It is well known that women fare less well after a heart attack than men. Women under 70 years of age are significantly more likely to die or suffer from recurrent cardiac problems than are men of the same age. Unfortunately, there is little information about why this is the case.

Although women tend to have more problems after a heart attack, it is unclear whether this is due to factors such as lack of proper medical care, lack of understanding of heart disease in women, or something that happens outside the hospital that leads to more problems for women. In order to find out more about the specifics of women's heart disease, studies are beginning to focus on women, whereas before, they had focused primarily on men.

It has been suggested that psychological and social factors such as the amount of support in a relationship, control over job situations, and stress level play a significant role in cardiovascular health, in terms of both onset, as well as progression of heart disease. However, most studies looking at factors such as stress have looked mainly at men. As a result, there is little information available about how stress affects women with heart disease.

To try to find out which factors might influence the progression of heart disease in women, researchers in Sweden examined heart disease patients to see how marital and work stress affected the course of their heart disease.

The Stockholm Female Coronary Risk (FemCor) Study was carried out at Karolinska Hospital in Stockholm, Sweden. The study was conducted from February 1991 through February 1994, and included 292 women participants. They were included in the study if they had been to the hospital for a heart attack, or for increasingly severe chest pains that lasted for at least four weeks. The women in the study ranged in age from 30 to 65 years.

In Sweden all citizens have equal access to health care, so all the women in the study were receiving the same level of care for their heart disease. The fact that all participants received an equal level of care meant that the outcome of the heart disease would be due to factors other than differences in quality of health care.

200 (68%) of the women in the study were working outside the home. The remaining 92 (32%) were disabled, sick or receiving an early pension. 187 (64%) of the women were married or cohabitating, and 130 (70%) of those women were working outside the home at the time of the study. The average age of participants was 55.8 years.

The women in the study provided a detailed medical history, along with lifestyle and demographic information. In addition, laboratory tests such as lipid and routine profiles were performed. Marital stress was assessed using a structured interview called the Stockholm Marital Stress Scale (SMSS)^{1 2}. It was designed to assess whether the relationship is stressful to the person answering the questions.

The questionnaire gathered information such as: "Is your relationship with your spouse loving?", "Have you had serious crises in your relationship?", "Is your spouse your closest confidant?".

According to the authors of this study, many women often think of their husbands as being less supportive than they would like them to be. Thus, it is possible that their experience of stress is a reflection of the lack of emotional support they feel in their marriage.

If the respondent answered "yes" to questions such as "Is you relationship with your spouse loving?", they were scored as having low marital stress. If they answered no to those questions, and "yes" to questions such as "Have you had serious crises in your relationship?", their relationship was rated as stressful.

Work stress was assessed using the Karasek demand control questionnaire³, which measures the relationship between work demand and work control. Half of the questionnaire asked questions about the demands placed on the individual at work (e.g. workload, time pressure, and deadlines), and the other half asked questions about how much control the individual has over their workload and work environment, (e.g. ability to make decisions, learn new skills, and master work situations). The two halves of the questionnaire were then compared to get an idea of how much control, and how much demand the individual experienced at work.

Work was rated as less stressful if the demands were low in comparison to the amount of control a person had. In contrast, work was rated as more stressful if the demands were high in relation to the amount of control a person experienced.

Information on the re-occurrence of heart disease complications was obtained for all patients at the time of follow-up. These patients were classified according to whether they had a second heart attack, had undergone bypass surgery or angioplasty due to blocked arteries, or had died from heart disease. This information was then used to compare the progress of heart disease in women who were cohabitating with those who were not.

Most women indicated fairly low levels of stress both in work and marriage. Cohabitating women reported more severe marital stress (with an average score of 4.5 on a 14 point scale), in comparison to women who did not live with a partner (who had an average score of 3.4). For work stress, there was no difference between the cohabitating and non-cohabitating women, (with the average score being .73, and the range .28 to 1.4). Additionally, there was no relationship between the marital stress scores and the work stress scores.

52 of the 187 study participants needed further hospitalization for heart disease during the course of this study. Of the 52 re-hospitalizations, 27 of them involved women with high levels of marital stress, while only 8 involved women with low levels of marital stress. Women with severe marital stress were three times as likely to have another heart attack, or require a bypass, or angioplasty, compared to women without marital stress. Cohabitation itself was not a cause of poor prognosis, but marital stress was associated with an increased risk of recurrent heart problems. Women who lived alone had no increased risk of future heart complications.

Work stress did not seem to have an impact on women's heart disease.This is very different than the previously published research on men, which suggests that work stress does make men's heart disease worse.

One possible explanation for the differences between men and women with regard to work stress is that women tend to rely more on social supports (such as friends). Thus they tend to be less affected by work stress than are men. They may also be finding sources of support in the work place. In contrast to women, men generally tend not to seek social support.

Since marital stress has not been looked at as a factor in men's heart disease there is no way to compare the women's results to those of men. Living alone also had no effect on heart disease prognosis.

The researchers speculate that women generally feel that they receive less social support from their husbands than they would like. This feeling of insufficient support then creates a chain of events that can play a role in precipitating heart problems.

The chain of events is believed to occur as follows: The women feel that they are not getting adequate support from their husbands; they become upset by this; their getting upset along with a sense of inadequate emotional support leads to increased stress and marital discord; the discord then generates hostility, which in turn can contribute to heart problems in some people.

Comments

In addition to shedding light on one possible cause of poor outcomes for heart disease among women, this study adds to the body of knowledge that shows the various negative effects of marital stress and discord. If that is the bad news, then the good news is that you can do something about it.

If you are experiencing high levels of conflict or tension in your marriage, a licensed mental health professional can be of help. (See link below for help with finding a marriage therapist.)

If your relationship is going well, there are still things you can actively do to keep it strong and healthy and to protect it from life's ups and downs. (See link below for more information on programs that help strengthen marriages.)

When things go wrong in a relationship, we speak of heart ache. This study substantiates these effects, not only metaphorically, but in a very literal sense, and thereby presents yet another compelling reason to do something about an unsatisfactory relationship.