Abstract & Commentary
Synopsis: High levels of anger are not heart healthy.
Source: Chang PP, et al. Arch Intern Med. 2002;162:901-906.
The Johns Hopkins Precursor Study enrolled 1337 male graduates of Hopkins’ medical school starting with the Class of 1948 and continuing through the Class of 1964. After appropriate exclusion, 1055 men remained. The subjects received medical examinations and completed questionnaires concerning health history, family history, demographics, and responses to stress (the Habits of Nervous Tension Questionnaire [HNT]). Additionally, starting with the Class of 1949, serum cholesterol was measured during medical school. The HNT asked the question, "Whenever you find yourself in situations of undue pressure or stress, how do you usually react?" Three items from a list of 27 were defined as anger: "expressed or concealed anger," "irritability," and "gripe sessions." Premature cardiovascular disease (CVD), the main outcome, was liberally defined as the usual events (myocardial infarction [MI], sudden death, angina, congestive heart failure, etc.) occurring before age 55, but also included cerebrovascular disease, aortic aneurysm, peripheral vascular disease, and arterial embolization.
The group was divided into 4 anger groups: those that answered affirmatively to all 3 items (n = 21), and those who answered to 2 (88), 1 (258), or none (688). The groups were statistically similar in terms of race (overwhelmingly white), smoking status (approximately 50-60%!), alcohol use, family history of premature coronary heart disease, age at graduation (26½), serum cholesterol (low 190s), body mass index (23.0-23.6), and blood pressure (about 115/70).
The 21 men in the highest anger group, those who answered affirmatively to all 3 items, had 3 premature MIs, a significantly increased incidence when compared to the other groups with a relative risk (RR) of 5.1 (confidence interval [CI], 1.6-16.8). The RR for MI over the entire study was 2.3, and the CI was 0.8-6.2, indicating that the risk attenuated with age when presumably other risk factors become more important.
In an interesting piece of disease-oriented evidence, Chang and colleagues also demonstrated greater vascular reactivity (as gauged by the rise in systolic blood pressure in response to the cold pressor test) among the high-anger med students.
Comment by Allan J. Wilke, MD
Caroline Bedell Thomas, MD, began the Johns Hopkins Precursor Study in 1946, long before institutional review boards and predating the birth of most of Internal Medicine Alert subscribers. I think that the longevity of this study gives it face validity, in spite of its nongeneralizable cohort of over-educated, well-to-do, nicotine-addicted white men. (To their credit, these guys were real pussycats; only 2% fell into the highest anger group. In fact, you could argue that they were preternaturally sweet-tempered. More than 65% said that whenever they found themselves in situations of undue pressure or stress, they never got angry, irritable, or griped!)
Physicians of my generation will remember studying "Type A Personality" as we tried to come to grips with the notion that emotions could affect overall health and that the mind-body dichotomy was an illusion. How could we reconcile the observation that Type As had more heart attacks than Type Bs, but seemed better equipped to survive them once they occurred? What was the physiology involved? Type A behavior is associated with premature development of coronary atherosclerosis.1 Anger increases epinephrine release, increases platelet reactivity, and constricts narrowed coronary arteries. It is associated with cardiac risk factors such as hypertension and depression. Does it cause CVD? In today’s parlance, we struggled with connecting the dots, getting from point A to point B to point C. We can connect the dots "anger" and "hypertension" and "hypertension" and "CVD," but can we connect "anger" and "CVD?" These may be associations, and not necessarily causal. This study seems to directly tie "anger" and "CVD," making a case for causation. Is there an alternative explanation for these findings? For instance, could anger be a marker for premature CVD or could premature CVD provoke anger? Is there any reason to believe that the mind-body gate doesn’t swing both ways?
There are secondary prevention programs for people with coronary heart disease that promote stress reduction and anger management. These programs decrease recurrent ischemic events. Will stress reduction and anger management prevent the first event? While that question is studied, you may want to avail yourself of a local meditation class.
Dr. Wilke, Assistant Professor of Family Medicine, Medical College of Ohio, Toledo, is Associate Editor of Internal Medicine Alert.
Reference
1. Sparagon B, et al. Atherosclerosis. 2001;156:145-149.
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