Even after suffering the same heart attack on paper, women are more likely to face longer recovery times than men, finds a new study from the American Heart Association. Publishing in the AHA journal Circulation, the research team finds stress may be the deciding factor in how long a patient takes to bounce back. For women, the mental load may simply be greater.

“Our study found a significantly higher level of mental stress in women 18-55 years old with heart attack compared to their male counterparts,” said Dr. Xiao Xu, lead author of the study and assistant professor of obstetrics, gynecology, and reproductive sciences at Yale University, in a statement. Heart disease remains the No. 1 cause of death in both men and women in the United States. Among women, it is deadlier than all forms of cancer combined.

Stress is thought to affect heart attack recovery — and many other aspects of a person’s health — in several ways. As opposed to normal acute stress, which happens in a flash, like the kind that kicks in when you are running with the bulls, the kind that leads to chronic disease is called episodic acute stress. It’s both recurring and momentary, so it can’t be considered full-blown chronic stress, but it still reappears. It can lead to damaging plaques in the arteries and impede blood flow.

To better understand the breakdown between men and women, Xu and her colleagues combed through data on 2,397 female and 1,175 male heart attack survivors. Using a 14-point scale to assess stress levels, they unearthed key differences between both genders’ psychology, which ended up influencing how quickly or slowly the subjects returned to health. Women, for instance, had worse overall health and quality of life, punctuated by chest-pain-related physical dysfunction, one month after the incident than compared to men.

Stress also manifested itself differently among the sexes. While women faced family challenges, men were more apt to stress over money; family conflict cropped up in 33 percent of female respondents and in 20 percent of male respondents. Illness too happened more frequently in women — 22.4 versus 16.6 percent. And death of a family member was reported by 36.6 percent of women versus 27.8 percent of men. Meanwhile, men faced financial woes twice as often: 7.4 versus 3.5 percent.

Overall, the study suggests heart attack recovery relies heavily on people’s mental well-being. Judging vital signs and how much physical pain someone is in won’t reveal the whole picture, the authors argue. “We need to think more broadly about our patients,” said Dr. Harlan Krumholz, the study's senior author. This includes not just the treatment for heart attack and heart disease, but the ways in which people fail to make a speedy recovery. “We have to consider their state of mind and the experiences of their lives.”

Source: Xu X, Bao H, Strait K, et al. Sex Differences in Perceived Stress and Early Recovery in Young and Middle-Aged Patients with Acute Myocardial Infarction. Circulation. 2015.