In recent years ever more studies emerged, that focused on women only. Numerous population-based and register-based studies have made a man’s risk factor profile known and predictable—but women’s are not. Psychosocial factors of particular importance and their measurement include (name of authors of gold standard methods in brackets): depressive symptoms (Pearlin), vital exhaustion (Appels), fatigue (Kecklund), stressful life at work (Karasek, Theorell), family problems and lack of social support and social isolation (Orth-Gomer and Undén). These factors have been linked to findings by means of Quantitative coronary angiography (QCA), a method, which was developed to measure very precisely, the effects on coronary artery disease (CAD) of medications, mainly statins. It has been increasingly used in research and found adequate to evaluate the rate of progression of underlying CAD (Büchi et al. 1990).

In Fig. 17.2 the progression of coronary atherosclerosis, assessed by QCA, as the mean luminal narrowing of the entire coronary artery tree, are shown. It is evident that both the negative emotions of depression and exhaustion, and the experience of stress and lack of social support are associated with significant CAD progression.

Such analyses and interpretations should be controlled for standard risk factors and medical/clinical indicators of poor prognosis, meaning that the role of, for example, heart failure or a transmural acute myocardial infarction is interpreted independently from the role of exhaustion (Horsten et al. 2000; Wamala et al. 1999a; Orth-Gomér et al. 1998, 2000).

Finally, sleep disturbances seem to be one of the most important CHD risk factors. In Stockholm women patients’ analysis of the sleep quality scale suggested an association of snoring with CAD progression (see Chap. 8). In this context the image of the excessively tired and fatigued woman, almost drowning in all her duties, is evoked. It was also an image that could be recognized in the stress interviews with 600 Stockholm women (see Chap. 16 and Blom 1997).

Inherent in this image is the working woman and mother having two jobs. On the one hand she may be employed in one, an office of the public sector, as a nurse or nurse’s aid or as a teacher, and on the other hand she fulfills and preserves the common duties of a mother and wife. Women often have part time jobs outside the home, but when all the work is included, like the household duties, care for children, care for significant others etc., then their total number of hours worked often exceeds a regular fulltime job (Statistics Sweden 2006). That this double workload is accompanied by parallel physiological stress responses has been repeatedly shown in work at the Stockholm University (Chap. 4; Fig. 17.3).

To meet the demands from the double roles, women neglect their own health and consequently become more vulnerable for such chronic stress-related disorders as atherosclerosis.

Already in 1991 the epidemiologists in Gothenburg observed a slight but consistent increase in women’s CHD in the ages of 50–59 years. Two decades later, the fact that younger women are at an increased mortality risk, a risk which is not really explained by their standard risk factor levels, is known and accepted (see Chap. 3). This “gender paradox” (Gulati et al. 2009) could explain the poorer prognosis of younger women with heart disease, which could not be predicted by standard risk factors. Similarly, in the “Mexican paradox” (Daviglus et al. 2012) a group of Hispanic US populations with an increased risk of heart disease—but without an explanatory standard risk factor profile—has been identified.

A similar discussion on the role of psychosocial factors was held in the Task Force of the European Society of Cardiology (ESC). The practicing cardiologists wondered why, “patients do not do as we tell them to. We give them the best of advice, but they don’t follow it”. To help improve the interaction with patients a behavioral/psychosocial medicine collaboration was established of the societies of International Behavioral Medicine and the European Psychosomatic Medicine, while serving on the Task Force for CVD Prevention in Clinical Practice together with eight other professional societies. On behalf of ISBM the very first version of guidelines on methods to prevent psychosocial risk factors was coordinated. The work was carried out with the help of an expert panel, which was recruited, chaired, and coordinated by ISBM. The group was loosely linked and had few meetings, whereas behavioral medicine was represented at the ESC committee encounters by ISBM. Each member of the group wrote a first raw version of guidelines on one specific psychosocial risk factor profile, which was repeatedly discussed and agreed upon, first within the behavioral medicine group and then within the Task Force. The final text, serving as a kind of template, has been included in the subsequent publications from the Task Force (De Backer et al. 2003; Graham et al. 2007). This collaboration is ongoing ever since it was initiated in 1999, and behavioral/psychosomatic medicine is represented in national committees on guidelines and recommendations for the implementation of evidence-based knowledge in clinical practice.

Women are protected from accelerating atherosclerosis by sex-related hormones, of which estrogen is most important (Hu et al. 1999; de Kleijn et al. 2002). When this protection begins to decrease (postmenopause) around age 50, the risk of clinical cardiac events increases (Kaplan and Manuck 2008b). Women get as much CHD as men do, but it occurs 7–10 years later in life, the reason believed to be endogenous estrogen. Women with an early menopause have an increased risk of heart disease. The replacement therapy failed to protect women against CHD. In contrast, The Women’s Health Initiative found stroke and AMI to be serious side effects of the HRT. However, between age 50 and 60 HRT was recently been found to benefit women’s hearts, suggesting that the vessel wall is still sensitive to estrogen in that age group.

Beside hormone regulation psychosocial aspects differ between genders and influence CHD, as we have previously shown. Thus it seems very clear that estrogen is not the only reason for the differences between men and women in the outcome after MI (Vaccarino et al. 1999; Parashar et al. 2009; Berger et al. 2009) and the long-term prognosis (Koek et al. 2006).