In women, the age of manifestation initially rises moderately after the onset of menopause, and then exponentially in the higher age groups (starting from age 75) . The cardiovascular mortality is higher than in men. This is likely due to the double burden of professional and family-related stress. Additional psychosocial stress factors in women include partnership, children, grandchildren and other family-related problem areas.

Depression is a confirmed demonstrated risk factor for the outcome of coronary heart disease . The mortality risk was 3–4 times higher for patients with clinically relevant depression. The correlation between depression and cardiovascular disease is illustrated in Table 13.2.

Due to an accumulation of stressful experiences in childhood rather fearful or suspicious interpretation and behaviour patterns develop. This leads to stress reactions in interpersonal relationships. A prolonged imbalance of stress systems increases depressive symptoms and promotes an unhealthy disease behaviour such as smoking, unhealthy diet and physical inactivity. On the other hand, depression in turn represents a persistent internal stressor that impacts the development of coronary heart disease through activation of the immune system, of blood coagulation and changes to the vascular endothelium (Table 13.2). The interaction of these somatic and psychosocial risk factors increases tenfold the probability of dying a cardiac death at an early age.