In addition to the major risk factors for heart disease (high cholesterol, high blood pressure, physical inactivity, smoking, and diabetes), stress can be a contributing factor. The effects of stress on your heart health are dif?cult to study and quantify in part because people not only expe- rience different levels of stress, but they also respond differently. Researchers have identi?ed several ways that stress may adversely affect some people’s hearts:
• Under stress, your body releases extra hormones (epinephrine and norepinephrine) that raise your blood pressure, which may over time injure the lining of your arteries. As the arteries repair them- selves, they may thicken, which promotes the buildup of plaque.
• A stressful situation tends to raise your heart rate and blood pres- sure, so your heart requires more oxygen. In someone who already has heart disease, this oxygen shortage can bring on chest pain (angina).
• Stress increases the clotting factors in your blood, which increases the chances that a blood clot will form and block an artery, espe- cially one already partially closed by plaque.
Then, of course, there are the ways that many people may choose to deal with stress—overeating, smoking, drinking excessively—that are damaging to the cardiovascular system.

The fact is that everyone is under stress of some kind at least intermittently and perhaps much of the time. You can usually recognize symptoms of your own stress in the form of aches and pains, dif?culty ?ghting off mild infections like colds, sleeplessness, or feelings of anxiety or irritability. You also probably know when some of your less healthy coping mecha- nisms are escalating—as, for example, when you put on weight during a tough time, or start smoking more.
Learning to manage stress makes good sense for your overall health. But more research is needed before experts can reliably recommend specific methods of stress reduction as treatments for cardio- vascular diseases. Generally, if you or your doctor believes that stress is having a harmful effect on your health, you can work on several strategies to manage its impact:

• Communicate with family and friends about the things that trou- ble you. Their support and love will help reduce your response to stressful situations.
• If you feel a sense of urgency because of competing demands on your time, consider time management techniques that will help you prioritize and set realistic expectations. Your workplace, library, or the Internet may offer speci?c methods. Also, be cau- tious about agreeing to take on new projects.
• Choose a relaxation technique, such as yoga, meditation, or biofeedback, and make time to master it and practice it regularly. Although there is no conclusive medical proof these techniques can lower blood pressure, there are some promising studies point- ing in that direction.
• When you know that a speci?c problem is causing you anxiety, talk to your doctor or other health-care provider about a support group that focuses on that problem. These resources may be avail- able through a community center, hospital, religious organization, or YMCA.
• Professional counseling or psychotherapy may help you through certain dif?cult periods. Your doctor can help refer you to an
appropriate professional. If medications such as antidepressants are appropriate, your doctor or a psychiatrist can prescribe them and help you get essential counseling as well.
• Use commonsense therapy: eat a healthy diet, exercise regularly (see the box on page 80), limit alcohol and caffeine, and do not smoke.

Managing stress, or preventing stress in the ?rst place, is especially important to people who have already had a heart attack or a stroke. Preventing another heart attack or stroke called secondary prevention by doctors is a key goal for the doctor-patient team. As noted repeat- edly in this book, lifestyle changes are crucial to prevention or second- ary prevention, and stress management should be a key focus of lifestyle changes that also include controlling your cholesterol level, controlling your blood pressure, losing weight if needed, exercising regularly, and stopping smoking.
Depression may be related to stress but is a disorder that needs treat- ment. It is natural to a certain degree to feel “blue” or be upset after a heart attack or a stroke. However, if you have persistent depression, it is important to note that it is treatable—that is, not just “something to live with” (see also “Depression after a Stroke,” page 232). Depression symptoms include prolonged periods of feeling sad or unable to cope, strong feelings of guilt, strong feelings of pessimism or loss of hope, a loss of interest in normal pleasures (including sex), unusual weight changes (unintentional losses or gains), and dif?culty relating to loved ones or coworkers. If you or a loved one has depression, seek treatment from your primary care doctor; he or she will make treatment sugges- tions, possibly including medications or talking therapy, or refer you to a psychiatrist or other mental health professional.