Chronic Stress, Exercise and Cardiovascular Disease: Placing the Benefits and Risks of Physical Activity into Perspective

Abstract

Chronic stress, which has been exacerbated worldwide by the lingering COVID pandemic, has been strongly linked to cardiovascular disease (CVD). In addition, autonomic dysregulation via sustained sympathetic activity has been shown to increase the risk of arrhythmias, platelet aggregation, acute coronary syndromes and heart failure. Fortunately, effective coping strategies have been shown to attenuate the magnitude of hyperarousal associated with the stress response, including moderate-to-vigorous lifestyle activity and/or structured exercise. A good-to-excellent level of cardiorespiratory fitness also appears to be highly cardioprotective. These beneficial effects have been substantiated by numerous studies that have evaluated the levels of stress reactivity and stress recovery in physically active individuals versus matched sedentary controls, as well as before and after exercise interventions. On the other hand, unaccustomed strenuous exercise in habitually sedentary persons with underlying CVD is associated with a disproportionate incidence of acute cardiac events. Moreover, extreme exercise regimens appear to increase coronary calcification and the likelihood of developing atrial fibrillation. This review summarizes these relations and more, with specific reference to placing the benefits and risks of physical activity into perspective.

Keywords: acute myocardial infarction; atherosclerotic cardiovascular disease; atrial fibrillation; chronic stress; coronary artery calcium; hypertrophic cardiomyopathy; physical activity; sudden cardiac death.

Figure 1

Stress bucket analogy. Chronic stress flows into the bucket.

Figure 2

Potential stress reducing effects of regular lifestyle physical activity, structured endurance exercise, or both.

Figure 3

Physiologic alterations accompanying acute exercise training and recovery and their possible sequelae. CHD, coronary heart disease; HR, heart rate; SBP, systolic blood pressure; MVO₂, myocardial oxygen consumption.

Figure 4

The relative risk for an acute myocardial infarction (AMI) is presented at rest (baseline) and during vigorous activity (days/week). No regular vigorous physical activity elevates the risk of an isolated, unaccustomed bout of vigorous exercise by ≥100-fold. Performing one to two days of weekly vigorous physical activity markedly lowers AMI risk during vigorous physical exertion. More frequent performance of vigorous physical activity further lowers exercise related AMI risk, although the relationship is not linear [74,75]. Vigorous exercise is delineated by the asterisks (*). Reprinted with permission from the American Heart Association.

Figure 5

Potential mechanisms and associated sequelae for atrial fibrillation induced by strenuous endurance exercise. Provided with permission from the American Heart Association.

Figure 6

Multiple mechanisms by which moderate-to-vigorous physical activity may reduce the risk of initial and recurrent cardiovascular events. ↑, increased; ↓, decreased; O₂, oxygen.