- Email: [email protected]
Hostility and Cardiovascular Disease⁎
Journal of the American College of Cardiology © 2011 by the American College of Cardiology Foundation Published by Elsevier Inc.
EDITORIAL COMMENT
Hostility and Cardiovascular Disease* Mary A. Whooley, MD,† Jonathan Wong, BA‡ San Francisco and Irvine, California
An association between hostility and coronary heart disease (CHD) was initially described one-half century ago. Two cardiologists, Friedman and Rosenman (1,2), identified a “coronary prone behavior pattern” that they called “type A,” which was primarily composed of competitiveness, excessive drive, and an enhanced sense of time urgency. They found that patients with “Type A behavior pattern” had both an increased prevalence of CHD risk factors and an increased incidence of CHD events (3). In an effort to reduce the excess risk of CHD associated with Type A behavior, Friedman et al. (4,5) conducted a randomized trial of 862 post-myocardial infarction patients in the Recurrent Coronary Prevention Project. During 4.5 years of follow-up, subjects randomly assigned to both cardiac counseling and Type A behavioral counseling had fewer recurrent events than those assigned to cardiac counseling alone (4,5). See page 1222
Although the association between Type A behavior and CHD was subsequently called into question (6,7), these important findings put psychological factors on the map as potential risk factors for CHD. Soon thereafter, Williams et al. (8), Shekelle et al. (9), and others identified hostility and anger as the key components of Type A behavior that were responsible for its connection with CHD. During the past 25 years, numerous studies have evaluated the links between hostility, anger, and CHD. In a comprehensive metaanalysis published in 2009, Chida and Steptoe (10) found that anger and hostility were associated with a 19% increased risk of incident CHD events among otherwise healthy subjects (25 studies) and a 24% increased risk of recurrent events among patients with existing CHD (19 studies). The association with recurrent events persisted after adjustment for baseline disease status and treatment. *Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the †Department of Medicine, VA Medical Center and University of California, San Francisco, California; and the ‡University of California Irvine School of Medicine, Irvine, California. Dr. Whooley and Mr. Wong have reported that they have no relationships relevant to the contents of this paper to disclose.
Vol. 58, No. 12, 2011 ISSN 0735-1097/$36.00 doi:10.1016/j.jacc.2011.06.018
In this issue of the Journal, Newman et al. (11) extend this body of published reports with their analysis of data from the 1995 Nova Scotia Health Survey. In a prospective study of 1,749 adults who were initially free of CHD, they measured observed hostility with the Expanded Structured Interview and evaluated self-reported hostility using subscales of the Cook-Medley hostility scale. During 10 years of follow-up, 8.9% (140 of 1,572) of patients with any observed hostility and 5.1% (9 of 177) of patients without any observed hostility developed CHD. After adjustment for age, sex, Framingham risk score, and other psychosocial variables, observed hostility was associated with a 2-fold greater risk of incident CHD (p ⫽ 0.04). In contrast, self-reported hostility was not predictive of incident CHD. Notable strengths of this study include its relatively large sample size, long-term follow-up, adjustment for other psychosocial risk factors, particularly depressive symptoms (12), and use of a standardized interview to characterize hostility. Hostility, typically defined as a negative mistrustful attitude that includes aggressive behavior and frequent angry feelings toward others (13), is a multidimensional construct that presents a significant challenge for investigators to accurately define and quantify. Patient-reported scales require self-awareness of hostility and tend to be influenced by reporting bias (14), whereas interview-based methods provide a more objective measure of hostility through observed interpersonal interactions (15). In the current study, the structured observed hostility interview was recorded and reviewed to ensure standardization. Although other studies have used interview-based measures of hostility to study its association with CHD (16,17), no prior study has directly compared the predictive value of patientreported versus interview-based hostility measures on CHD outcomes. It is important to note that the absolute difference in risk of CHD between subjects with and without hostility was small (3.8% during 10 years of follow-up). Likewise, the limited number of patients without hostility made the results somewhat challenging to interpret. The authors initially divided participants into 5 categories (ranging from no to frequent hostile statements) and reported a significant test for trend between hostility category and incident CHD (p ⫽ 0.01). However, because there were no significant differences in CHD across categories 2 through 5, all subsequent analyses evaluated incident CHD in patients with any observed hostility (n ⫽ 1,572) versus no observed hostility (n ⫽ 177). Given that 90% of study participants had some observed hostility, it is difficult to consider hostility as a risk factor. A more valuable message might be that the absence of hostility was protective against CHD. Another issue is that the mechanisms linking hostility (or lack of hostility) with CHD were not explored. Hostility is known to be associated with poor health behaviors such as physical inactivity, dietary indiscretion, higher body mass index, and smoking (18 –20). In the meta-analysis by Chida
1230
Whooley and Wong Hostility and Cardiovascular Disease
and Steptoe (10), there were no significant associations between anger or hostility and CHD among the subset of studies that controlled for possible behavioral covariates. Thus, although the current study adjusted for smoking, it remains possible that the observed association was explained by physical inactivity or other health behaviors. An alternative potential mechanism linking hostility and CHD involves the sympathetic nervous system. Exaggerated adrenergic responses to stressful psychological stimuli can increase blood pressure (21); induce coronary vasoconstriction (22); increase inflammation (23); and activate platelets (24). A triggering event, such as an outburst of anger, might increase the risk of nonfatal myocardial infarction or CHD death (25). However, Sloan et al. (26) recently conducted a trial in which 158 hostile volunteers were randomly assigned to a 12-week cognitive behavior therapy program for hostility or to a wait-list control. The intervention reduced hostility and anger as expected, but surprisingly, this was not accompanied by improvements in cardiac autonomic modulation. These findings raised questions about autonomic nervous system dysregulation as a pathophysiological mechanism underlying the hostility–CHD relationship. In summary, Newman et al. (11) have demonstrated that observed hostility is superior to patient-reported hostility for the prediction of incident CHD, independent of baseline Framingham risk score and other psychosocial variables. However, 90% of the participants were classified as having observed hostility, and thus it might be more useful to consider the absence of hostility as protective. Whether reducing hostility can improve cardiovascular outcomes is unknown. The next step is to better understand the exact mechanisms of this association and, in particular, to evaluate whether health behaviors might explain the effects of hostility on CHD. Reprint requests and correspondence: Dr. Mary A. Whooley, University of California-San Francisco, VA Medical Center, 4150 Clement Street (111A1), San Francisco, California 94121. E-mail: [email protected].
JACC Vol. 58, No. 12, 2011 September 13, 2011:1229–30
5. 6. 7. 8. 9. 10. 11.
12. 13. 14. 15. 16.
17.
18. 19.
20. 21. 22. 23.
REFERENCES
1. Friedman M, Rosenman RH. Association of specific overt behavior pattern with blood and cardiovascular findings; blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease. JAMA 1959;169:1286 –96. 2. Rosenman RH, Friedman M. Association of specific behavior pattern in women with blood and cardiovascular findings. Circulation 1961; 24:1173– 84. 3. Rosenman RH, Brand RJ, Jenkins D, Friedman M, Straus R, Wurm M. Coronary heart disease in Western Collaborative Group Study. Final follow-up experience of 8 1/2 years. JAMA 1975;233:872–7. 4. Friedman M, Thoresen CE, Gill JJ, et al. Feasibility of altering type A behavior pattern after myocardial infarction. Recurrent Coronary
24. 25.
26.
Prevention Project Study: methods, baseline results and preliminary findings. Circulation 1982;66:83–92. Friedman M, Thoresen CE, Gill JJ, et al. Alteration of type A behavior and reduction in cardiac recurrences in postmyocardial infarction patients. Am Heart J 1984;108:237– 48. Ragland DR, Brand RJ. Type A behavior and mortality from coronary heart disease. N Engl J Med 1988;318:65–9. Ragland DR, Brand RJ. Coronary heart disease mortality in the Western Collaborative Group Study. Follow-up experience of 22 years. Am J Epidemiol 1988;127:462–75. Williams RB Jr., Haney TL, Lee KL, Kong YH, Blumenthal JA, Whalen RE. Type A behavior, hostility, and coronary atherosclerosis. Psychosom Med 1980;42:539 – 49. Shekelle RB, Gale M, Ostfeld AM, Paul O. Hostility, risk of coronary heart disease, and mortality. Psychosom Med 1983;45:109 –14. Chida Y, Steptoe A. The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol 2009;53:936 – 46. Newman JD, Davidson KW, Shaffer JA, et al. Observed hostility and the risk of incident ischemic heart disease: a prospective population study from the 1995 Canadian Nova Scotia Health Survey. J Am Coll Cardiol 2011;58:1222– 8. Stewart JC, Fitzgerald GJ, Kamarck TW. Hostility now, depression later? Longitudinal associations among emotional risk factors for coronary artery disease. Ann Behav Med 2010;39:258 – 66. Miller TQ, Smith TW, Turner CW, Guijarro ML, Hallet AJ. A meta-analytic review of research on hostility and physical health. Psychol Bull 1996;119:322– 48. Davidson K, Hall P. Potential for hostility and faking-good in high-hostile men. J Behav Med 1997;20:47–54. Barefoot JC, editor. Developments in the Measurement of Hostility. Washington, DC: American Psychological Association, 1992. Matthews KA, Gump BB, Harris KF, Haney TL, Barefoot JC. Hostile behaviors predict cardiovascular mortality among men enrolled in the Multiple Risk Factor Intervention Trial. Circulation 2004;109: 66 –70. Dembroski TM, MacDougall JM, Costa PT Jr., Grandits GA. Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial. Psychosom Med 1989;51:514 –22. Leiker M, Hailey BJ. A link between hostility and disease: poor health habits? Behav Med 1988;14:129 –33. Scherwitz LW, Perkins LL, Chesney MA, Hughes GH, Sidney S, Manolio TA. Hostility and health behaviors in young adults: the CARDIA Study. Coronary Artery Risk Development in Young Adults Study. Am J Epidemiol 1992;136:136 – 45. Siegler IC, Peterson BL, Barefoot JC, Williams RB. Hostility during late adolescence predicts coronary risk factors at mid-life. Am J Epidemiol 1992;136:146 –54. Spicer J, Chamberlain K. Cynical hostility, anger, and resting blood pressure. J Psychosom Res 1996;40:359 – 68. Boltwood MD, Taylor CB, Burke MB, Grogin H, Giacomini J. Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments. Am J Cardiol 1993;72:1361–5. Brummett BH, Boyle SH, Ortel TL, Becker RC, Siegler IC, Williams RB. Associations of depressive symptoms, trait hostility, and gender with C-reactive protein and interleukin-6 response after emotion recall. Psychosom Med 2010;72:333–9. Jern C, Eriksson E, Tengborn L, Risberg B, Wadenvik H, Jern S. Changes of plasma coagulation and fibrinolysis in response to mental stress. Thromb Haemost 1989;62:767–71. Mittleman MA, Maclure M, Sherwood JB, et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation 1995;92: 1720 –5. Sloan RP, Shapiro PA, Gorenstein EE, et al. Cardiac autonomic control and treatment of hostility: a randomized controlled trial. Psychosom Med 2010;72:1– 8.
Key Words: hostility y ischemic heart disease y observational study.
EDITORIAL COMMENT
Hostility and Cardiovascular Disease* Mary A. Whooley, MD,† Jonathan Wong, BA‡ San Francisco and Irvine, California
An association between hostility and coronary heart disease (CHD) was initially described one-half century ago. Two cardiologists, Friedman and Rosenman (1,2), identified a “coronary prone behavior pattern” that they called “type A,” which was primarily composed of competitiveness, excessive drive, and an enhanced sense of time urgency. They found that patients with “Type A behavior pattern” had both an increased prevalence of CHD risk factors and an increased incidence of CHD events (3). In an effort to reduce the excess risk of CHD associated with Type A behavior, Friedman et al. (4,5) conducted a randomized trial of 862 post-myocardial infarction patients in the Recurrent Coronary Prevention Project. During 4.5 years of follow-up, subjects randomly assigned to both cardiac counseling and Type A behavioral counseling had fewer recurrent events than those assigned to cardiac counseling alone (4,5). See page 1222
Although the association between Type A behavior and CHD was subsequently called into question (6,7), these important findings put psychological factors on the map as potential risk factors for CHD. Soon thereafter, Williams et al. (8), Shekelle et al. (9), and others identified hostility and anger as the key components of Type A behavior that were responsible for its connection with CHD. During the past 25 years, numerous studies have evaluated the links between hostility, anger, and CHD. In a comprehensive metaanalysis published in 2009, Chida and Steptoe (10) found that anger and hostility were associated with a 19% increased risk of incident CHD events among otherwise healthy subjects (25 studies) and a 24% increased risk of recurrent events among patients with existing CHD (19 studies). The association with recurrent events persisted after adjustment for baseline disease status and treatment. *Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the †Department of Medicine, VA Medical Center and University of California, San Francisco, California; and the ‡University of California Irvine School of Medicine, Irvine, California. Dr. Whooley and Mr. Wong have reported that they have no relationships relevant to the contents of this paper to disclose.
Vol. 58, No. 12, 2011 ISSN 0735-1097/$36.00 doi:10.1016/j.jacc.2011.06.018
In this issue of the Journal, Newman et al. (11) extend this body of published reports with their analysis of data from the 1995 Nova Scotia Health Survey. In a prospective study of 1,749 adults who were initially free of CHD, they measured observed hostility with the Expanded Structured Interview and evaluated self-reported hostility using subscales of the Cook-Medley hostility scale. During 10 years of follow-up, 8.9% (140 of 1,572) of patients with any observed hostility and 5.1% (9 of 177) of patients without any observed hostility developed CHD. After adjustment for age, sex, Framingham risk score, and other psychosocial variables, observed hostility was associated with a 2-fold greater risk of incident CHD (p ⫽ 0.04). In contrast, self-reported hostility was not predictive of incident CHD. Notable strengths of this study include its relatively large sample size, long-term follow-up, adjustment for other psychosocial risk factors, particularly depressive symptoms (12), and use of a standardized interview to characterize hostility. Hostility, typically defined as a negative mistrustful attitude that includes aggressive behavior and frequent angry feelings toward others (13), is a multidimensional construct that presents a significant challenge for investigators to accurately define and quantify. Patient-reported scales require self-awareness of hostility and tend to be influenced by reporting bias (14), whereas interview-based methods provide a more objective measure of hostility through observed interpersonal interactions (15). In the current study, the structured observed hostility interview was recorded and reviewed to ensure standardization. Although other studies have used interview-based measures of hostility to study its association with CHD (16,17), no prior study has directly compared the predictive value of patientreported versus interview-based hostility measures on CHD outcomes. It is important to note that the absolute difference in risk of CHD between subjects with and without hostility was small (3.8% during 10 years of follow-up). Likewise, the limited number of patients without hostility made the results somewhat challenging to interpret. The authors initially divided participants into 5 categories (ranging from no to frequent hostile statements) and reported a significant test for trend between hostility category and incident CHD (p ⫽ 0.01). However, because there were no significant differences in CHD across categories 2 through 5, all subsequent analyses evaluated incident CHD in patients with any observed hostility (n ⫽ 1,572) versus no observed hostility (n ⫽ 177). Given that 90% of study participants had some observed hostility, it is difficult to consider hostility as a risk factor. A more valuable message might be that the absence of hostility was protective against CHD. Another issue is that the mechanisms linking hostility (or lack of hostility) with CHD were not explored. Hostility is known to be associated with poor health behaviors such as physical inactivity, dietary indiscretion, higher body mass index, and smoking (18 –20). In the meta-analysis by Chida
1230
Whooley and Wong Hostility and Cardiovascular Disease
and Steptoe (10), there were no significant associations between anger or hostility and CHD among the subset of studies that controlled for possible behavioral covariates. Thus, although the current study adjusted for smoking, it remains possible that the observed association was explained by physical inactivity or other health behaviors. An alternative potential mechanism linking hostility and CHD involves the sympathetic nervous system. Exaggerated adrenergic responses to stressful psychological stimuli can increase blood pressure (21); induce coronary vasoconstriction (22); increase inflammation (23); and activate platelets (24). A triggering event, such as an outburst of anger, might increase the risk of nonfatal myocardial infarction or CHD death (25). However, Sloan et al. (26) recently conducted a trial in which 158 hostile volunteers were randomly assigned to a 12-week cognitive behavior therapy program for hostility or to a wait-list control. The intervention reduced hostility and anger as expected, but surprisingly, this was not accompanied by improvements in cardiac autonomic modulation. These findings raised questions about autonomic nervous system dysregulation as a pathophysiological mechanism underlying the hostility–CHD relationship. In summary, Newman et al. (11) have demonstrated that observed hostility is superior to patient-reported hostility for the prediction of incident CHD, independent of baseline Framingham risk score and other psychosocial variables. However, 90% of the participants were classified as having observed hostility, and thus it might be more useful to consider the absence of hostility as protective. Whether reducing hostility can improve cardiovascular outcomes is unknown. The next step is to better understand the exact mechanisms of this association and, in particular, to evaluate whether health behaviors might explain the effects of hostility on CHD. Reprint requests and correspondence: Dr. Mary A. Whooley, University of California-San Francisco, VA Medical Center, 4150 Clement Street (111A1), San Francisco, California 94121. E-mail: [email protected].
JACC Vol. 58, No. 12, 2011 September 13, 2011:1229–30
5. 6. 7. 8. 9. 10. 11.
12. 13. 14. 15. 16.
17.
18. 19.
20. 21. 22. 23.
REFERENCES
1. Friedman M, Rosenman RH. Association of specific overt behavior pattern with blood and cardiovascular findings; blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease. JAMA 1959;169:1286 –96. 2. Rosenman RH, Friedman M. Association of specific behavior pattern in women with blood and cardiovascular findings. Circulation 1961; 24:1173– 84. 3. Rosenman RH, Brand RJ, Jenkins D, Friedman M, Straus R, Wurm M. Coronary heart disease in Western Collaborative Group Study. Final follow-up experience of 8 1/2 years. JAMA 1975;233:872–7. 4. Friedman M, Thoresen CE, Gill JJ, et al. Feasibility of altering type A behavior pattern after myocardial infarction. Recurrent Coronary
24. 25.
26.
Prevention Project Study: methods, baseline results and preliminary findings. Circulation 1982;66:83–92. Friedman M, Thoresen CE, Gill JJ, et al. Alteration of type A behavior and reduction in cardiac recurrences in postmyocardial infarction patients. Am Heart J 1984;108:237– 48. Ragland DR, Brand RJ. Type A behavior and mortality from coronary heart disease. N Engl J Med 1988;318:65–9. Ragland DR, Brand RJ. Coronary heart disease mortality in the Western Collaborative Group Study. Follow-up experience of 22 years. Am J Epidemiol 1988;127:462–75. Williams RB Jr., Haney TL, Lee KL, Kong YH, Blumenthal JA, Whalen RE. Type A behavior, hostility, and coronary atherosclerosis. Psychosom Med 1980;42:539 – 49. Shekelle RB, Gale M, Ostfeld AM, Paul O. Hostility, risk of coronary heart disease, and mortality. Psychosom Med 1983;45:109 –14. Chida Y, Steptoe A. The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol 2009;53:936 – 46. Newman JD, Davidson KW, Shaffer JA, et al. Observed hostility and the risk of incident ischemic heart disease: a prospective population study from the 1995 Canadian Nova Scotia Health Survey. J Am Coll Cardiol 2011;58:1222– 8. Stewart JC, Fitzgerald GJ, Kamarck TW. Hostility now, depression later? Longitudinal associations among emotional risk factors for coronary artery disease. Ann Behav Med 2010;39:258 – 66. Miller TQ, Smith TW, Turner CW, Guijarro ML, Hallet AJ. A meta-analytic review of research on hostility and physical health. Psychol Bull 1996;119:322– 48. Davidson K, Hall P. Potential for hostility and faking-good in high-hostile men. J Behav Med 1997;20:47–54. Barefoot JC, editor. Developments in the Measurement of Hostility. Washington, DC: American Psychological Association, 1992. Matthews KA, Gump BB, Harris KF, Haney TL, Barefoot JC. Hostile behaviors predict cardiovascular mortality among men enrolled in the Multiple Risk Factor Intervention Trial. Circulation 2004;109: 66 –70. Dembroski TM, MacDougall JM, Costa PT Jr., Grandits GA. Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial. Psychosom Med 1989;51:514 –22. Leiker M, Hailey BJ. A link between hostility and disease: poor health habits? Behav Med 1988;14:129 –33. Scherwitz LW, Perkins LL, Chesney MA, Hughes GH, Sidney S, Manolio TA. Hostility and health behaviors in young adults: the CARDIA Study. Coronary Artery Risk Development in Young Adults Study. Am J Epidemiol 1992;136:136 – 45. Siegler IC, Peterson BL, Barefoot JC, Williams RB. Hostility during late adolescence predicts coronary risk factors at mid-life. Am J Epidemiol 1992;136:146 –54. Spicer J, Chamberlain K. Cynical hostility, anger, and resting blood pressure. J Psychosom Res 1996;40:359 – 68. Boltwood MD, Taylor CB, Burke MB, Grogin H, Giacomini J. Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments. Am J Cardiol 1993;72:1361–5. Brummett BH, Boyle SH, Ortel TL, Becker RC, Siegler IC, Williams RB. Associations of depressive symptoms, trait hostility, and gender with C-reactive protein and interleukin-6 response after emotion recall. Psychosom Med 2010;72:333–9. Jern C, Eriksson E, Tengborn L, Risberg B, Wadenvik H, Jern S. Changes of plasma coagulation and fibrinolysis in response to mental stress. Thromb Haemost 1989;62:767–71. Mittleman MA, Maclure M, Sherwood JB, et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation 1995;92: 1720 –5. Sloan RP, Shapiro PA, Gorenstein EE, et al. Cardiac autonomic control and treatment of hostility: a randomized controlled trial. Psychosom Med 2010;72:1– 8.
Key Words: hostility y ischemic heart disease y observational study.