Heightened Risk of Myocardial Ischemia with Mental Stress Among Black Women Survivors of a Myocardial Infarction in Midlife

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Abstract
Background Stark disparities in the outcome of myocardial infarction (MI) persist, with large unexplained variations affecting younger Black women. Mental stress induced myocardial ischemia (MSIMI) is an emerging mechanistic pathway that may help explain excess risks in this group. Objectives To determine whether MSIMI is more common in Black women with recent premature MI than other demographic groups. Methods We studied 602 individuals ≤ 61 years of age who were hospitalized for MI in the previous 8 months. Participants underwent 99mTc-sestamibi myocardial perfusion imaging at rest and after mental stress (speech task). A summed difference score (SDS) was used to quantify ischemia. Clinically significant MSIMI was defined as an SDS ≥3. Log-binomial regression models adjusted for sociodemographic, lifestyle, clinical and psychosocial factors. Results The mean age was 51 years (range, 25-61), 46% were women and 59% self-identified as Black. Black women had a more adverse psychosocial profile and higher rates of obesity and diabetes, but a less severe index MI. The incidence of MSIMI was approximately doubled in Black women than the other groups (p<.001 for interaction). Clinical and psychosocial risk factors did not explain these differences. In a fully adjusted model, the risk ratio of MSIMI for Black women was 2.2 (95% CI, 2.0-2.5) compared to Black men, 2.3 (1.8-2.9) compared to non-Black women, and 1.8 (1.4-2.2) compared to non-Black men. Conclusions Among midlife individuals with a recent MI, Black women have a disproportionately higher risk of MSIMI. Targeted interventions for this high-risk group are needed. What is new?We show for the first time that Black women in midlife who have recently experienced a myocardial infarction face a disproportionately high risk of developing myocardial ischemia when under mental stress. This elevated risk cannot be attributed to more severe coronary artery disease, suggesting a stress-related cardiovascular vulnerability that may help explain why Black women experience both higher rates of premature heart attacks and worse outcomes following these events. What are the clinical implications?The high rate of ischemia with mental stress in Black women highlights the need for new targeted risk assessment protocols and prevention strategies that go beyond the control of conventional risk factors to address stress-related risk pathways. This paradigm shift in cardiac care should help reduce cardiovascular disparities and improve outcomes in this historically underserved population. Differences in Myocardial Ischemia with Mental Stress by Sex and Race Among 602 individuals ≤ 61 years of age who were hospitalized for a myocardial infarction in the previous 8 months, and who underwent myocardial perfusion imaging with mental stress, Black women had approximately a twofold higher risk of developing myocardial ischemia compared with other demographic groups, even after adjusting for clinical and psychosocial factors.

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