Type A behavior and angiographic findings

Journalol’Psychosoms~kRereaxh Vol. 23, pp. 273 10 276 PergamonPressLtd. 1979. Printedin Great Britain.

TYPE A BEHAVIOR AND ANGIOGRAPHIC FINDINGS* JOELE.

DIMsoALE,t THOMAS P. HACKETT,?ADOLPH M. HUTTER, JR.,$ CATANZANO~ and PAMELA J. WHIrEt

From the Massachusetts

PETERC. BLOCK,~ DONNA M.

General Hospital, Harvard Medical School, Boston, MA, 02114, U.S.A. (Received

5 March 1979)

Abstract-This study examines the association between Type A personality and the extent of coronary artery disease found at angiography. Our initial work failed to demonstrate an association between Type A as measured by the Jenkins Activity Survey (JAS) and vessel disease. In this study on a second cohort of 105 patients, we have used both the JAS and semi-structured interview as measures for Type A personality. All patients were assessed prior to angiography. Coronary arteries were judged significantly narrowed if angiography revealed >SO% narrowing of the vessels’ diameter. Neither the JAS nor the semi-structured interview were significantly associated with the extent of vessel disease. The discrepancy between our findings and those of other investigators may be attributable to population differences. RECENTLY, there has been a convergence of reports investigating the possible pathophysiological effects of Type A behavior [I] on the heart. Four centers have related Type A behavior to the extent of coronary artery pathology found on angiography. This paper presents an extension of our earlier work, combining evaluation of Type A behavior by both questionnaire and interview-based assessment to allow better comparison with other studies. The first angiographic study reported was that of Zyzanski et nl., who found that type A behavior was positively associated with the extent of coronary artery disease [2]. Frank ef al. also found such a positive association [3]. Blumenthal et al. reported that the extent of coronary artery disease was associated with one measure for Type A (the interview) but was unassociated with another Type A measure (the Jenkins Activity Survey) [4]. We previously found that Type A as determined by the JAS was not associated with extent of coronary artery disease [5]. Although these studies are all similar in aim and approach, there are differences in methodology among them. Table 1 analyzes each of the above studies on the dimensions of these methodological differences. Coronary artery disease was defined in differing ways. Some studies defined vessel disease as > 50 % occlusion, others defined vessel disease as > 7.5% occlusion. Rather than merely count the number of vessels significantly occluded, one study derived a “total coronary index” that weighted vessel disease according to the amount of occlusion present. Some of the studies included both men and women in their sample while others considered only men. The population approached for study varied slightly from one center to another in that some studies specifically excluded those patients who came to angiography primarily because of valvular heart disease. In measuring Type A behavior, some studies used the Jenkins Activity Survey (JAS), an objective self-administered check list questionnaire [6], whereas other studies used the semi-structured interview as developed by Rosenman [7]. It is this final methodological difference in instrument choice for measuring Type A behavior that is the focus of an ongoing controversy. Although the JAS is the most widely used objective questionnaire for measuring Type A behavior, its validity has been disputed recently [8]. It is on the other hand far easier to administer than the interview and less susceptible to differences in administration. Our initial study was designed to replicate the research of Zyzanski ef al. 121.We lvere unsuccessful in finding any significant association between Type A behavior as determined by the JAS and extent of coronary artery disease. As this finding was rather unexpected, we have repeated the study with a second cohort of patients and also included the interview-based Type A assessment to allow better comparison of our findings with those of Blumenthal [4] and Frank [3].

*Supported by Grant No. HL 19567 from the National Heart, Lung and Blood Institute. TDepartment of Psychiatry. $Department of Medicine, Cardiac Unit. @Department of Social Services. 273

274

Jort

E.

TAULE I .--AMXK;KA~HIC

Sex Studies studied --..~._~~~~__~~__..__~~~.____~_ Zyzanski et al. Men Frank

et trl.

Men and women

Definition of vessel

DIMSI~ALI:

et

t/i.

FINU~KGSAND TYIVI A BEI-IAVIOII

Indications for angiography

Time of behavior Assessment

Measure for Type A Findings ~__ ___ JAS I

,. SO;/, narrowing

Unspecitied

Before catheterization

_ 50 ‘;I narrowing

Symptomatic of heart disease

Bcforc ~--~--~h%er~ie~ catheterization

+

I. Blumenthal

et ~1.

Men and Woman

75;s<>

After Exclude catheterization subjects catheterized primarily fat valvular heart disease

(a) JAS (b) Interview

Exclude After subjects catheterization catheterized primarily f01 valvulat heart disease

(a, JAS (b) Interview

(a) Not significant (bj +

,,50”/, narrowing

Exclude Bcforc catheterization subjects catheterized primarily for valvular heart discasc

JAS

Not signiticant

/ 50% nart-owing

Before Exclude catheterization subjects catheterized primarily for valvular heart disease

JAS

Not significant

narrowing

_~~ Dimsdale

r/ rrl.

1. Men and women

2. Men

(a) Not significant (b)

t

* I-, KO.05 2 tail. f p -rO.Ol 2 tail. METHODOLOGI Patients selected for study underwent cardiac catheterization because of symptoms of coronary artery disease. Patients eligible for study were English speaking men, between the ages of 18 and 70, with apparent average intelligence. The patients’ willingness to cooperate in this study and its followup as well as the permission of their attending cardiologist were also required. Patients were excluded from the study if the catheterization was obtained primarily because of valvular heart disease. They were also excluded if they were in critical medical condition or had some other major illness that may have influenced the follow-up results. All exclusions were made prior to psychological assessment. During a I$.-yr interval, 108 patients were approached for study. Three patients refused to participate; one patient did not complete the JAS. Thus. 105 patients completed the interview and 104 patients completed the JAS. The average age was SO with a standard deviation of 9 yr. Patients were seen prior to angiography and completed a JAS Form B as part of a larger inventory of risk factors. Patients were also interviewed using the Rosenman-derived semi-structured interview for assessing Type A behavior. Both of our interviewers (JD and DC) were trained and certified at the Harold Brunn Institute in San Francisco for administering the interview. The interviews were tape recorded and scored by both raters. Although the interview is designed to be scored as Al (strong Type A), A2 (mild Type A), X (uncertain), and B (the absence of Type A behavior), for this study as in the other studies analyzing interview data with angiographic results, the interviews were classified as “A” (including Al and A2), or “not A” (including X and B). Interviews

Type A behavior and angiographic

275

findings

were audited by the two raters who achieved a reliability of 0.92. Interviews that were regarded as technically questionable or those on which the two raters could not agree were sent for arbitration to the Harold Brunn Institute. Two interviews were discarded as technically unacceptable. Cardiac catheterization was performed using the Judkins or the Sones technique. Angiograms were then read by the cardiac radiologist who, along with the cardiologist, was unaware of the patient’s personality classification. A coronary vessel was judged significantly narrowed if angiography revealed greater than 50% narrowing of the vessel’s diameter. The following four coronary artery segments were measured: left main coronary, left anterior descending, circumflex, and right coronary artery. The relation between JAS scores and number of vessels occluded was studied with a correlational analysis. Because the score for number of vessels occluded ranged only from zero to four, it is conceivable that correlation techniques may not be appropriate statistically. Thus, additional analyses were performed utilizing a t-test to contrast the JAS scores of those with and without vessel disease and also to contrast the scores of oatients with zero or one vessel diseased with those who had multiple vessels diseased. For analyzing the relationship between vessel disease and Type A behavior as assessed by interview, a Chi-square analysis was performed. Because of the small number of cases with four diseased vessels, we grouped the three vessel and four vessel patients together. 1

RESULTS One hundred and four patients completed the JAS profile. The Pearson correlation coefficient of JAS by vessels diseased was -0.1610 and was not significant. Two t-tests were performed; the first contrasting the JAS scores in patients with vessel disease vs patients without vessel disease, the second contrasting the scores of patients with many vessels diseased with the scores of those patients having zero of one vessel diseased. Table 2 presents the data from the I-test. In neither instance was a positive significant association found. TABLE ~.-JENKINS ACTIVITY SCORES AND THE EXTENT OF CORONARY

JAS Score 7.51

Coronary artery disease None vs Some 0 and 1 Vessel

ARTERY DISEASE IN 104 MEN T

P

-2.32

<0.02

1.47 4.26 1.43

>0.15

1.38

For More Vessel

IPositive score indicates Type A personality. In analyzing the semi-structured interview data, we had a sample size of 103 patients. A Chi-square analysis was performed (Table 3). Again, there was no significant relationship discovered between Type A as judged by interview and the extent of coronary vessel disease. TABLE 3.-INTERVIEW

BASED ASSESSMENT OF TYPE A AND EXTENT OF CORONARY 103MEN Vesselsdiseased 0

1 2 3 and 4

Type A

10 15 16 25

ARTERY DISEASE IN

Not Type A 6 7 10 14

xe = 0.25 Not significant. DISCUSSION This study’s lack of a significantly positive relationship between the extent of vessel disease and Type A behavior as determined by the JAS represents another contradiction of Zyzanski’s findings. Such a repeated “failure to reolicate” on our part would make it difficult to dismiss our earlier work as an anomaly.

276

JOEL E. DIMSDALEet al.

Because of the growing controversy about the validity of the JAS as a measure for Type A behavior we added the semi-structured interview for Type A assessment in this study of a second cohort of patients. We were thus in a position to attempt to verify the findings of Frank et ul. [3]. However, here too, we failed to find any evidence of a significant association or even a trend of an association between Type A personality and the extent of coronary artery disease. With the publication of this paper, there are now five studies of similar design that examine the relationship between Type A behavior and angiographic evidence of coronary disease. Although each of the five studies differs slightly and subtly in methodology, they were all very carefully designed. Then how can we explain the discrepancy between our two studies and those of Zyzanski (using the JAS) and Frank (using the semi-structured interview)? The most likely explanation is that the samples studied in the three academic centers differ substantially on some relevant dimension. This component may then act to either “confound” or “obfuscate” the relationship between Type A personality and vessel disease. Although we have no evidence about what this dimension may be, various psychosocial factors such as ethnicity, social class, stress, and depression may well act to augment or dilute such a relationship [9, lo]. We cannot explain the discrepancy in findings between our study and those of Zyzanski and Frank. Although we examined and indeed re-examined the data from our sample, we were unable to find a positive association. Such a relationship may, nevertheless, exist but somehow may have elluded us. It is altogether possible, however, that our findings may depict the more common “reality” and that the findings reported in the other studies may represent more of the exception. There is no way of knowing which of the above studies is the most appropriate from which to generalize to the larger United States population. So, rather than be discouraged by such differences in studies, we consider these differences to be extremely productive in sharpening the inquiry into the possible pathophysiological effects of Type A behavior. REFERENCES 1. ROSENMANR. H., BRANDR. G. and JENKINSC. D. et al. Coronary heart disease in the western collaborative group study : final follow-up experience of 8s years. J. Am. Med. Ass. 233, 872-77 (1975). \-- -,2. ZYZANSKIS. J., JENKINSC. D. and RYAN T. J. et 01.Psychological correlates of coronary angiographic findings. Arch. infern. Med. 136, 1234-37 (1976). 3. FRANK K. A., MILLER S. S., KORNFELDD. S., SPORN A. A. and WEISS M. B. Type A behavior pattern and coronary angiographic findings. J. A/n. Med. Ass. 240, 761-63 (1978). J. A., WILLIAMSR. B. and CONG Y. et al. Type A behavior pattern and coronary 4. BLUMENTHAL atherosclerosis. Circulation, 58, 634-39 (1978). 5. DIMSDALEJ. D., HACKETTT. P. and HUTTERA. M., JR. et al. Type A personality and the extent of coronary atherosclerosis. Am. J. Cardiol. 42, 583-86 (1978). 6. JENKINSC. D., ROSENMANR. H. and FRIEDMANM. Development of an objective psychological test fol- the determination of the coronary prone behavior pattern in employed men. J. Chron. Dis. 20, 371-79 (1967). I. FRIEDMANM., BROWNA. E. and ROSENMANR. H. Voice analysis test for detection of behavior pattern: responses of normal men and coronary patients. J. Am. Med. Ass. 208, 828-36 (1969)., 8. BRANDR. J., ROSENMANR. H. and JENKINSC. D. et al. Comparison of coronary heart disease prediction in the western collaborative group study using the structured interview and the Jenkins activity survey assessments of the coronary prone type A behavior pattern, unpublished manuscript (1977). 9. DIMS~AL~J. D. Speech patterns in type A personality. Psychouon~. Med. 40, 76 (1978). 10. DIMSDALEJ. D., HACKETTT. P. BLOCK P. C. and HUTTER A. M., JR. Emotional correlates of type A behavior pattern. Psychosum. Med. 40, 580-583 (1978).