Thomas L. Haney

Type A behavior, hostility, and coronary atherosclerosis.

&NA; Type A behavior pattern was assessed using the structured interview and hostility level was assessed using a subscale of the Minnesota Multiphase Personality Inventory in 424 patients who underwent diagnostic coronary arteriography for suspected coronary heart disease. In contrast to non‐Type A patients, a significantly greater proportion of Type A patients had at least one artery with a clinically significant occlusion of 75% or greater. In addition, only 48% of those patients with very low scores (less than or equal to 10) on the Hostility scale exhibited a significant occlusion; in contrast, patients in all groups scoring higher than 10 on the Hostility scale showed a 70% rate of significant disease. The essential difference between low and high scorers on the Hostility scale appears to consist of an unwillingness on the part of the low scorers to endorse items reflective of the attitude that others are bad, selfish, and exploitive. Multivariate analysis showed that both Type A behavior pattern and Hostility score are independently related to presence of atherosclerosis. In this analysis, however, Hostility score emerged as more related to presence of atherosclerosis than Type A behavior pattern. These findings confirm previous observations of increased coronary atherosclerosis among Type A patients. They suggest further that an attitudinal set reflective of hostility toward people in general is over and above that accounted for by Type A behavior pattern. These findings also suggest that interventions to reduce the contribution of behavioral patterns to coronary disease risk might profitably focus especially closely on reduction of anger and hostility.

Depression and Long-Term Mortality Risk in Patients With Coronary Artery Disease *

Previous research has established that patients with coronary artery disease (CAD) have an increased risk of death if they are depressed at the time of hospitalization. Follow-up periods have been short in these studies; therefore, the present investigation examined this phenomenon over an extended period of time. Patients with established CAD (n = 1,250) were assessed for depression with the Zung Self-Rating Depression Scale (SDS) and followed for subsequent mortality. Follow-up ranged up to 19.4 years. SDS scores were associated with increased risk of subsequent cardiac death (p = 0.002) and total mortality (p < 0.001) after controlling for initial disease severity and treatment. Patients with moderate to severe depression had a 69% greater odds of cardiac death and a 78% greater odds of mortality from all causes than nondepressed patients. Increased risk was not confined to the initial months after hospitalization. Patients with high SDS scores at baseline still had a higher risk of cardiac death > 5 years later (p < 0.005). Compared with the nondepressed, patients with moderate to severe depression had an 84% greater risk 5 to 10 years later and a 72% greater risk after > 10 years. Patients with mild depression had intermediate levels of risk in all models. The heightened long-term risk of depressed patients suggests that depression may be persistent or frequently recurrent in CAD patients and is associated with CAD progression, triggering of acute events, or both.

Components of type A, hostility, and anger-in: relationship to angiographic findings

&NA; Previous research has linked the Type A coronary‐prone behavior pattern to angiographically documented severity of coronary atherosclerosis (CAD). The present study sought through component scoring of the Type A Structured Interview (SI) to determine what elements of the multidimensional Type A pattern are related to coronary disease severity in a selected group of patients with minimal or severe CAD. Multivariate analyses controlling for the major risk factors showed no relationship between global Type A and extent of disease. Of all attributes measured, only Potential for Hostility and Anger‐In were significantly and positively associated with the disease severity, including angina symptoms and number of myocardial infarctions. Further analysis revealed that Potential for Hostility and Anger‐In were interactive in their association, such that Potential for Hostility was associated with disease endpoints only for patients who were high on the Anger‐In dimension. These findings support previous research in suggesting that anger and hostility may be the critical aspects of the Type A pattern in predisposing individuals to risk of CAD.

Social support, Type A behavior, and coronary artery disease

&NA; The interaction of Type A behavior and social support in relation to the degree of coronary artery disease (CAD) severity was investigated. One hundred thirteen patients undergoing diagnostic coronary angiography received the Type A structured interview (SI) and completed a battery of psychometric tests, including the Perceived Social Support Scale (PSSS). Statistical analyses revealed a Type by social support interaction, such that the probability of significant CAD was inversely related to the level of social support for Type As but not Type Bs. Type As with low levels of social support had more severe CAD than Type As with high levels of social support. On the other hand, this relationship was not present for Type Bs. These results are consistent with the hypothesis that social support moderates the long‐term health consequences of the Type A behavior pattern.

Type A behavior and angiographically documented coronary atherosclerosis in a sample of 2,289 patients

&NA; To determine the relationship between Type A behavior pattern and angiographically documented coronary atherosclerosis (CAD), we analyzed risk factor, behavioral, and angiographic data collected on 2,289 patients undergoing diagnostic coronary angiography at Duke University Medical Center between 1974 and 1980. Multivariable analyses using ordinal logistic regression techniques showed that Type A behavior as assessed by the structured interview (SI) is significantly associated with CAD severity after age, sex, hyperlipidemia, smoking, hypertension, and their various significant interactions were controlled for. This relationship, however, is dependent upon age. Among patients aged 45 or younger, Type As had more severe CAD than did Type Bs; among patients aged 46–54, CAD severity was similar between Type As and Bs; and among patients 55 and older, there was a trend toward more severe CAD among Type Bs than among Type As. These Type A‐CAD relationships did not appear to be the result of various factors relating to the selection of patients for angiography. Type A behavior as assessed by the Jenkins Activity Survey was unrelated to CAD severity. These findings suggest that SI‐determined Type A behavior is associated with more severe CAD among younger patients referred for diagnostic coronary angiography. The reversal of the Type A‐CAD relationship among older patients may be due to survival effects. Inadequate sample sizes, use of assessment tools other than the SI, and failure to consider the Type A by age interaction could account for failures to find a Type A‐CAD relationship in other studies. We conclude that the present findings are consistent with the hypothesis that Type A behavior is involved in the pathogenesis of CAD, but only in younger age groups. The Type A effect in the present data is small relative to that of both smoking and hyperlipidemia, however, and future research should focus more specifically on the hostility and anger components of Type A behavior, particularly in younger samples.

Hostility Predicts Magnitude and Duration of Blood Pressure Response to Anger

The hypothesis that hostile and nonhostile individuals would differ in both magnitude and duration of cardiovascular reactivity to relived anger was tested. Participants were 66 older adults (mean age, 62; 38 women and 28 men; 70% Caucasian American, 30% African American). Each took part in a structured interview scored using the Interpersonal Hostility Assessment Technique. Later each relived a self-chosen anger memory while heart rate and systolic and diastolic blood pressures were measured continuously using an Ohmeda Finapres monitor. Hostile participants had larger and longer-lasting blood pressure responses to anger. African Americans also showed longer-lasting blood pressure reactivity to anger. Health and measurement implications are discussed.

Unimproved chest pain in patients with minimal or no coronary disease: A behavioral phenomenon

Patients with chest pain and minimal or no coronary disease have a good prognosis for survival, yet many continue to have pain. In our experience with 821 medically treated patients there were three cardiac deaths (0.3%) and two nonfatal myocardial infarctions (0.2%) in the first year after angiography, which had revealed insignificant (less than 75% narrowing of the luminal diameter) or no coronary artery stenosis. In a subset of 548 patients selected with no apparent systematic difference from the inception cohort of 821 patients, there was complete absence of chest pain in 178 (33%) patients but 155 (28%) had similar or worse pain. From an analysis of clinical history and catheterization data entered in a stepwise logistic regression function, unimproved chest pain was significantly associated with female sex (p = 0.01) and an index of five chest pain descriptors (p = 0.0005). After adding selected behavioral variables available for a representative sample of 217 patients, a high hypochondriasis score (scale I from the Minnesota Multiphasic Personality Inventory) became the strongest determinant of continued pain (p less than 0.0001). In our experience, an exaggerated preoccupation with personal health is prospectively associated with continued chest pain in patients with minimal or no coronary disease.

Hostile Behaviors Predict Cardiovascular Mortality Among Men Enrolled in the Multiple Risk Factor Intervention Trial

Background—Hostility is associated with incident coronary disease in most large population-based studies, but little is known about its association with cardiovascular disease (CVD) mortality in high-risk individuals. The aim of this study was to assess the association of hostility with CVD mortality in the subsequent 16 years in the Multiple Risk Factor Intervention Trial (MRFIT) participants and to explore the influence of hostility in the subset that had a nonfatal CVD event during the trial. Methods and Results—We coded the Structured Interview responses of 259 men who died of CVD during the 16 years of follow-up and 259 matching living control subjects. Signs of hostility were assessed by use of the Interpersonal Hostility Assessment Technique. Matching was based on center, intervention group, age, race, and interviewer; covariates included study entry diastolic blood pressure, cholesterol, smoking status, and nonfatal CVD event during the trial. High-hostile men were more likely to die of CVD than were low-hostile men. Adjusted odds ratio (OR) and 95% confidence intervals (CIs) were 1.61, 1.09 to 2.39. After the trial, high-hostile men who also had a nonfatal event during the trial were particularly likely to die of CVD, OR, 5.06, 1.42 to 8.22, compared with low-hostile men without a nonfatal event during the trial. Conclusions—Hostility may be a risk factor for CVD mortality among high-risk men. Interventions aimed at anger management and stress reduction along with risk factor modification may be useful for hostile patients.

Immediate and Remote Prognostic Significance of Fascicular Block during Acute Myocardial Infarction

The electrocardiograms of 538 patients with acute myocardial infarction were searched to identify all instances of atrioventricular (A-V) and intraventricular (I-V) conduction disturbances. Data concerning mode of therapy and clinical complications were obtained by review of the record. These variables were then analyzed for significance in relation to the development of type II A-V block acutely and syncope or sudden death during the first year of follow-up.The most accurate predictor for both these events was the status of A-V conduction in combination with the status of I-V conduction. At highest risk (50%) for type II progression were patients with acute adjacent fascicular block plus P-R prolongation, i.e., left anterior hemiblock plus right bundle-branch block (RBBB), or left bundle-branch block (LBBB), or patients with acute nonadjacent fascicular block, i.e., RBBB plus left posterior hemiblock or alternating bundle-branch block. The nonpaced survivors from this same group, plus any other patients with transient type II progression, were also at high risk (45%) for syncope or sudden death in follow-up. No syncope or sudden death has occurred in seven patients with type II progression discharged with a pacemaker. All other patients were at lower risk for these acute and chronic complications.Thus, the electrocardiogram in acute myocardial infarction can identify a high-risk group for acute type II progression in whom prophylactic pacer insertion may be beneficial. Similarly, the electrocardiogram can identify a high-risk group for syncope or sudden death in follow-up and implicates progression to higher degrees of A-V block as an important pathophysiologic mechanism.The possible role of permanent pacemaker therapy in preventing syncope or sudden death in this high-risk group is also suggested.

Suspiciousness, health, and mortality: a follow-up study of 500 older adults.

&NA; Scores on Factor L of the 16 PF, a measure of suspiciousness that is closely related to the Cook and Medley hostility scale, predicted survival in a sample of 500 older men and women during a follow‐up of approximately 15 years. Those individuals with scores indicating higher levels of suspiciousness had greater mortality risk. This association remained significant after controlling for age, sex, physicians ratings of functional health, smoking, cholesterol, and alcohol intake. In addition, Factor L was associated with physicians ratings of health at the initiation of follow‐up. These findings add to the weight of evidence that implicates a set of negative interpersonal attitudes in the domain of hostility, anger, cynicism, and mistrust as a prospective marker of individuals at risk for adverse health outcomes.