Stress: Be still, my beating heart

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Be still, my beating heart ; Even when the game is fast and furious, it's best to take it slow

Hockey playoffs and other emotional and psychological stressors really can cause heart attacks and strokes and the irregular heartbeats that lead to them. And you don't even have to be the coach.

I once heard of a man in Winnipeg who died while watching the Grey Cup on television and I'm not sure that the Blue Bombers were even playing.

People who rub the left side of their chests when spouses or bosses yell at them or parents who tell their teenagers to stop their bad behaviour before Dad gets a heart attack are not necessarily being overly dramatic.

The irregular heartbeats, or arrhythmia, that hospitalized Leafs' coach Pat Quinn this week after a tense playoff game may be a perfect example of this mind-body interaction.

"Absolutely, no question about it," says Kansas City, Mo., cardiologist James O'Keefe, Jr. by phone about the possibility of arrhythmia being provoked by the stress of coaching a team in the Stanley Cup playoffs. "There's no question that the chemicals that go up with stress can pre-dispose to arrhythmia." Those chemicals include adrenaline, cortisol and norepinephrine- "the classic stress hormones. It's the same thing that happens with amphetamines and cocaine.

"All kinds of arrhythmias are associated with these stress hormones," he adds.

O'Keefe, who grew up in North Dakota and knows about icing and boarding, recently published a comprehensive review in Mayo Clinic Proceedings of the link between emotional stress and the risk of developing and dying from heart disease.

Commenting on the risk of a hockey coach, who no doubt is feeling hostility to the opposing team and experiencing anger about how his team is treated (or is performing), a hockey coach who is middle- aged, overweight and smokes, O'Keefe says succinctly, "It's a recipe for disaster."

Nearly everyone knows heart attacks can be caused by excessive physical stress, especially if the body is unaccustomed to it. In fact, the stress test- a controlled physical workout at the doctor's office- is an important way to assess risk of heart disease and stroke.

But there's increasing scientific, and not just anecdotal, evidence illustrating the strong relationship between excessive emotional stress and a higher risk of developing and dying of heart disease. In short, bouts of severe anxiety, tension and mental stress can be dangerous, especially for those sensitive to stress and for people whose cardiovascular systems are already compromised.

For example, emotional stress doesn't cause high blood pressure, says Dr. Doug Ryan, a hypertension specialist at Mount Sinai hospital, but it can exacerbate it. And changes to the heart as a result of high blood pressure can predispose a person to arrhythmia.

A heart made vulnerable by damage from poorly controlled high blood pressure, bad eating habits, too much weight, and not enough exercise is ripe for trouble when overloaded by psychological stress.

Florida cardiologist and researcher Dr. David Sheps devised a diabolical psychological stress test to assess the risk for people who already had some symptoms of coronary artery disease, such as a decreased blood flow to the heart.

"We used a relative being mistreated in a nursing home," Sheps explained after study results were published in March in Circulation, the American Heart Association journal. "They had to give a speech about how to deal with it. They gave the speech in front of an audience." Sheps noted that the stress of public speaking was part of the test.

Using radionuclide imaging, which provides a motion picture of the heart beating, researchers determined that mental stress can increase the risk of death from heart disease. "This adds to a growing body of evidence that links mental stress and bad outcomes in individuals with coronary artery disease," he said.

Sheps and his colleagues said their study gives credence to doctors who advise people to calm down if they want to live longer.

"The heart reacts to mental stress," agrees New York cardiologist Dr. Jonathan Steinberg. "In vulnerable people, this can be a potentially fatal heart arrhythmia," he told The Record, a New Jersey newspaper, earlier this month.

Steinberg is the author of a post-Sept. 11, month-long study of 200 patients in and around New York city showing how the mind can cause the heart to misfire.

The study revealed "a much higher incidence of dangerous arrhythmias" experienced in the month after the attacks, said Steinberg. "The magnitude of the risk in our study surprised me."

New York Times health columnist Jane Brody wrote recently about her father's fatal heart attack. "Though he was a very sweet and caring man, patience was not his strong suit, and my mother was convinced that his irritation over being stuck behind a garbage truck on the way to the store ultimately did him in."

Most of the 250,000 deaths in the U.S. (and likely about 25,000 in Canada) from coronary heart disease that occur before sufferers reach the hospital are probably caused by arrhythmia, experts say.

The mechanism that transfers the impact of stress on the mind into irregular beats of the heart is the "fight or flight" response hard-wired into us. The rate of beats or contractions can be influenced by nerve impulses and hormones in the blood. High levels of adrenaline and the other hormones provoked by stress can cause the rapid heartbeats that throw off the heart's normal regulation.

A rush of adrenaline is produced by the sympathetic nervous system, which evolved to help mammals survive in a hostile, life- threatening world full of predators. The problem is that making a work deadline, getting stuck in the wrong lane of traffic because of road repairs or even watching the Leafs in overtime battling the Carolina Hurricanes (predatory though they may be) are not exactly life-threatening events, but our bodies react as if they are, producing a rush of adrenaline that can't be worked off.

"I would guess it's more stressful to the cardiovascular system for a coach than for the players," observes cardiologist O'Keefe. "When you're intensely interested as a coach, your system is preparing for physical stress as if you were playing, but when you're playing, you use your muscles and use the chemicals your body is producing and you blow off steam."

But when the body has geared up to physically get out there and play, and instead you just stand around watching, blood pressure goes up and pulse rate goes up, says O'Keefe.

"Also, the players are young and active and fit and coaches," O'Keefe pauses, searching for a tactful phrase, "coaches are often notthose things."

The flight-fight instinct is more pronounced in people who are quick to anger, chronically impatient or who overreact to stressful situations- people O'Keefe calls "hot responders."

The sympathetic nervous system also can become overactive in response to major depression, chronic anxiety and social isolation.

It's these psychosocial stressors that tend to provoke heart attacks in women, according to a study by Minnesota cardiologist Norman Ratliffe.

He asked 122 men and women who had experienced cardiac arrest outside of a hospital setting to describe the emotional states and stress they were experienced before the attack. They found that 40 per cent of the women said they'd been experiencing stress such as divorce or depression in the period just before their cardiac arrest. Only 16 per cent of the men reported that kind of stress.

On the other hand, 40 per cent of men said they'd been exerting themselves physically. Only 5 per cent of women reported physical stress.

Researchers aren't sure whether there really are biological gender differences in stress triggers for heart attacks or whether women are more likely than men to admit to emotional problems.

Also, notes O'Keefe, "Stress, especially emotional stress, is very subjective. What some people consider very stressful, others don't feel at all. It's how you react to it, and also how your body reacts to the stress hormones. Some people's adrenaline flows, and it doesn't do much to their blood pressure or the irritability of their heart. Others are very sensitive to increased stress hormones."

In fact, a study published today in the British Medical Journal that followed Scottish men for 20 years, beginning in the 1970s, suggests that some people see themselves as experiencing more symptoms of stress and also more symptoms of illness.

So what's a person to do avoid cardiovascular problems related to emotional stress, short of joining a monastery in the Himalayas or watching PBS or the Discovery Channel instead of the Stanley Cup or the upcoming World Cup?

First, you can support the part of the nervous system that works to calm and soothe- the parasympathetic nervous system- by forming strong social connections, participating in group activities, owning a dog and by seeking relaxing situations and getting married. (No, the latter two are not contradictory.)

A study published today in Psychosomatic Medicine reveals that lonely people face a higher risk of heart disease, possibly because of differences in how their cardiovascular system reacts in times of stress rather than because of unhealthy behaviour.

And even though sudden exercise and athletic sex may activate the sympathetic nervous system and stress the heart in the short term, especially if practised by a normally sedentary or celibate older person, in the long term physical conditioning and a satisfied mood are good for the cardiovascular system.

Regular physical activity helps to reduce activity of the sympathetic nervous system through weight loss, reduced anxiety and depression and improved insulin sensitivity, say O'Keefe and his colleagues.

Also, you can eat lots of oily fish such as tuna and salmon or supplement your diet with 1 gram daily of the fatty acid found in fish oil, also known as omega-3 fatty acids. The fish oil has been shown to fight arrhythmia and sudden cardiac deaths caused by irregular heartbeat, according to an Italian study published last month in Circulation: Journal Of The American Heart Association.

Finally, when it comes to hockey playoffs, remember that the game is played on ice for a reason. It's so you can chill.