Type A personality and extent of coronary atherosclerosis

Type A Personality and Extent of Coronary Atherosclerosis

Boston. Massachusetts

The relation between type A personality and the extent of coronary artery disease was studied in 109 patients who underwent selective coronary angiography. Type A personality as measured with the Jenkins Activity Survey was not correlated with the extent of coronary artery disease as assessed from the number of vessels with 50 percent or greater narrowing of diameter.

the Departments of Psychiatry* and of Medicine,+ Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts. This research was supported by Grant HL-19567 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Manuscript received November 28, 1977; revised manuscript received April 11, 1978, accepted May 3, 1978. Address for reprints: Joel E. Dimsdale, MD, Massachusetts General Hospital, Boston, Massachusetts02114.

In the past 15 years, there has been considerable research on the relation between the type A personality pattern and the occurrence of coronary events. Most noteworthy is the Western Collaborative Group Study,l a carefully designed investigation that followed up 3,500 men for 8 l/2 years. This study concluded that men characterized as manifesting type A behavior (hard-driving, intense competitive behavior) are at greater risk of having coronary heart disease than are men without such behavior (this group is called type B). Recently, the type A pattern has been reported to be associated with increased coronary artery disease as demonstrated at cardiac catheterization.2-4 Zyzanski et a1.2 found that men with type A behavior as measured with the Jenkins Activity Survey5 had more coronary arteries with more than 50 percent narrowing than did men with type B behavior. Frank et a1.4 found a positive association between similarly defined coronary vessel disease and type A behavior as measured with an interview. Blumenthal et a1.3 found a positive association between the extent of coronary artery disease and type A behavior as measured with an interview but not as measured with the Jenkins Activity Survey. These studies have been regarded as provisional demonstrations of a pathophysiologic link between type A personality and the occurrence of heart disease. However, the discrepant results regarding the use of the Jenkins Activity Survey to predict coronary artery disease deserve further consideration. Zyzanski et al. 2 found a positive association; Blumenthal et a1.3 did not. Because the study of Blumenthal et al. included a large subset of women, their Survey scores are regarded as having questionable validity. The Jenkins Activity Survey itself has recently been criticized6 as accurately classifying only 63 percent of type A and type B subjects. Other studies7 reported that it accurately classifies 73 percent of subjects. Nevertheless, it is the most widely used objective scale for assessing type A personality.8 This study to test the hypothesis that type A personality is associated with an increased extent of coronary artery disease is intended to replicate the study of Zyzanski et a1.,2 not only in design, but also in characteristics of the population studied. Both studies examine Boston-based populations treated at two university hospitals, Massachusetts General Hospital and Boston University Medical Center.

JOEL E. DIMSDALE, MD’ THOMAS P. HACKETT, MD* ADOLPH M. HUTTER, Jr., MD, FACC+ PETER C. BLOCK, MD, FACC+ DONNA CATANZANO, BS’

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JAS FIGURE 1. Relation between the number of diseased coronary vessels and Jenkins Activity Survey (JAS) score in 109 subjects. The positive Survey scores indicate type A personality, the negative scores type 6 personality.

Methodology The study patients

were selected from those awaiting cardiac catheterization at Massachusetts General Hospital. Indications for angiography were variable, but all patients had clinical evidence of coronary artery disease or worrisome chest pain of uncertain cause not elucidated by noninvasive testing. Patients were eligible for inclusion in the study if they (1) were 18 to 70 years old; (2) had apparent average intelligence; (3) were English-speaking; (4) had permission of their cardiologist; and (5) gave consent for study and were willing to cooperate in follow-up studies. Patients were excluded from the study if they had evidence of valvular heart disease, a critical medical condition (such as cardiogenic shock) that might preclude adequate testing with the Jenkins Activity Survey or the presence of other major disease that might influence the 1 year follow-up (for example, malignancy). All such exclusions were made before personality assessment. During a 1 year period, an attempt was made to contact 118 patients. The physician of three patients refused their participation; three patients were ineligible, and three refused participation. Thus, 109 patients, approximately 90 percent, were judged eligible and completed the evaluation. The sample included 99 men and 10 women. The average age was 49 years with a standard deviation of 9 years; 65 percent had a history of myocardial infarction and 55 percent had exertional angina (functional classes II, III and IV of the New York Heart Association).g Patients were seen before cardiac catheterization and completed a Jenkins Actiuity Survey Form B as part of a larger risk factor inventory. This survey is an objective selfadministered questionnaire designed to replicate closely the type A and B assignments that would be made in a Rosenman type A semi-structured interview.5

I

TABLE Average

Jenkins

Vessels Diseased (no.) 0

Activity

Patients (no.)

Survey Mean JAS Score

(JAS)

Scores’

Average Age (yr)

in 99 Men AgeAdjusted Mean JAS Score

16 18

2.99 6.38

44

1

48

2.85 6.53

f 4

fZ 5

-0.74 1.01 2.74

.z 54

-0.86 1.48 4.21

Positive Jenkins Activity Survey scores indicate type A personality, negative scores type B. l

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Cardiac catheterization was performed by a cardiologist who did not know the patients’ Survey score. Coronary angiography was performed with the Sones or the Judkins technique. Angiograms were read by the cardiac radiologist, who also did not know the Survey score. A coronary vessel was considered significantly narrowed if angiography revealed 50 percent or greater narrowing of the vessel’s diameter (equivalent to 75 percent cross-sectional narrowing of the vessel). The relation between the number of vessels diseased and Jenkins Activity Survey score was plotted. A correlation analysis was performed. Because the score foriiessels diseased ranged from 0 to 4, it is conceivable that the correlation techniques might be inappropriate. For this reason, the data were also reexamined with a t test contrasting the Jenkins Activity Survey scores of those with normal vessels or one vessel disease versus those with multiple vessel disease.

Results The relation between the number of diseased coronary vessels and the Jenkins Activity Survey score for the total study population is shown in Figure 1. The regression line is negative with a slope of -0.02. The correlation coefficient itself is -0.12 and is not significant (P <0.20). In view of the questionable validity of the Survey in women, we analyzed the male subsample

alone. Table I presents for the 99 men the mean Jenkins Activity Survey score in each category of vessel disease. There was no trend toward increased Survey scores among patients with an increased number of diseased vessels. The severity of coronary-disease was age-related in the sample (r = 0.29, P O.l). The Jenkins Activity Survey scores in each category of vessel disease were age-adjusted by the direct methodlo (Table I). Even after age adjustment, there is no clear trend relating type A personality as assessed with the Jenkins Activity Survey and extent of coronary artery disease. A t test analysis was performed in two ways (Table II). In the first, comparing patients with no coronary vessel disease and patients with some significant vessel disease, the difference in Jenkins Activity Survey scores was not significant. In a second t test, comparing patients with no disease or single vessel disease with patients who had disease of more than one vessel, the Jenkins Activity Survey scores were significantly different. (P <0.027); however, the patients with mild disease had the higher Jenkins Activity Survey score

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TABLE II

TABLE III

Jenkins Activity Survey Score and the Extent of Coronary Artery Disease in 99 Men

Jenkins Activity Survey (JAS) Score and Coronary Artery Disease in Four Clinical Subgroups of the 109 Patients

Coronary Artery Disease

JAS Score’

No versus Some

2.99

0 and 1 vessel versus 2 or more vessels

4.79

t -0.49

P History of Ml No

>0.60

Vessels Diseased (no.)

Mean JAS Score*

Patients (no.1

0

4.54

16

:

0.54 0.4855

1.75 -2.24

<0.027

:

-7.50 -0.12

: 61

0.47

Positive scores indicate type A personality. P = probability; t = t test value. l

Yes

indicative of a type A pattern. These analyses were based on men alone, but the results were essentially unchanged by separate analyses including the 10 women from the sample. It is striking that in all of these statistical examinations, there was no evidence for a positive significant association nor even a trend toward a positive association between type A behavior and number of diseased vessels.

Discussion

01

1.540 6.269

1:

: 4

-1.347 0.066 5.300

:‘2 4

01

3.13 5.63

::

x 4

-0.6696 1.081 3.567

:: 3

0 1

10.450 5.199

: 4

-0.9165 -1.253 1.500

Severity of angina+ Grades I and II

Grades Ill and IV

s

6 17 2

A positive score indicated type A personality, a negative score type B personality. + New York Heart Association functional classification. MI = myocardial infarction. l

Differences from previous studies: We were unable to confirm the findings of Zyzanski et a1.,2 who found a positive association between the extent of coronary artery disease and type A personality as measured with the Jenkins Activity Survey score. This major difference in findings is troublesome to interpret. Both studies were performed on a similar population-Boston-based patients who were seeking angiography at a teaching hospital. Both studies included only those for whom the Jenkins Activity Survey was standardized-basically a white male population. Both studies examined subjects with a similar age distribution and educational background. Both studies found a similar distribution of coronary artery disease.ll It is possible that the indications for cardiac catheterization may have been different for the two studies. In the study of Zyzanski et al. the group with no vessel disease included some patients with congenital valve disease. We considered such patients ineligible for our study. One might hypothesize that patients with congenital valve disease may have been required to lead slower less active lives and thus be more likely to manifest type B behavior. By comparison, a population with only coronary artery disease may represent the full continuum of type A and B personality patterns. If the patients with coronary artery disease are compared with the group with no vessel disease (which contains the group with valve disease) the former would appear to contain more persons with a type A personality. This difference in inclusion criteria may account for the difference in our results. It is possible that unknown differences in the sample population affect the relation between type A personality and coronary artery disease. Researchers in this field have not yet elucidated the precise population

characteristics that are required to demonstrate an association between type A behavior and coronary artery disease. Ethnicity may seriously affect the determination of type A behavior.12 The Boston University sample and the Massachusetts General Hospital sample may have differed in ethnic background sufficiently to affect the Jenkins Activity Score classification. The patient’s experience with clinically significant disease may also affect the relation between type A behavior and coronary vessel disease; nevertheless, when our sample was subdivided according to extent of angina and history of past myocardial infarction, there was still no trend for a relation between type A personality and coronary vessel disease in any of the subgroups (Table III). It is conceivable that type A determination, whether with the Jenkins Activity Survey or an interview, is made difficult by anxiety-arousing circumstances such as hospitalization. However, this problem is common to all the other studies of this type.2-4 It seems unlikely that our patients were somehow more anxious than those undergoing angiography in the other studies. Although it is not clear which factors may account for the different findings, one must consider that the evidence favoring an uncomplicated association between type A personality as assessed with the Jenkins Activity Survey and the extent of coronary artery disease is unconfirmed and under some question. Implications: From this study no inference can be made regarding the ability of the type A interview as-

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sessment to predict the extent of coronary artery disease. Because the Jenkins Activity Survey has recently come under some criticism,6 it would be important to perform a similar study utilizing the same methodology but measuring type A behavior with the type A structured interview. This work is in progress and will be reported on in a future publication. The data in all the studies relating coronary angiographic findings to personality type are retrospective and thus cannot exclude the possibility that symptomatic heart disease may have modified the type A behavior by the time the patient arrived for cardiac

catheterization. Finally, type A behavior may be interacting with the heart on other pathophysiologic levels, such as plasma catecholamines or lipids. From the present study one must conclude that type A behavior, as measured with the Jenkins Activity Survey, is not positively assoEiated with the extent of coronary artery disease found on cardiac catheterization.

Acknowledgment We thank statistical consultation.

References 1. Rosenman RH, Brand RG, Jenklns CD, et al: Coronary heart disease in the Western Collaborative Croup Study: final follow up experience of 8 l/2 years. JAMA 233:872-877, 1975 2. Zyzanski SJ, Jenkins CD, Ryan TJ, et al: Psychological corretates of coronary angiographic findings. Arch Intern Med 136: 1234-37. 1976 3. Blumenthal JA, Kong Y, Rosenman RH, et al: Type A behavior pattern ‘and angiographically documented coronary disease. Prs sented at the meeting of the American Psychosomatic Society, New Orleans, March 21, 1975 4. Frank KA, Heller SS, Kornfeld DS, et al: Type A behavior and coronary artery disease: angiographic confirmation. JAMA, in press 5. Jenkins CD, Rosenman RH, Frledman M: Development of an objective psychological test for the determination of the coronary prone behavior pattern in employed men. J Chronic Dis 20: 371-379, 1967 6. Brand RJ, Rosenman RH, Jenklns CD, et al: Comparison of cor-

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8.

9.

10. 11. 12.

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onary heart disease prediction in the Western Collaborative Croup Study using the structured interview and the Jenkins Activity Survey assessments of the coronary prone Type A behavior pattern. Unpublished manuscript, 1977 Jenkins C, Zyzanskl S, Rosenman R: Progress toward validation of a computer scored test for type A coronary prone behavior. Psychosom Med 33: 193-202, 197 1 Jenkins CD: Recent evidence supporting psychological and social risk factors for coronary disease. N Engl J Med 294:987-994. 1033-1038.1976 Criteria Committee of the New York Heart Association: Nomenctatwe and Criteria for Diagnosis of Diseases of the Heart and Great Vessels, seventh edition. Boston, Little, Brown, 1973, p 286 Armltage P: Statistical Methods in Medical Research. Oxford, Blackwell Publications, 1971, p 384-388 Zyzanskl S: Personal communication, 1977 Dlmsdale JE: Speech patterns in type A personality. Psychosom Med 46176, 1978