Risk score offers new way to assess the impact that stress can have on the heart

By combining three measures of a person’s cardiovascular response to stress into one equation, researchers could better predict risks for future cardiac events among people with heart disease

A scientific team funded by the National Institutes of Health (NIH) has developed a risk calculation to determine how a person’s cardiovascular system adapts to stress with the goal of better predicting future heart-related events among people with heart disease. The findings, which published in the Journal of the American Heart Association, showed that people whose cardiovascular systems were less adaptive in response to sudden stress, such as giving a public speech for example, had double the associated risk for a future heart attack, severe heart failure, or death years later.

Researchers have previously found that people with heart disease are more likely to experience future heart problems if they have long-lasting, overreactive or blunted responses to stress. This was the first study to combine multiple measures into one cardiovascular reactivity risk score — which improved predictions for future cardiovascular events compared to any of the three measures assessed alone.

To assess a person’s cardiovascular response to stress, investigators worked with 629 adults with heart disease who were part of two prospective, observational studies. They assigned each participant a five-minute stress task and measured their blood pressure and blood flow (hemodynamic reactivity), the functioning of cells lining their blood vessels (endothelial function), and the narrowing of blood vessels (vasoconstriction).

To elicit sudden stress, each participant had two minutes to prepare a speech about how they would handle learning about the mistreatment of a loved one in a nursing home. Then, they had three minutes to deliver the speech in front of researchers in lab coats. Researchers compared changes in a person’s heart rate and blood pressure during the stressful task to when their bodies were at rest. They also assessed whether the arteries in a person’s arms and fingertips fully dilated, or opened, at various points of rest and during the stress task.

People who had the most typical reactive responses — meaning their blood pressure and heart rate increased in response to stress, while their small arteries constricted less and they released more nitric oxide, a substance that preserves arterial health, shortly after stress — scored lowest for each test. The three measures, all of which independently predicted future events, were combined into a single cardiovascular reactivity risk score.

The risk scores ranged from 0-9. People with scores of 0-3 had normal reactions to stress. People in the study had average scores of about 4.5, which meant they had intermediate responses that were linked with a 50% greater chance of experiencing future heart problems compared to the lowest scores. Adults with the highest scores of 6-9 were about 100% more likely to experience future cardiovascular events.

Overall, about one in every four to five adults — who were followed for up to six years — experienced a future cardiovascular event. This could include having a heart attack, severe heart failure that required hospital care, or dying from a heart-related emergency.

If a person had a blunted response to stress, it could mean many things. For example, a less adaptive response to stress may mean that a person’s body wasn’t receiving signals from their brain and other organs and systems in real time, or that they couldn’t quickly react. It could also mean that their bodies took longer to calm down from stress.

While this is the first time that a risk score for cardiovascular reactivity was created, it is limited to a research setting. Researchers will continue to study if and how these types of findings could be used to improve standard risk predictions for heart disease and help people with less adaptive responses to stress take steps to protect their hearts.

The study was funded by NIH’s National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Mental Health, and the National Center for Advancing Translational Sciences.

Study: Moazzami K, Sullivan S, Wang M, et al. Cardiovascular reactivity to mental stress and adverse cardiovascular outcomes in patients with coronary artery disease. J Am Heart Assoc. 2025; doi: 10.1161/JAHA.124.034683.