It's time to be well with your health. I'm Shanna.

I'm Nimeet.

Welcome to the Adventist HealthCare and You Podcast. We are excited today to talk about how stress, anxiety, and burnout can harm our hearts over time.

Yeah. You know, as I was prepping for this podcast, I was reading one of the articles from Yale Medicine and it mentioned that, you know, people with high stress and history of depression are two and a half times more likely to get a heart attack, which, you know, I found fascinating.

Well, you don't really think about it. And now that we know stress affects our physical health, our mental health, why wouldn't it affect our heart? So we have a great guest today to talk to with us about that. Doctor Brian White, who is a general cardiologist with Adventist HealthCare Cardiac Associates. Welcome Doctor White.

Good morning. Good morning. Thank you for having me today.

Thank you for being here. You have a unique perspective on the heart and stress from your background. Talk to us a little bit about that. Tell our listeners why you are passionate about this.

I was in the military for twenty five years and obviously very grateful for all the tremendous opportunities I had to serve our veterans through the VA administration, our retirees, our active duty members.

And with that, I got an opportunity to see a high prevalence of cardiovascular symptoms, but also a high prevalence of cardiovascular disease. And especially in our retiree and our veteran communities, where you can imagine that stresses, fatigue, strain, all very prevalent, especially our Vietnam generation, our Korean generation, where we saw a lot of people that had a lot of depression, a lot of anxiety, a lot of alcohol use, a lot of smoking, a lot of sedentary activities, where we saw a very high prevalence of cardiovascular disease. So it's something that from my very beginnings has been a huge part of my experience and my practice today.

Thank you. Thank you for your service as well.

Thank you for your service.

Thank you. Most listeners don't know I did do a small stint in the military.

Thank you for your service.

Thank you. A million years ago, it feels like. Doctor White, you mentioned one group, our veterans, our military population, but there are other groups that also have a high relationship between stress and heart disease. What are those groups?

Doctor. When you look at patients who've had heart attacks, are being diagnosed with heart disease, and you ask yourself, what is the prevalence of depression, anxiety in those patient populations? It's quite big, actually. So you can kind of think about it as the thirds, right?

So about a third of patients that are being diagnosed with a heart attack or cardiovascular disease may have depression or anxiety, and over half have significant stress in their life. And understanding that these diagnoses are not mutually exclusive. You can have both stress and you can have both anxiety, and they can be very additive. And so the increased risk of cardiovascular disease goes up as you have a combination of both.

So how's like everyday stress different than like chronic stress? You know, people stress on a daily basis sometimes, and how does that convert to like chronic stress that they need to like, you know, take some measures to either correct it or be at least aware of it?

Yeah, I think that you bring up a really good question, you know, so you're going to have a litany of stressors, right? And I think that before we talk about what are the potential negative impacts, let's just kind of talk about what those stressors are, because they're around us. I think that sometimes we struggle to kind of talk about what those stressors are, right? You know, getting your kids to school on time, you know, what are people's finances? Understanding that in the current situation, finances are more challenging. People may be underemployed, people may be unemployed, or even if they are employed, then the job stresses may be much greater than they ever have before. They're having to do the same amount of work, if not more, with less resources, less people.

So other stresses are things also around us, like aging parents. Or we may be aging ourselves and then our spouse is aging.

We talk about our kids, but often do we talk about our marriages. So I think when you talk about those type of events or stressors, it's important to kind of identify those. Obviously, you can have, you know, acute stressors that may be someone's now very ill, someone now has a diagnosis of breast cancer, someone may have a diagnosis of some serious illness that led to hospitalization. Those are more of your acute stressors versus your chronic stressors, your family health, your finances, your job, your commute, interpersonal relationships.

Both of those can contribute to cardiovascular disease and contribute to cardiovascular symptoms, right? So not all cardiovascular symptoms are actually a sign of cardiovascular disease. So acute stress can give you chest pain, give you shorts of breath and give you heart pounding, otherwise known as palpitations. But yes, long term stresses, you know, can lead to long term strain, and that can lead to a significant increased risk of heart disease.

And if you were to compare it to some of the other traditional risk factors, maybe like diabetes, smoking, it actually is on par with that as a degree of a risk for development of heart disease. So long term stress is equivalent to other high risk features for development of heart disease, but short term stress should be evaluated, should not be dismissed. What are some of the short term stress events? We talked about chest pain syndromes, but in all other things that may occur is a stress induced cardiomyopathy, right?

Or you can actually have subclinical coronary atherosclerosis, meaning that you have plaque buildup in your arteries, and then you get an acute stressor Driving here and you get cut off, your adrenaline goes up.

Or you're out shoveling snow, or you're lifting something heavy in the basement.

It could be a good stressor, it could be not a good stressor, but that sudden surge in adrenaline, sudden surge in blood pressure can be very traumatizing to your arteries and precipitate a heart attack. So you can have non heart attack symptoms, you can have heart attack symptoms where the heart is damaged, but the arteries are preserved, a stress induced cardiomyopathy, or heart attack where the arteries are damaged and the heart muscle is damaged because the heart arteries have been disrupted.

And I think many of the individuals are going through so many different stressors, not just a single one. So I think the variety of them kind of adds up as well.

And based on the stresses, people may choose to do, you know, some other coping mechanisms that may not be healthy, like drinking or smoking, like you That all adds up.

Yeah, that all adds up. So what are some of the recommendations you have to at least deal with those stressors in a healthy way?

Well, I think one of the things to take a step back is to say the word acknowledgement. Yeah, Right? So what is this podcast about? It's about the word acknowledgement, right? You are acknowledging that stress is there and you're acknowledging that needs to be discussed and you're acknowledging that it can have negative effects on people's health, not just their heart health, but their entire health. So I think that one of the things that we can do is, and again, we don't always have all the time in the role, but within the time that we have, try to identify those stresses in our office visits. I know that within our Cardiac Associates Program, we are trying now to implement the PHQ-two, which is a short two question questionnaire for screening for depression.

In our military days, we actually would include the PHQ-two and the PHQ-nine. And we did that actually at every point of contact. So you come in for an x-ray, you get a PHQ-two. You come in to see a specialist, you get a PHQ-two.

So right now we're implementing that. So we're trying to identify when patients are at risk, because the best way to intervene is to identify those that need to help. Yeah. And then start giving them the resources, right?

So it's like, if a patient is smoking or vaping because they feel stressed, is the best answer to say, No, you're wrong. Or is the better answer to think about the composite of what's required to address that?

I mean, I think one of the most important The whole person.

The whole person and the whole problem. One of the most important things that we need to do is not come across as disingenuous, you know, in the sense that, Oh, you have a problem, it's easy to fix. Just close the door, it's done. So I think that things that we can help address in, Hey, finances are a real stressor, kids going to college, kids going to work, kids going into the military, job security, job insecurity, food insecurity, these are all real risks, and all real stressors. I think if we can acknowledge that, that's a good foundation. As far as what we can do is if patients come across as anxious or depressed, is get them the right referral to the right mental health resources.

Also understanding that our primary care networks play a huge role in that because traditional behavioral resources are somewhat limited. So again, want to make sure we get people the right resources, but what are some good, healthy lifestyle things that we can do, right? So some of the bad behaviors that people may have is going to be physical inactivity, sedentary lifestyle, smoking, drinking, marijuana use.

So simple things. So again, asking them who, what is your social construct? Mom, dad, brother, sisters, husband, wife, children.

The more we can un isolate someone and more we can associate someone with other people, the better off they're going to be. Secondly, obviously trying to employ good eating habits. You know, as far as trying to find ways to avoid stress eating or boredom eating. You're thinking about the next paycheck, the next thing you do is you sit down and have a bag of pretzels. So how do we turn bad eating habits into good eating habits?

Maybe eat carrots instead of pretzels, drink water instead of drinking sodas, drink water instead of drinking beer, trying to limit the time in which you have food. When the sun is set and it's two hours before bedtime, that's the wrong time to be eating. And that only promotes further bad eating habits. And again, then you begin this vicious cycle.

I'm eating poorly, I'm putting on weight, I feel bad about myself, and that perpetuates anxiety and depression. I think one of the other things that you can do is exercise. And, you know, it's one of those where we always have to be modest about our goals. You know, we don't want to say, Hey, let's run out there and you're going to run an hour every day.

You know, you want to find goals that are appropriate for your patient. If they're a twenty five year old, maybe they go and they start walking fifteen minutes a day, thirty minutes a day, they walk up to an hour a day. If they're sixty five, seventy, and they have bad knees, bad hips, Maybe that's a little bit different paradigm. But exercise is a great way to relieve stress.

It's a great way to release endorphins. We think about that adrenaline high, that's a myth, adrenaline does not make you feel good, but exercise releases endorphins. That makes you feel good. And if you compare exercise to antidepressants, they match.

They're equals. Interesting.

Doctor White, you said in an interaction we had a little while ago that resonated with me, which was in this area, we have, I probably, I don't know, one of the worst commutes in the country, right? It takes forever to get anywhere. Traffic is bad.

You know, it's what it is to live here. And I realized for me, that was a big stress. I just, and I never really thought about it. So now when you say take little steps, I was like, oh, I am sitting for like an hour in the car every day.

And that means I'm not moving and I'm getting stressed while I'm sitting in the car. So it was the acknowledgement that you were talking about. And then the sort of, okay, well, can I do to let it go and do something else while I'm not driving? Like when I get home or so now I'm like, okay, I'm going to listen to a podcast or I'm going to make sure when I go home, I'm going to walk for a half hour.

So, I like what you said, acknowledging some of the things that could be causing you stress and finding something to combat it that works for you.

No, I totally agree. And I appreciate you bringing up this subject because I think it really applies to a large portion of the audience. And I think that obviously from a cardiovascular standpoint, we're trying to recommend aerobic exercise, thirty minutes, five days a week. And so when you're talking about someone that maybe if you're spending an hour a day in the car, you're the lucky one.

You know, most people are spending two to three hours a day in the car because they may live in Germantown, and commute to Arlington or Northern Virginia. And so with that, you hit the nail on the head, you are stressed the entire time that you're there, you're driving, because it's not a nice gentle drive is actually bumper to bumper. You're always worried about that car accident, you're always worried about the next driver, you're always worried about getting to work on time. And you're always worried about the stress about what's going to happen when you get to work late, and how's that going to impact your day.

So you expend all this energy, you raise all of your blood pressure. And one things that we talk about emotional stress and physical stress, they lead to sheer stress, meaning that as you increase your stress levels, and you're increasing your adrenaline, you're causing endothelial dysfunction or causing the arteries to be more constricted or more narrow. As you have more flow coming from your heart, because it's beating harder, it's beating faster under the influences of adrenaline, but you're just sitting there, all that's doing is causing the stress, the sheer stress in those arteries to go higher.

That sheer stress is part of that mechanism for the development and the proliferation of coronary disease. Trauma leads to disruption of the line of the arteries that leads to the inflammatory response that leads the lipid deposition that leads to development of plaque. So not only is it a complete negative, it also takes away two to three hours for you to be actually doing exercise. So now if you look at your day, instead of saying, I'm going work for eight hours and I'm going to drive for one hour and spend one hour doing aerobic exercise, now you've worked for nine hours and driven for two to three hours, now you're at fifteen hours.

You got a spouse, you have kids, you have bills, you have other responsibilities, you have to eat and sleep. There's no time for you to take care of yourself. So Doctor McNeil had a guest speaker and she did a great job of talking about how do you rest? How do you incorporate rest into your day?

And so you're absolutely right when you talk about, you know, let's put down the phones, let's not do the doom scrolling, which I'm just as guilty as everybody else is But if you can be in the car and find a way to de stress a little right?

We want to be genuine. Yeah. We can't tell people don't drive to work. So they have to go to work, they have to have a job.

And for many people, they're going to have a difficult commute. So how do we stay genuine and say, I like your ideas, instead of just being in the car without something to relax you, put on an audible type of book on tape or a podcast or some form of music that relaxes you. So then you can take your stress levels. Because again, if you're running or you're doing aerobic exercise, your adrenaline and your blood pressure goes up proportionally to your physical activity.

So your whole skeleton, all the muscles taken up that adrenaline. But if you're sedentary and your adrenaline goes up, the only thing that's taking all that adrenaline is your heart and your blood vessels. And that's obviously bad for your short term health and your long term health.

Yeah. One of the things you said was about the typical day, you know, individual experiences and two to three hours in commute, eight to ten hours of work. And by the time they're at home, they're just exhausted and can't really do anything.

One of the things I started doing, and Shannon and ran into you at the stairs.

We ran into each other on the stairs.

We started doing stairs at lunch and just like going up and down.

You know And I'm ashamed to say I lasted two days.

I lasted lasted still lasting all year.

Okay. Are you still doing okay. You're gonna inspire me to get back to it.

Yes. But I think one of the things you said earlier, doctor White, was around, you know, healthy eating, healthy habits, and how to incorporate that into the normal day.

Yeah. It's the little things.

It is the little Even just the little things can help.

Because they all add up and that all helps out, you know, instead of just sitting around or worrying about the stress and looking at other options that may be incorporated within your life. And be realistic about it. You know, don't do them, you know, ten miles if that's not realistic. Start by baby steps. Do some walk for fifteen minutes, twenty minutes. That'll be helping in the long term.

I like what you said. Be genuine about it. Yeah. You know, from a physician standpoint, I like that because it's less judgmental. It's more about let's figure out what works for you versus holding them to some sort of standard that is impossible.

Absolutely. You want to see that progressive personal development. Yeah.

And so if I can, I want to use you for Please do?

So stairs, everyone loves to talk about stairs.

Yeah.

And stairs would actually be not the first thing I would recommend.

Oh, okay.

Good to know.

We're doing it wrong, Emmett.

I know.

And the other thing I would recommend is actually socialization.

I think that you would get much more benefit from being with a group of your four closest friends walking outside for thirty minutes.

And then you could come back and say it's cold, it's wet, it's rainy, maybe that's not the easiest thing to do. There is free walking, right? Even just going to a grocery store is an easy way to do free walking.

Stairs require three things. So when you walk, you do aerobic exercise. And when you go to the gym, you do lifting weights, that's resistance exercise.

But there's a simple physics principle, and that is gravity always wins. So when you go upstairs, you are doing it in a sense that you're doing aerobic exercise. So you're turning over the skeleton, you're using the skeletal muscles, you're moving, you're moving, moving aerobic exercise, you're pushing against the forces of gravity. So you're now engaging that resistance.

But also as you go up an incline, you're actually having gravity dilate your arteries and veins and pull blood into your pelvis and legs. So now you're doing more activity with maybe ten to twenty percent less blood. So going back to more modest type of goals, you know, I see this all the time in my patients where they'll come in and say, I'm short of breath. And I'm like, well, what can you do?

Or what can you not do? And for the most part, the stairs is the number one thing. And so with that, what I try to do with those patients is to say, ambulate for three to five minutes and then use the stairs, get the blood circulating. So when you're sitting still right now, you're using four liters per minute, but to go up a flight of stairs, you need to be at seven to ten liters per minute.

Try to get there by walking, then going up the stairs. But going back to our analogy earlier, if I asked you to do the more arduous task first, you're most likely going to get fatigued.

Overwhelmed and fatigued, yep.

And wanting to back off. So if we ask you to take on activities such as walking, and then added the stairs later, I think you'd be more successful.

I like that. Think walking is so underrated too.

One last question before we wrap up.

Men and women's hearts are different. Most people don't think about it like that, but they're different. How does stress affect women a little differently?

Well, I think that you're absolutely right that, stress definitely affects both men and women. And it's definitely a significant risk factor for the development of heart disease.

I think that where women may differ is going to be in some of their fundamentals, meaning that women tend to be of smaller statue and tend to have smaller hearts and may be susceptible to coronary disease and heart failure syndromes in a slightly different way because their arteries are smaller and their hearts are smaller. But I think one of the other things to really look at is going to be how stress translates in the symptoms, and are we making sure that we are identifying the symptoms correctly? So I don't want to turn into, you know, who experiences stress more. Yeah.

Both genders experience stress. Now, with that being said, one interesting piece of literature I came across was when they looked at post menopausal women and the happiness of their marriage, women who are more dissatisfied in their marriage had more progression of their carotid atherosclerotic disease. So there are a lot of specific stressors that women may experience that men may not experience. So marital discourse or caregiver issues, right?

So one of the key people to think about again, is the caregiver, the wife that has the husband that is progressing in age and disability. And that's a tremendous stress. So while stress affects heart disease in both women, women and men, there's different stresses that women have that are unique to women. And then secondly, their symptoms may be different.

And I think that one of the key things we look at the twenty twenty chest pain guidelines was trying to focus on how we identify symptoms in women correctly. And how do we give heart, you know, cardiovascular care to women equally?

Right? So that's one of the key take home points is we're talking about heart disease, all things leading to heart disease. So we want to make sure we identify it correctly, and we treat it correctly, and we treat it equally.

So women are more likely to experience things such as indigestion, nausea, shortness of breath, sweatiness, and fatigue. That's symptoms of heart disease, and those are the symptoms of stress. So you can see easily how one can mimic the other. And then all of a sudden you walk into a room, you start talking to someone, they're explaining their symptoms, and you may not catch on that they're having heart disease symptoms. And you're thinking it may be something else. I think that the other part of that is going to be an inherent bias on practitioners.

I don't want to go too long, but remember, there is a history of bias in medicine. So we kind of talked about this before, right? If you remove your appendix, it's called an appendectomy. If you remove your uterus, it's called a hysterectomy.

Why? It's a woman's source of hysteria. So with that being said, there is a history of bias in medicine. And so we want to make sure that we eliminate and overcome those biases, so that we identify those symptoms of women, give them the appropriate treatment earlier, and give them the quality outcomes.

But let's come back and say, Hey, in a patient that is having symptoms of fatigue, shortness of breath, and we come to conclusion it is stress, the door doesn't stop there. The door has to stay open. We have to walk through, give you the treatment, the resources, so that that long term stress doesn't turn into long term cardiovascular disease.

I that's well Yes.

You, Doctor. White. That was, yes, very well said. Well, thank you for this wonderful conversation.

I hope our listeners got a lot from it. I certainly did. Thank you for your time, Doctor. White.

I know you're a busy guy. You're off to the hospital here later today. So please remember listeners, each year in the U. S.

One in four deaths are caused by heart disease. If you want to learn your risks for heart disease, take our heart health risk assessment at AdventistHealthCare.com/LoveYourHeart. If you want to get more information about Doctor White, visit AdventistHealthcare.com and click Find a Doctor, or you can click the link in today's show note.

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