What if … your stress isn’t “just in your head”? What if … it’s injuring your heart?
Here’s what cardiology is finally catching up to; especially for women.
By Dr. Amy Chhadia, MD
For decades, women with chest pain were told it was anxiety, stress, or “nothing serious” because their angiograms looked normal.
Now we know better.
Women often do not develop heart disease the same way men do.
Men more commonly show large-vessel atherosclerotic obstruction.
Women disproportionately develop coronary microvascular dysfunction - where small coronary vessels fail to regulate blood flow appropriately, even when there are no obstructive plaques.
This is INOCA: Ischemia with No Obstructive Coronary Arteries.
In plain terms: the epicardial vessels are patent, but coronary blood flow regulation is impaired; the blood vessels are not behaving the way they should.
And it’s common:
• Nearly two-thirds of women with chest pain and “normal” angiography
• At least 50% demonstrate coronary microvascular dysfunction, contributing to reduced exercise tolerance, persistent symptoms, and functional limitation
Here’s the part that deserves real attention:
Mental stress alone can induce myocardial ischemia.
No treadmill.
No plaque rupture.
Just stress.
Sustained cortisol and sympathetic activation raise blood pressure, heart rate, and glycemic load - disrupting endothelial function and coronary microcirculation. This can trigger mental stress - induced myocardial ischemia, particularly in women.
Even more striking, women demonstrate inducible ischemic changes with mental stress testing and emotional provocation (anger induction), with measurable reductions in myocardial blood flow.
This is not psychological fragility.
This is vascular biology.
Which is why “manage your stress” is not a wellness cliché - it is a core cardiovascular prevention strategy.
Longevity is not only about LDL, calcium scores, or VO₂ max.
It also depends on:
• Stress resilience
• Autonomic regulation
• Mental health
• Sleep quality and recovery capacity
If we continue to treat mental stress as secondary - especially in women - we will keep missing clinically meaningful heart disease until irreversible damage occurs.
The heart responds to the nervous system.
Medicine is finally starting to listen.