Ray H. Rosenman

Epidemiology as a guide to clinical decisions. The association between triglyceride and coronary heart disease.

The hypothesis that triglyceride is a cause of coronary heart disease, although unconfirmed and never universally accepted, has nonetheless strongly influenced the practice of preventive medicine. We have examined the epidemiologic association between triglyceride and coronary heart disease to evaluate the validity of inferring that there is a causal relation between the two. Neither the evidence from published studies nor an analysis of data from the Western Collaborative Group Study provides strong support for the causal hypothesis. Information from other scientific disciplines is also meager, contrasting with the coherence of diverse evidence supporting the hypothesis that cholesterol is a cause of coronary heart disease. These arguments fall short of disproving the belief that lowering triglyceride will prevent coronary heart disease, especially since triglyceride and cholesterol are inextricably associated through mutual lipoprotein carriers. But we propose that the ethics of preventive medicine place the burden of proof on the proponents of intervention. We therefore recommend that widespread screening and treatment of healthy persons for hypertriglyceridemia be abandoned until more persuasive evidence becomes available.

Coronary heart disease in the Western Collaborative Group Study

Abstract A prospective study of coronary heart disease (CHD) was initiated in 1960–1961 in 39–59 year old men. Some of the relevant findings observed during a mean four and one-half year period of follow-up of 3182 subjects are presented. A significantly increased incidence of CHD was found to be associated with parental history of CHD, elevated systolic or diastolic blood pressure, cigarette smoking, higher serum levels of cholesterol, triglyceride and beta lipoproteins, and the Type A behavior pattern. The association of the Type A behavior pattern with a significantly increased rate of CHD was not found to be ascribable to an association of the behavior pattern with other risk factors.

Competitive drive, pattern A, and coronary heart disease: a further analysis of some data from the Western Collaborative Group Study.

Abstract This paper reports a further analysis of data from a prospective study of coronary heart disease, the Western Collaborative Group Study (WCGS). An effort was made to identify a subset of factors in the standardized interview used to assess the Type A coronary-prone behavior pattern which were related to coronary heart disease. Factor analysis of the interview variables for a subsample of the WCGS resulted in five primary factors. Only two of these factors, labeled Competitive Drive and Impatience, were associated with subsequent occurrence of coronary disease. The theoretical significance of the results was discussed in terms of Pattern A as a coping style designed to maintain control over the environment.

Multivariate prediction of coronary heart disease during 8.5 year follow-up in the western collaborative group study

The Western Collaborative Group Study is a prospective study of 3,154 employed men aged 39 to 59 years. Ischemic heart disease occurred in 257 subjects during 8.5 years of follow-up. Risk of coronary heart disease was studied with use of the multiple logistic risk model. The incidence of coronary heart disease had a highly significant association with serum cholesterol level, behavior pattern, cigarette smoking and systolic blood pressure in younger (39 to 49 years) and older (50 to 59 years) men and also with age and corneal arcus in the younger group. Type A behavior pattern was strongly related to the incidence of coronary disease in both age groups, independent of interrelations of behavior patterns with any other risk factor.

Development of an objective psychological test for the determination of the coronary-prone behavior pattern in employed men☆

Abstract An overt behavior pattern described by investigators of the Harold Brunn Institute of the Mt. Zion Hospital and Medical Center, San Francisco, has been shown in several studies to be associated both with prevalence and incidence of coronary heart disease. The coronary-prone behavior pattern is characterized by intense striving for achievement, competitiveness, aggressiveness, pressures for vocational productivity, excessive sense of time urgency, impatience and restlessness. Because of the importance of this behavior pattern in predicting risk to coronary heart disease, a rapid, objective method for measuring the pattern is needed for use in epidemiologic studies and for mass-screening in industrial health programs. This paper describes the development of a self-administered, machine-scored psychological test to measure this behavioral pattern. The present form of the test questionnaire distinguishes at high levels of statistical significance between groups of men clinically judged to manifest the coronary-prone behavior pattern and those groups judged not to manifest the pattern. Categorization of individuals is also promising. A series of validity studies using biological and medical criteria is underway.

Progress toward validation of a computer-scored test for the type A coronary-prone behavior pattern.

&NA; A self‐administered, machine‐scored test questionnaire to discriminate between men with the Type A coronary‐prone behavior pattern and those without that pattern (Type B) was taken twice by over 2800 men in the Western Collaborative Group Study in 1965 and 1966. Optimal weighting, discriminant function, and factor analytic procedures were applied to these test items to produce scales measuring Behavior Type A, Speed and Impatience, Job Involvement, and Hard‐Driving traits, respectively. In a retrospective study, 83 men who had sustained a first attack of CHD before taking the test in 1965 were compared with 468 random control subjects. The mean Type A score was significantly higher for cases than for controls (P=0.01). The mean Factor H score showed cases to be more hard‐driving, competitive and responsible than controls (P=0.01). Contingency tables also supported these discriminations. The other two factor scales did not discriminate significantly.

Prediction of Clinical Coronary Heart Disease by a Test for the Coronary-Prone Behavior Pattern

Abstract Prospective study of 2750 employed men who completed a computer-scored test questionnaire measuring the coronary-prone Type A behavior pattern showed that high scorers had twice the incide...

Plasma catecholamine response of coronary-prone subjects (type A) to a specific challenge☆

Plasma norepinephrine (NE) and epinephrine (E) were assayed in 15 men prone to develop coronary heart disease (type-A behavior pattern) and in 15 coronary-disease-resistant men (type-B behavior pattern) under resting, noncompetitive conditions and also immediately before, during, and after participation in a nonphysical competitive struggle. The average concentration of catecholamines was virtually the same in both groups under resting conditions. Under competitive conditions the NE concentration of the coronary-susceptible group rose an average of 30%, while that of the resistant group remained essentially unchanged. E concentration remained unchanged in both groups.

Risk of new myocardial infarction in middle-aged men with manifest coronary heart disease.

Men incurring coronary heart disease (CHD) during surveillance of an employed population were studied for risk factors associated with additional myocardial infarctions. The coronaryprone Type A behavior pattern measured by a test score, number of cigarettes smoked daily, and serum cholesterol were significant discriminators between the 67 men with recurrent CHD and the 220 with but a single clinical CHD event. Diastolic blood pressure and fasting serum triglycerides were not significant discriminators. Statistical analyses directed to possible sources of bias occasioned by the combined retrospective-prospective study design revealed that these problems are negligible and do not alter the findings observed. Type A score appears relatively unaffected by whether the measure was made before or after the initial CHD event. Multivariable discriminant function equations showed Type A score to be the strongest single predictor of recurrent CHD among the variables available. Number of cigarettes smoked and serum cholesterol accounted for additional variance. Future field trials for the secondary prevention of myocardial infarction would be strengthened by consideration of the possible role of Type A behavior.

Psychological correlates of the Type A behavior pattern

Psychological characteristics of 384 adult males classified as Type A or Type B by the structured interview were examined. Subjects classified Type A differed significantly from subjects classified Type B on a number of psychological scales including measures of aggression, autonomy, extroversion, and impulsiveness but not on measures of psychological distress. The extent to which pencil and paper questionnaire assessments of Type A differ from structured interview ratings was also studied. Correlations between the various Type A questionnaire scales and the structured interview were found to be notably low. The use of Type A questionnaires and implications for Type A interventions are discussed.