As a cardiologist in New York City who treats a sizable Bangladeshi‑American community, I have witnessed otherwise healthy individuals exhibit concerning cardiovascular events, frequently in the absence of conventional risk markers. What unites them? Severe, protracted psychological stress brought on by prejudice, family court disputes, immigration problems, or financial instability.
The mechanisms of prolonged stress
Prolonged stress raises cortisol, adrenaline, and inflammatory cytokines via activating the sympathetic nervous system and hypothalamic‑pituitary‑adrenal (HPA) axis. This eventually leads to:
- Chronic high blood pressure
- Endothelial malfunction
- Increased blood sugar levels
- Enhanced activation of platelets
- Reduced fluctuation in heart rate
- Accelerated atherosclerosis
A clinical trend that we ignore
Minority men, many of whom are Bangladeshi, Caribbean, or West African, frequently come to me in my clinic with:
- Tightness in the chest or palpitations
- Blood pressure fluctuations in spite of medication
- Anxiety is mistaken for panic attacks.
- Hypertension at night or rises in blood pressure in the morning
- Minimal heart rate fluctuation during Holter monitoring
Cultural restrictions on expression
In many immigrant and minority groups, men are brought up to be stoic. Emotional anguish is viewed as a sign of weakness. They rarely seek therapy, keep quiet, and absorb trauma.
Men are specifically forbidden from discussing mental distress, even when it is killing them from the inside out, in South Asian culture. Stigma and shame rule. They might somaticize their suffering by exhibiting symptoms that we frequently write off as anxiety or “functional,” such as tiredness, dyspnea, or nonspecific chest pain.
Clinical tip: As part of your ROS (review of systems), inquire about emotional, familial, and legal stress. They may have told no one else but you
Chronic stress from emotional trauma as a cardiovascular multiplier
- Cases in family court (such as divorce or custody)
- Hearings on immigration or asylum
- Loss of visitation or parental rights
- Unfounded legal charges have the potential to spark a protracted outpouring of sympathy.
Prolonged exposure to this “fight or flight” state causes aberrant cardiac remodeling, increased norepinephrine exposure, sleep disturbance, and a decrease in heart rate variability.
Even after controlling for lipids, blood pressure, and body mass index, a 2022 study published in the Journal of the American Heart Association revealed that long‑term discriminating stress was linked to elevated CAC scores and an elevated risk of MI.
The role of clinicians
ADVERTISEMENT
1. Screen with empathy. “Is anything in your personal life making it hard to sleep or feel safe?” is an example of an open‑ended inquiry.
2. Confirm the encounter. Many men of color experience feelings of invisibility, judgment, or disbelief. Just acknowledgment has therapeutic effects.
3. Work together to support mental health. Refer patients to culturally competent clinicians even if they decline counseling. Think about cardiac rehabilitation programs that offer behavioral help.
4. Make use of impartial tools. To identify stress‑induced arrhythmias, track ambulatory blood pressure, heart rate variability, and wearable technology.
5. Advocate. Participate in neighborhood initiatives to address inequalities in access to social and mental health resources, court bias, and legal injustice.
In addition to spending years learning how to read lipid panels and EKGs, we also need to learn how to read our patients’ emotional EKGs, particularly those who are silently suffering from emotional and legal pressure. Men of color and immigrants are more susceptible to this unseen cardiovascular load.
As doctors, we need to be more empathetic outside of the exam room. It is not optional to identify and treat psychological trauma; doing so is critical for heart health.
Monzur Morshed is a cardiologist. Kaysan Morshed is a medical student.
