All the concern we quite rightly invest in frightening diseases like cancer and Alzheimer’s disease shouldn’t blind us to the fact that the number one killer in America has been and continues to be heart disease. The cardiac endgame varies – maybe it’s a fatal heart attack or heart failure or arrhythmia – but let’s face it, when the heart stops, so do we. 

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By now, regular visits to our primary care doc have made most of us aware of the obvious cardiovascular disease risk factors, things like high Apolipoprotein B, high blood pressure, high blood sugar. But what often gets ignored is our mental health which, the most recent research is making clear, is a major part of the heart disease story and indeed may be what’s helping make the conventional risk factors so toxic in the first place. Mental health issues can drive up heart risk directly, as is the case with blood pressure, or indirectly, when they give rise to bad lifestyle choices which eat away at heart health in different ways. But in just about every case, the common denominator that links heart health with mental health is stress. When stress gains the upper hand, our brain becomes the enemy of the heart, and believe me, that’s not what you want. So here are the basics that you need to know about how a stressed-out mental state can damage the heart, and how you can turn down the stress dial to restore peace between mind and heart. 

So, what is stress and what’s it have to do with the heart?

Probably the most useful way to think about stress is that it’s a challenge to your nervous system. It might come from any direction, from a rough patch at work to worrying about the upcoming Presidential election. But by itself, stress isn’t good or bad, it’s how we interpret and respond to the challenge that defines it. An extra dose of nervous energy may help us rise to the occasion and finish an important project on deadline. But too often the stress doesn’t serve any useful purpose, when your nervous system regularly shoots up to 11 (for instance, every time you have a run-in with your boss, “episodic acute stress”) or, even worse, when it just stays jacked up all the time, “chronic stress,” when, for instance, you’re locked in a seemingly intractable unhappy family situation. 

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When we’re on, our brain tells our adrenal glands to secrete cortisol, our primary energy (and stress) hormone, and when something extra is required, adrenaline, the “fight or flight” hormone. We call that the sympathetic nervous system. The parasympathetic system takes over when it’s time to cool down and relax on auto-pilot. Our lives are a necessary balance between the two. When we’re stuck, periodically or all the time, in the sympathetic system, that’s when the heart problems are likely to kick in. 

Old problems, new evidence.

At some level, doctors have always understood that stress was well, stressing out the cardiovascular system. They measure and treat with drugs the direct effects of stress like elevated heart rate and high blood pressure, which along with the stiffening of the arteries that hypertension causes, increases the risk of heart attack and heart failure. But because the sources of stress, and how to address them, aren’t so medically cut and dried, that often gets left out of the therapeutic equation. But that’s changing. In an influential 2004 study that looked at the stress levels of 25,000 people across over fifty countries, high stress, as measured by answers on a questionnaire, more than doubled the risk of heart attack, independent of conventional risk factors like blood pressure and cholesterol. (You can measure your own Perceived Stress Score with this 10-question questionnaire at: www.mdapp.co/perceived-stress-scale-pss-calculator-389/ .) Another study found that stress levels raised the risk of heart attack in patients who had already been diagnosed with cardiovascular disease. 

Stress and the inflamed heart.

Being bombarded by stress has an inflammatory effect on your coronary arteries. This isn’t a new idea but now we can actually see the process working in real time. There have been a number of recent studies looking at patients whose brains are processing high amounts of emotion. One set of images shows you the overactive amygdala (the emotional center of the brain), another set, from the same patients, the coronary arteries filling up with potentially lethal plaque, in a word, atherosclerosis. What happens is, the more inflamed the vessels, the more susceptible they are to LDL cholesterol lodging inside the artery walls and developing into atherosclerotic plaques, in other words, the thing that causes heart disease. 

The inflammation-depression connection.

I’ve been talking a lot about stress but let’s take a step back and consider the whole person. If you’re regularly stressed-out, you’re likely to not be very happy. That can lead to depression or chronic anxiety, or both, more extreme forms of feeling, and being stuck. Researchers are still trying to puzzle out cause and effect but it now seems likely that depression is driven as much or more by an out-of-control stress response as by an imbalance in brain chemicals like serotonin, even though that’s the rationale for the standard SSRI anti-depression drugs. Whatever the case, depression has a way of locking in an over-active stress response and contributing to, maybe even just plain causing, many of the difficult symptoms that depressed people experience, like insomnia and exhaustion. And the toll on your heart health is considerable. It almost goes without saying but, if you feel like low moods are gaining the upper hand, seek help with a good therapist. 

Pushing back against stress.

One of the most powerful ways you can protect your mental health, and push back against stress, is to devote a regular chunk of time – it may only be 10 or 20 minutes a day – to deliberately calming the mind, which, as we know, calms the body as well. I’m a great believer in “mindfulness” techniques like sitting meditation, which often emphasize tuning out the world and tuning into yourself by “following the breath.” (Studies have shown that different forms of stress reduction actually quiet down activity in the amygdala.) But it’s important to remember, you don’t have to have formal practice. For some people, it’s a matter of carving out a little space in the day to be by yourself and relax. Going for a walk outside, especially in a natural setting, is easy and rejuvenating. For some, engaging the body in a mindful way is the ticket, for instance with a yoga practice (I’m a fan), even if it’s just a few daily poses. Most anyone can enjoy a hot bath or shower at the end of a tough day, or a sauna if you are lucky enough to have access to one. I’m gratified to learn that many cardiac rehab programs are now incorporating stress reduction work in their programs.  

Change your mind, change your diet, change your life.

Unfortunately, a high-stress lifestyle encourages the sort of toxic habits that injure your heart. Quiet the stress and upgrade your habits, now you’ve really got something! Not smoking and cutting back on alcohol consumption, if you must drink, are the obvious starting points. Let’s move on to diet. A diet heavy in sugary low-fiber carbs, low on non-starchy veggies and loaded with processed crap is a one-way ticket to inflammation and heart problems down the road. My prescription in brief: lose the bad stuff and replace it with more non-starchy veggies, clean proteins from healthy sources, and foods high in omega 3 fatty acids, like small oily fish like sardines and herring, can have a directly positive effect on mood and mental health. 

Move more, seriously and not so...

Few things have a more immediately beneficial impact on mood and mental health as simply moving the body. It doesn’t have to be a hard-core session in the gym. (Some of my patients can go too far in that direction, in my opinion.) It might be a long daily walk or regular “movement breaks”– some stretches or calisthenics or body-weight squats. It all adds up and it all serves to lift mood and protect your heart, especially against high blood pressure and blood sugar. A number of studies have found that regular aerobic exercise is as effective therapy for milder forms of depression as conventional drug therapy. An added bonus: regular physical activity helps with sleep, lengthening the time your body stays under in the deeper, more restorative phases of the sleep cycle. Trouble finding time some days? Put on a few of your favorite toe-tappers and dance around the living room for a few minutes or shake it while you’re prepping dinner.

Sleep more, and better.

Sleep deserves its own category because it’s a two-way street. High stress raises cortisol levels which can make it more difficult to fall asleep or more likely that you’ll wake up at 3 in the morning unable to fall back asleep. What’s the consequence of insufficient or restless sleep? You guessed it, higher cortisol levels, a classic vicious circle. Not to mention that living in a high-cortisol zone typically increases your appetite for the sort of junk “comfort” foods that contribute to obesity and metabolic problems like insulin resistance and type 2 diabetes, two great enemies of heart health. So, invest the time to make sure you can get 7-8 hours of high-quality sleep. Your mind and your heart will thank you. Also, slip in a nap from time to time. It won’t make up for lost sleep but 20-minute naps can help refresh the body and brain in a pinch.

Social connection to the rescue.

Though it’s massively important, a healthy mind and a healthy heart isn’t exclusively about tending to the physiological processes going on inside your body. Other people matter. A lot. One of the most enduring harms the COVID pandemic dealt us was the weakening of bonds between ourselves and our families and friends. Phone calls and Zoom have their place but nothing can truly replace spending time with our loved ones. Here’s one high-powered way to relieve stress – enjoy a good laugh with them. Some of you are old enough to remember the monthly Readers’ Digest section, “Laughter is the Best Medicine.” It wasn’t wrong. Shared giggles and guffaws are excellent for connection and building social bonds, and, according to the Mayo Clinic, help stimulate circulation and aid muscle relaxation, in turn helping to curb some of the physical symptoms of stress. 

With gratitude, you can never go wrong.

Finally, take the time to be grateful. One powerful way to build up your resistance against the difficult stressors that life throws at you is to be more conscious of the good things that you may be taking for granted. During the day, when you have a positive experience, take a moment, and a breath, and note it. Here’s one helpful and simple exercise, before you go to bed at night, bring out a pen and pad (yes, they still exist) and list three things that happened to you that day that you can be grateful about. (After a few nights you’ll have built quite a list.) Think of it as the gift of perspective.