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Sex Differences in Mental Stress–Induced Myocardial Ischemia in Young Survivors of an Acute Myocardial Infarction

Vaccarino, Viola MD, PhD; Shah, Amit J. MD, MSCR; Rooks, Cherie PhD; Ibeanu, Ijeoma MPH; Nye, Jonathon A. PhD; Pimple, Pratik MBBS, MPH; Salerno, Amy MD; D’Marco, Luis MD; Karohl, Cristina MD; Bremner, James Douglas MD; Raggi, Paolo MD

doi: 10.1097/PSY.0000000000000045
Original Article

Objectives Emotional stress may disproportionally affect young women with ischemic heart disease. We sought to examine whether mental stress–induced myocardial ischemia (MSIMI), but not exercise-induced ischemia, is more common in young women with previous myocardial infarction (MI) than in men.

Methods We studied 98 post-MI patients (49 women and 49 men) aged 38 to 60 years. Women and men were matched for age, MI type, and months since MI. Patients underwent technetium-99m sestamibi perfusion imaging at rest, after mental stress, and after exercise/pharmacological stress. Perfusion defect scores were obtained with observer-independent software. A summed difference score (SDS), the difference between stress and rest scores, was used to quantify ischemia under both stress conditions.

Results Women 50 years or younger, but not older women, showed a more adverse psychosocial profile than did age-matched men but did not differ for conventional risk factors and tended to have less angiographic coronary artery disease. Compared with age-matched men, women 50 years or younger exhibited a higher SDS with mental stress (3.1 versus 1.5, p = .029) and had twice the rate of MSIMI (SDS ≥3; 52% versus 25%), whereas ischemia with physical stress did not differ (36% versus 25%). In older patients, there were no sex differences in MSIMI. The higher prevalence of MSIMI in young women persisted when adjusting for sociodemographic and life-style factors, coronary artery disease severity, and depression.

Conclusions MSIMI post-MI is more common in women 50 years or younger compared with age-matched men. These sex differences are not observed in post-MI patients who are older than 50 years.

From the Department of Epidemiology (V.V., A.J.S., C.R., I.I., P.P., P.R.), Rollins School of Public Health, Emory University, Atlanta, Georgia; Departments of Medicine (V.V., A.J.S., A.S., L.D’M., C.K.), Radiology (J.A.N., P.R.), and Psychiatry and Behavioral Sciences (J.D.B.), Emory University School of Medicine, Atlanta, Georgia; Department of Internal Medicine (A.S.), Tuba City Regional Healthcare Corporation, Tuba City, Arizona; Division of Nephrology (L.D’M.), Hospital Universitario Ruiz y Páez, Universidad de Oriente, Bolívar, Venezuela; Division of Nephrology (C.K.), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; and Mazankowski Alberta Heart Institute (P.R.), University of Alberta, Edmonton, Alberta, Canada.

Address correspondence and reprint requests to Viola Vaccarino, MD, PhD, Department of Epidemiology, Rollins School of Public Health, Emory University, Room 3011, 1518 Clifton Rd NE, Atlanta, GA 30322. E-mail:

Received for publication August 5, 2013; revision received January 12, 2014.

Copyright © 2014 by American Psychosomatic Society
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