Studies Highlight Role of Stress, Social Disadvantage in Heart Health Disparities

Both studies were featured during the American College of Cardiology's annual briefing on results for consumers. They will be presented during the 70th Scientific Session, which is set for May 15-17, 2021.

A pair of studies to be presented next week during the annual meeting of the American College of Cardiology (ACC) will highlight the links among stress, inflammation, social status, and heart health. Taken together, the findings suggest that the added strain of COVID-19 could have a lingering impact those already at risk for heart disease.

Both studies were featured during the ACC’s annual briefing on results for consumers. They will be presented during the 70th Scientific Session, which is set for May 15-17. For the second year, ACC will have a virtual meeting due to the pandemic.

Mariana Garcia, MD, a cardiology fellow at Emory University in Atlanta, presented a study that examined how psychological stress, including depression and anxiety, hampers the ability of younger adults to recover from a heart attack.1 Results showed that those under stress were twice as likely to suffer a second cardiac event within 5 years, and the study uncovered key inflammatory markers that could signal increased cardiovascular risk.

For this study, researchers examined 283 patients between ages 18 and 61 who had survived a heart attack. The participants answered questionnaires that measured levels of depression, anxiety, perceived stress, anger, and posttraumatic stress disorder within 6 months of the episode. These results were used to create a stress score for each patient, and the patients were then grouped by stress level—mild, moderate, or high. Eighty patients had a second heart attack, stroke, or heart failure hospitalization within 5 years, with 47% of the high-stress patients having a second episode, compared with 22% of those with mild stress.

Garcia noted that while cardiovascular mortality has declined overall in the past 40 years, young adults appear to have benefited less from this trend—and this group faces a higher risk of mental health disorders. “Observational studies have suggested that stress is associated with adverse outcomes,” she said, noting that stress appears to be a particular trigger with high-risk groups.

Patients in the study who reported high stress were more likely to be Black, female and from a disadvantaged socioeconomic background. They were also more likely to smoke, or to have diabetes or high blood pressure, which are all known cardiovascular risk factors. “This finding highlights the importance of socioeconomic status in regard to higher distress and raises important questions about the role of race, sex and other factors,” Garcia said.

Garcia explained that her research group looked at several possible inflammatory markers to see if there was a link between stress and outcomes. Among 4 markers examined, the team found a direct positive association with interleukin-6 and monocyte chemoattractant protein-1, or MCP-1. “At least in our study, we're thinking is that these markers have shown a significant association with patients with established coronary disease and adverse outcomes. And they're specifically increased during acute mental stress.”

The study comes as CDC data from the pandemic show that minorities and those with social disadvantage are more likely to develop COVID-19, and other signs show a marked increase of psychological distress over the past year. New data released Thursday by Blue Cross Blue Shield of Massachusetts, for example, show a 20% increase in use of outpatient mental health services, along with a 10% increase in spending on substance abuse disorder. Among telehealth users, 60% of mental health diagnoses have been for anxiety, with increases across all age groups.

COVID-19 has been shown to leave lingering heart effects, including cardiomyopathy, even among some young patients. In a separate study presented at the consumer briefing, the same groups shown to be more likely to experience distress in Garcia’s study were found to have a harder time avoiding the virus that causes COVID-19. Kobina Hagan, MD, a postdoctoral fellow at Houston Methodist Research Institute, presented results that show strong links between social factors such as education, financial stability, and neighborhood condition, and the ability of patients with heart disease to comply with CDC recommendations on avoiding COVID-19.2

Wearing masks and working from home were all more challenging for those at the lower end of the socioeconomic scale; in particular, those with the highest level of social risk were least likely to have workplace flexibility.

Hagan’s research starts with data from the COVID-19 Household Impact Survey, which measured how well people were complying with preventive steps, including wearing masks and social distancing. The survey also recorded health and sociodemographic factors among more than 25,000 US adults. About 2000 respondents reported a history of heart disease, heart attack or stroke, putting them at high risk of serious complications from COVID-19. This high-risk group was separated into quartiles based on social risk factors, including income and financial security, job and health insurance status, education, food insecurity and neighborhood quality. Among those with heart disease:

Those with the highest level of social risk were 46% less likely to have flexible work options, when compared with respondents with little social risk.

The high-risk respondents were 31% less likely to follow all social distancing protocols, such as avoiding crowds or restaurants or limiting contact with high-risk people.

Researchers found the differences remained stark, even when accounting for comorbidities or other demographic factors.

“Unless we look at COVID-19 through the lens of social determinants of health, we may not optimize our yield from interventions, and we might not be reaching the group of individuals who need these interventions the most,” Hagan said.

While his study took place before vaccines were available, Hagan questioned whether the same patterns would continue as people try to get access to vaccines. “I think we are repeating the same mistakes and expecting better results,” he said, explaining that even for factors that involve personal choices, a lack of health literacy may play a role.

A future of inflammation?

The American Journal of Managed Care® asked Garcia and Hagan if their combined findings point to a future of increased inflammation due to COVID-19, which would hit hardest among those already at risk for heart disease. Garcia said the mechanics of the inflammatory markers could involve “plaque vulnerability,” which is a characteristic of coronary plaques that rupture and cause acute events, or thrombogenesis, which is the formation of a blood clot.

“In terms of COVID-19, I think we have seen a lot these kinds of effects,” she said, especially the formation of blood clots, which can occur more frequently among patients who have both inflammation and long stretches of immobility.

Hagan said while his study did not focus on a particular pathophysiological process, the results do point to a need for health systems to recognize “social needs and social supports,” including efforts to “mitigate any other physiologic process of inflammation whatsoever that would occur due to COVID-19.”

Both study authors said their findings call for changes in health care delivery, particularly for the most vulnerable.

“Our findings suggest that cardiologists should consider the value of regular psychological assessments, especially among younger patients,” said Garcia. “Equally importantly, they should explore treatment modalities for ameliorating psychological distress in young patients after a heart attack, such as meditation, relaxation techniques and holistic approaches, in addition to traditional medical therapy and cardiac rehabilitation.”

Hagan said the year 2020 marked the moment when “We could no longer ignore the disparities. We need to focus on holistic strategies to effectively fight this pandemic and ensure those not afforded the privilege of personal protection, social distancing and work flexibilities are prioritized with vaccine outreach to avoid further compounding existing health inequalities.”


1. Garcia M, Young A, Almuwaggat Z, et al. Psychological distress and risk of adverse cardiovascular outcomes in young and middle-aged survivors of myocardial infarction. To be presented at the 70th American College of Cardiology Scientific Session; May 16, 2021. Abstract 1021-05.

2. Hagan K, Javed Z, Valero-Elizondo J, et al. Social determinants of health disparities for COVID-19 mitigation measures among adults with cardiovascular disease in the United States. To be presented at the 70th American College of Cardiology Scientific Session; May 15, 2021. Session 2018.

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