You’re probably familiar with these major risk factors for heart disease:high blood pressure, high cholesterol, smoking, diabetes, obesity and physical inactivity.

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And chances are your doctor has checked you more than once for these risks and, I would hope, offered advice or treatment to help ward off a heart attack or stroke.

But has your doctor also asked about the level of stress in your life? Chronic psychological stress, recent studies indicate, may be as important – and possibly more important – to the health of your heart than the traditional cardiac risk factors.

In fact, in people with less-than-healthy hearts, mental stress trumps physical stress as a potential precipitant of fatal and nonfatal heart attacks and other cardiovascular events, according to the latest report.

The new study, published in November in JAMA, assessed the fates of 918 patients known to have underlying, but stable, heart disease to see how their bodies reacted to physical and mental stress.

The participants underwent standardised physical and mental stress tests to see if their hearts developed myocardial ischemia – a significantly reduced blood flow to the muscles of the heart, which can be a trigger for cardiovascular events – during either or both forms of stress. Then the researchers followed them for four to nine years.

Among the study participants who experienced ischemia during one or both tests, this adverse reaction to mental stress took a significantly greater toll on the hearts and lives of the patients than did physical stress. They were more likely to suffer a nonfatal heart attack or die of cardiovascular disease in the years that followed.