A woman who has been through two or more divorces is at a higher risk of having a heart attack than women who remain married, according to a new study.

Even among women who remarry after the stress of divorce, their heart attack risk remains higher, according to the study published Tuesday in Circulation: Cardiovascular Quality and Outcomes, a journal of the American Heart Association.

Heart disease is the No. 1 killer of women, claiming more lives than all forms of cancer combined.

The study’s lead author, Matthew Dupre, Ph.D., said the study is the first to show that divorce can have a large, lasting impact on women’s heart health — and it provides strong, growing evidence of how social stressors can hurt it.

“We’ve known for some time that divorce is a major life stressor that can have serious economic, emotional and physical health consequences,” said Dupre, associate professor of medicine at Duke Medicine. “The heart attack risks related to marital loss are on par with what we found for job loss and really show how the social world can get under our skin and damage our heart.”

The findings were based on responses from 15,827 people ages 45 to 80 who were born between 1942 and 1953. About one-third of participants had been divorced at least once during the 18-year study.

American Heart Association Past President Donna Arnett, chairperson of the department of epidemiology at the University of Alabama at Birmingham School of Public Health, said the findings are interesting but should be viewed with caution.

“We need to further understand the economic and social forces that may underlie this association between divorce and heart attack, particularly in women,” Arnett said.

It may not be reflective of the current reality of partnerships in the U.S. today, she said.

Arnett pointed out that only 8 percent in the group had been divorced more than once.

“Even though the findings are statistically significant, it was based on a very small sample,” Arnett said, adding that it’s important to factor in the economic consequences women faced if they got divorced in the 1970s and 1980s.

“There weren’t as many job opportunities and educational experiences,” she said. “When women began entering the job market, their level of pay was not equal to men’s,” she said. “We know that income level is a strong predictor of cardiovascular disease, so this may simply be more about loss of income.”

Men with one divorce  had about the same heart attack risk as those who stayed married, with risk increasing after two or more divorces, the study found. The study also found that men who remarried also fared better than women. These men experienced the same risk of heart attack as men who had been married continuously to one partner.