Most people know that smoking, high cholesterol and high blood pressure are among the main risk factors for heart disease. Few of us realize that daily stress is another key risk factor. It can damage the heart and arteries even in people who are otherwise healthy.

Recent finding: A University of Southern California study that looked at 735 patients for more than 12 years found that chronic stress and anxiety were better predictors of future cardiovascular events (such as a heart attack) than other risk factors. The researchers estimate that those who reduce or stabilize their stress levels are 50% to 60% less likely to have a heart attack than those who experience increasing stress.

Toxic Over Time

Researchers have known for a long time that sudden traumatic events can trigger heart problems. Three years after the 9/11 terrorist attacks, for example, study participants-most of whom watched the attacks on live television-were questioned about their stress levels. Those who still were severely stressed were 53% more likely to have heart problems, and twice as likely to develop high blood pressure, as those with lower stress levels.

It appears that even "normal" stress-financial pressures or an unhappy job situation is dangerous when it continues for a long time. It's estimated that more than 75% of visits to primary care physicians are linked to disorders that are stress-related.

What happens: Chronic stress increases vascular resistance, the main cause of high blood pressure. It increases the activity of platelets, cell-like structures in blood that clump together and trigger most heart attacks. It increases levels of cortisol, adrenaline and other stress hormones and can contribute to arterial inflammation.

Doctors have been slow to acknowledge stress as a major cardiovascular risk factor. This is partly because stress (like pain) is subjective and highly individual—it's difficult to quantify, because everyone has different stress triggers and experiences stress differently. One lawyer might thrive on hectic 16-hour days, while another might react with high anxiety.

Stress can't be directly measured, but tests show its toxic effects. When laboratory subjects who are asked to count backward from 100 by eights get increasingly frustrated, there is a corresponding increase in their heart rate, adrenaline and substances linked to inflammation, such as C-reactive protein and interleukins.

Stress Reduction Works

We can only partly control our emotional environments-stress-causing events can't always be avoided. But we can greatly change the ways in which we react to stress. People who do this can significantly lower their cardiovascular risks.

In one study, patients with heart disease were divided into three groups and followed for up to five years. Those in one group practiced stress reduction. Those in the other groups were treated either with an exercise program or with standard medical care. (The standard-care group maintained their regular medical regimen and did not participate in an exercise or stress-management program.)

Only 10% of those in the stress-control group had a subsequent heart attack or required bypass surgery or angioplasty, compared with 21% in the exercise group and 30% in the medical-care group.


The traditional techniques for reducing stress, such as yoga, are helpful but typically too complicated and time-consuming for most people. My colleagues and I have developed a simpler approach that anyone can do in about 15 minutes a day. It goes by the acronym B-R-E-A-TH-E, which stands for Begin, Relax, Envision, Apply, Treat, Heal and End.

  • Begin. Pick a time of day when you won't be interrupted for 15 minutes. Find a comfortable location. Many patients use their bedrooms, but any quiet, private place will work.
  • Relax. This phase of the exercise is meant to elicit the relaxation response, a physiological process that reduces stress hormones, slows electrical activity in the brain and reduces inflammation.

Sit or lie quietly. Focus so completely on your breathing that there isn't room in your mind for anything else. Inhale slowly and deeply through your nose. Then exhale just as slowly through your mouth. Each inhalation and exhalation should take about seven seconds.

Repeat the breathing cycle seven times. You'll know you're ready to go to the next step when your body is so relaxed that it feels as if all of your weight is supported by the chair or bed rather than by your muscles.

  • Envision. Spend a few minutes imagining that every part of your heart—the arteries, muscles, valves and the electrical system-is strong and healthy. Form a mental picture it doesn't have to be anatomically accurate) of the heart pumping blood and sending nourishment throughout your body. Hold this image in your mind for several minutes.

Studies using positron emission tomography (PET) scans show that people who imagine that they are performing an action activate the same part of the brain that is involved when they actually do that action. Imagining a healthy heart literally can make the heart healthier.

  • Apply. It's up to you when and how often) you perform this relaxation exercise. Most people can find 15 minutes a day to take a mental break from stress to keep their hearts healthy. Others also use this technique when they notice that their stress levels are rising.

During a hectic day at work, for example, you might take a break for 15 minutes to calm down with conscious breathing and visualization.

  • Treat and heal. I encourage patients to embrace the pleasurable aspects of this exercise. Don't consider it a chore. It's more like a spa treatment than a physical workout.

The healing aspect can be strongly motivating, particularly if you already have a history of heart disease. Every time you do this exercise, you are strengthening the neural networks that connect the heart and brain. This can lead to a decrease in heart arrhythmias (irregularities), an increase in immune-cell activity and even better sleep.

  • End. Finish each relaxation session by making a mental checklist of what you have achieved. You have imagined that your heart and arteries are healthy. You have reduced stress hormones, and you are feeling more relaxed and energized than you did before.

The results are long-lasting, People who practice this for a few weeks will find themselves dealing with unexpected stressful events productively and in a calm, focused manner.

Go to Bed! (It's Good for Your Heart)

In a study of 251 healthy men, those who typically went to bed after midnight were more likely to have arterial stiffening, an early stage of atherosclerosis (hardening of the arteries)—a heart disease risk factor.

Theory: A late bedtime may promote insulin resistance (a condition in which the body is less able to respond to insulin), which can lead to atherosclerosis and heart disease.

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