, who serves as the director of Preventive Cardiology and a cardiology professor at Cedars-Sina, the associate director of the Barbra Streisand Women's Heart Center and the Anita Dann Friedman Chair in Women's Cardiovascular Medicine and Research, added. 'We must move beyond the bikini if we are going to care for women throughout their lifespan.'
In midlife, caring for the whole body—particularly, when it comes to cardiovascular health—becomes even more critical.
'Heart disease is the leading killer of women, and their risk increases with age,'Gulati said. 'Women need to know if they are at risk; often, they have not been assessed or talked to about their risk.'
One of the five major heart disease risk factors for women is hormonal changes associated with menopause. Estrogen has cardioprotective factors, so when estrogen levels decrease in menopause, cholesterol levels and blood vessel elasticity change—and heart disease risk rises.
'Menopause is an important risk factor for cardiovascular disease,' Dr. Puja K. Mehta—an associate professor in the division of cardiology at Emory University, director of Women's Translational Cardiovascular Research, and a Fellow of the American College of Cardiology and the American Heart Association—told Flow Space. 'What we mean by this is that a woman's risk of having a heart attack or stroke increases post-menopause compared to pre-menopausal years. A number of risk factors change during the menopause transition, which can vary from woman to woman.'
During the transition, 'bad' cholesterol levels may increase, 'good' cholesterol might decrease and blood pressure can elevate. Plaque also builds up in women's arteries faster after menopause than it does in men's bodies as they age.
'Risk factors that might have previously not been present become more likely [during midlife and throughout the menopausal transition],' Gulati explained. 'Many women, for example, spend much of their younger years being told their blood pressure is low. Blood pressure actually increases with age for more women, and, at menopause, blood pressure is often noted to be elevated.'
The symptoms of menopause can also impact the heart.
Hot flashes and night sweats can increase cardiovascular risk factors, as well as that stubborn 'menopause belly.' While hormone replacement therapy (HRT), can be a critical intervention for the physiological symptoms of menopause, tending to mental health is also a critical form of heart disease prevention, especially in midlife.
Various studies have demonstrated that mental health is closely tied to women's heart health—even more so than men's. Depression and anxiety can accelerate women's risk of heart disease, and the psychological stress of heart disease itself may contribute to women's increased risk of mortality following a cardiac event.
'Stress is obviously a normal part of life, and in small doses, it's likely not harmful,' Gulati explained. 'Short exposures to stress often helps us.'
She offered the example of someone being motivated by the stress of a deadline to finish a project, or how the stress of a job interview can improve performance.
'Even the acute stress of surgery improves our immune response and often helps us fight infections,' she added. 'That's the good effect of short-term stress.'
Although there are forms of 'good stress,' triggering our fight-or-flight response over time can become toxic in the body. Bodies in a state of chronic stress release high levels of hormones like cortisol and adrenaline—which can raise blood pressure, glucose and cholesterol levels, and increase women's vulnerability to anxiety and depression.
Chronic stress can also lead to high blood pressure and disproportionately fuel inflammation in women's bodies, which can sharply increase the risk of major cardiac events.
'Excess stress can be harmful,' Gulati cautioned. 'Chronic stress also can disrupt sleep, affect eating patterns, reduce physical activity, and cause emotional and psychological damage.'
Women's bodies see more activation in the left prefrontal cortex of the brain when under stress than men's and a higher activation of the amygdala. Since the amygdala is part of the brain's fear center, the amygdala tells the body to continue its stress response, making women particularly vulnerable to chronic stress—and the more chronic stress we have, the harder it becomes for our prefrontal cortex to calm us down and control our emotional responses.
The brain-heart connection 'is very important in both men and women,' Mehta noted, 'however, it seems that women may be particularly susceptible to psychological and psychosocial stress.'
Takotsubo syndrome, also called 'broken-heart syndrome—in which sudden emotional or physical stress causes physical symptoms mimicking a heart attack—is a powerful example. More than 85% of cases occur in postmenopausal women, Mehta explained.
'It is unclear why postmenopausal women are more at risk of having a Takotsubo event, but it is thought that microvascular dysfunction and heart artery spasm are important players in this. Even younger women with a history of coronary artery disease, when they are exposed to acute mental stress testing in the laboratory, they can have abnormalities of blood flow to the heart in response to acute mental stress.'
Broken-heart syndrome cases reinforce the gendered differences in how women's bodies react to stress physiologically.
'Death of a loved one, acute fear, but also surprise birthday parties have preceded this type of heart attack,' Gulati added. 'An acute surge of stress hormones, [such as] adrenaline, often precedes such events.'
Studies have demonstrated that women are more susceptible than men to diminished blood flow during acute stress events, and our microvascular response to stress is associated with poorer health outcomes. Stress in women also disrupts lipid balance, increases platelet aggregation and impairs glucose regulation.
'Menopause can itself increase stress with all its physiological and mental changes that often affect sleep and mood,' Gulati explained. 'Frequent hot flashes can induce stress and anxiety for many women.'
In fact, symptoms of menopause include anxiety, mood swings and depression, increasing the mental health burden women carry in midlife. Levels of cortisol also rise naturally as women age, increasing the risks of chronic stress.
Gulati noted that stressors like 'work, family, marriage, financial worries, and taking care of someone sick' can happen at any age—but for women in midlife, stress management is even more critical.
What that looks like is up to you: 'Some like mindfulness and meditation; some enjoy gardening, nature walks; some need to turn off devices and sleep more, limit social media, which can be a time sink,' Mehta offered. 'Pool exercises can be very helpful. Chair exercises, gentle exercises for seniors, and those with ortho limitations can work with a therapist.'
No matter what form it takes, regular physical activity—even a brisk walk—can reduce stress. 'It's also important to exercise, including weight bearing,' she noted, 'to attenuate muscle loss.'
'Stress reduction may result with biofeedback tools, exercise, yoga, tai-chai,' Gulati added. 'Avoiding alcohol, eating healthy and improved sleep can also help reduce stress.' So can tidying up your living spaces; getting organized can decrease stress and improve your sleep.
Having sources of emotional support can also be a lifeline.
Studies show that women's heart health, more than men's, benefits from consistent relationships with family members and friends. Laughing with friends and loved ones can reduce your heart disease risk in a myriad of ways: Laughter lowers stress, increases blood flow and lowers blood pressure; it also lowers cortisol, increases dopamine and strengthens our emotional resilience.
Pets can also make a big difference.
'Dogs can reduce stress—truly, there's some literature on this!' Gulati shared. 'Get a dog for the exercise and stress reduction, with a little unconditional love on the side!'
'Find a friend to go walking or exercise with,' Mehta recommended. 'Turn off late-night TV watching or binging on shows so you can get enough rest, block time in the calendar for self-care… Even a few minutes counts and is better than nothing on busy days. Learn to say 'no' and not over-commit. It can help with reducing stress and making heart healthy choices.'
For those who have the option, one of the best strategies to relieve the body of the impacts of chronic stress, is a good vacation—and experts suggest women need them even more than men to really rest and restore their bodies.
Monitoring and managing your own stress is important—but don't be embarrassed to ask for help if your efforts are only going so far.
'Sometimes medications may be needed, including potentially the need for hormone replacement therapy for those who need it,' Gulati clarified. 'Occasionally, some people might need medications to control stress.'
Whether you're feeling stressed or serene, even the heart-healthiest lifestyle isn't a substitute for screening and addressing your risks.
'It is very important to identify risk factors early, implement lifestyle changes and start treatment if needed instead of waiting and postponing,' Mehta urged. 'Seeking a trusted healthcare provider and communicating that you want a heart health assessment/review of risk factors can be helpful.'
'This is an important time to know your numbers,' Gulati added. 'Get your cholesterol checked, know your Lp(a), know your BP, be screened for diabetes, know your short- and long-term risk of cardiovascular disease. Menopause is such a critical time, and things change, including these risk factors, so it is important to be screened and know what, if anything, has changed and what you can do to lower your risk.'
