Psychosocial, emotional, and external factors are important triggers to cardiac events like myocardial infarction (MI). Other types of stress—including work-related, financial, and general—have also been linked with a higher risk of acute MI. In recent decades, the incidence rate for first-time MI has decreased for men but has remained unchanged for women. Published data show that women tend to be 5-10 years older at the time of their first MI when compared with men. Sex differences are also apparent with regard to symptoms, treatment, and outcomes associated with MI.

For a study published in the European Heart Journal Open, Anneli Olsson and colleagues sought to identify self-experienced triggers of MI and determine if sex differences exist. The authors identified patients with a recent MI during the holidays and on weekdays using a nationwide survey. They rated 27 potential MI triggers to see which occurred more or less frequently than usual during the last 24 hours before an MI. The study group explored three areas: 1) activities, 2) emotions, and 3) food or alcohol consumption. They collected responses from 451 people in total, 317 of whom were men.

Emotional Triggers Common Prior to MI

Results from the study showed that the most commonly reported MI trigger among both men and women was stress (35.3%), followed by worry (26.2%), depression (21.1%), and insomnia (20.0%). “Emotional triggers were the most common among all respondents,” Olsson says. More than one-half of responders (56.3%) reported increased emotions within 24 hours prior to their MI. In addition, 43.5% took part in physical activity that was a little more or much more than usual before their MI. More than usual food and alcohol consumption was cited by 27.3% of respondents.

Prior to experiencing an MI, the most common symptoms overall for men and women were chest pain (52.5%), followed by chest pain or dyspnea on slight exertion (51.7%), fatigue (44.6%), and general dyspnea (38.8%). About one-quarter of patients (26.6%) experienced a general sense of illness, whereas 13.3% had nausea, 7.1% had syncope or pre-syncope, and 3.8% had a current infection.

Women Experience More Emotional Triggers

Emotional triggers were more pronounced in women in both unadjusted and adjusted analyses, according to investigators. “Most of the emotional triggers, such as sadness, upsettedness, anger, stress, loneliness, anxiety, worry, and depression, were reported by more women than men,” says Olsson (Figure). Women with NSTEMI experienced greater stress than women with STEMI. Loneliness was more commonly reported by older women, whereas economic worries were more frequently reported by younger men.

Results from the study showed that women experienced sadness, stress, insomnia, fatigue, and nausea to a greater extent than men before their MI. When compared with women, the only MI trigger that was significantly increased in men was outdoor activity. No significant sex differences were seen regarding food or alcohol consumption. The authors also reported that ongoing infection occurred more frequently in women than men, but these figures were relatively low for both groups.

Findings May Lead to Improved Prevention Strategies

Unlike other well-known risk factors for MI, emotional distress is more difficult and complex to measure. “Understanding the sex perspective in acute MI triggers may help us find preventive strategies and reduce the excess number of these events,” Olsson says. The findings suggest that emotional distress affects the hearts of women differently than those of men. Other studies support these data, having shown that women who are depressed and have established coronary heart disease have a higher risk for mental stress–induced myocardial ischemia.

Psychological interventions, such as cognitive behavioral therapy and stress management programs, may help reduce risk for new cardiovascular events, including MI. Additional studies are needed to find relevant secondary prevention strategies for people with emotional distress to reduce risks for poor clinical outcomes.