Stalking and restraining orders linked to higher risk of heart disease in women

Women who reported having been stalked or obtained a restraining order were each more likely to experience a heart attack and/or stroke in later years compared to those who did not, according to new research published today in the American Heart Association’s flagship journal Circulation.

“Although violence against women is common, and evidence has linked violence with consequences for women’s later heart health, it is still not widely recognized or routinely considered by health care professionals as a potential cardiovascular risk factor among women,” said study author Rebecca B. Lawn, Ph.D., a research associate in epidemiology at Harvard T.H. Chan School of Public Health in Boston and at the School of Population and Public Health at the University of British Columbia in Vancouver, Canada.

“We felt it was essential to look beyond traditional cardiovascular risk factors in women and strengthen our understanding of the relationship between underexplored types of violence and heart health.”

About 1 in 3 women have been stalked at some point in their lives, according to data on intimate partner violence collected by the U.S. Centers for Disease Control and Prevention. The study notes that common forms of violence against women, such as stalking, are rarely discussed in cardiovascular research. Lawn’s previous research linked sexual assault and workplace harassment to higher blood pressure in women. Other studies report that people with restraining orders are more likely to experience poorer health.

Researchers analyzed stalking, restraining orders, and heart disease or stroke development among participants in the Nurses’ Health Study II, from 2001 to 2021. The analysis includes data for more than 66,000 women, average age 46 years in 2001. These women did not have cardiovascular disease in 2001, when they first shared whether they had experienced stalking or stalking harassment behaviors, such as receiving unsolicited correspondence, that made them fearful. The study also asked if participants had “ever taken out” a restraining order, which is a legal document that seeks to limit contact between a victim and perpetrator. Obtaining a restraining order was considered a sign of severe violence.

The analysis found:

• Overall, nearly 12% of the women in the study reported that they had been stalked, while nearly 6% of them said they had obtained a restraining order.
• About 3% of all women studied reported new-onset heart disease or stroke during the 20 years of the study.
• Compared to women who had not been stalked, women who reported experiencing stalking were 41% more likely to have cardiovascular disease.
• Women who had obtained a restraining order were 70% more likely to report cardiovascular disease versus those who had not.
• Similarly, women whose medical records confirmed heart attacks or strokes were more likely to have reported being stalked or obtaining a restraining order.
• The increased risks for heart attack and stroke associated with stalking and restraining orders remained despite the existence of other self-reported cardiovascular risk factors, such as health and lifestyle behaviors, medications, health conditions, childhood abuse and symptoms of depression.

Stalking is often seen as a form of violence that does not involve physical contact, which may make it seem less serious. However, our findings suggest stalking should not be minimized. Stalking can be chronic, and women often report making significant changes in response such as moving.”

Rebecca B. Lawn, Ph.D., research associate in epidemiology at Harvard T.H. Chan School of Public Health, Boston and at the School of Population and Public Health, University of British Columbia, Vancouver, Canada

Harmony R. Reynolds, M.D., FAHA, immediate past chair of the American Heart Association’s Clinical Cardiology & Stroke Women’s Health Science Committee, said she was surprised at the strong association this study found between stalking and cardiovascular disease.

“A variety of stressful life experiences are known to increase the risk of cardiovascular disease, including adverse childhood experiences, financial stressors, grief and other experiences,” Reynolds said. “People subjected to intimate partner violence face about a 30% higher risk of developing cardiovascular disease in the next few years compared to others. While this study shows a more moderate risk, given the long-time frame, it highlights how feeling unsafe can affect the body, in addition to the mind.”

Reynolds, the Joel and Joan Smilow Professor of Cardiology and Director of the Sarah Ross Soter Center for Women’s Cardiovascular Research at NYU Grossman School of Medicine in New York City, was not involved in this research, and noted that the effects of stress can be long-lasting. “Perhaps because it is our nature to re-think about things that happen to us, making us experience the situation over and over. However, social support may mitigate the effects of stress. It’s helpful to have people you can trust to talk with, whether they are family, friends, people in the community or professionals,” she said.

Study authors note that the link between stalking and cardiovascular disease may be due to psychological distress, which may disrupt the nervous system, proper blood vessel function and other biological processes; however, these potential mechanisms were not examined in detail in this study.

Lawn said more research, as well as training for health care professionals, is needed to understand the link between stalking or obtaining a restraining order and women’s cardiovascular health.

“We also need to increase awareness about the potential health harms of experiencing violence and provide women with help and resources,” she said.

Among the study’s limitations are that participants-U.S. registered nurses-were mostly non-Hispanic white women. The findings may not apply to other populations or groups of people. The study notes that previous research indicated that, “violence history, including stalking, is more common among women from minority racial/ethnic backgrounds and those with low income.” In addition, the study relied on participants self-reporting their history of experiencing stalking and restraining orders.

Study background:

• The study included 66,270 U.S. women ages 36-56 years at enrollment in 2001 in the Nurses’ Health Study II, part of a larger, ongoing survey of U.S. female nurses that began in 1989.
• Self-reported data on stalking was collected in 2001. Information about heart attacks and strokes was self-reported and verified with medical records.
• The study used a prospective analysis, meaning researchers started with women who had never had a heart attack or stroke when asked about stalking or obtaining a restraining order. They then followed these women for more than 20 years to see if they reported experiencing stalking or obtaining a restraining order and were more likely to develop a heart attack or stroke compared to women who did not report these experiences.