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Anger Management

By Eric Van De Graaff, MD October 10, 2011 Posted in: Heart Health

A study published in the Journal of the American College of Cardiology recently caught my eye (I lead in with this sentence as a way of making my readers believe that I actually spend time reading professional research rather than just surfing the internet looking for humorous medical trivia—something I would never do). Researchers in New York and Canada conducted a study on the link between behavioral hostility and one’s risk of future heart attacks and found that angry people suffer cardiac problems twice as often as the more placid individuals.

Why the study was conducted in Nova Scotia, Canada, I can’t exactly say. One would think that researchers from New York City would need to look no further than their own backyard for a large cohort of amply aggravated subjects. When I think “hostile” my first thoughts don’t exactly turn to our neighbors to the north—although one might just find the perfect study population in a land where half the year is spent in the arctic darkness and leisure activity consists of beer-fueled hockey games.

To pursue their research the scientists tapped into a database of several thousand Canadians whose level of hostility had been assessed years earlier as part of a larger Nova Scotia Health Survey conducted in 1995. Rather than rely on the standard tools for the assessment of hostility—such as the Bedford-Foulds Personality Deviance Scale (I’m not sure if, as a survey volunteer, it’s better to have a low or a high personality deviance score)—the 1995 survey employed nurses actually trained in hostility assessment (I ask you, what nurse is not already an expert in working with hostile people? They have to interact with doctors, after all) to grade their subjects on “anger, irritability, antagonism, disagreeableness, rudeness, surliness, criticalness and uncooperativeness” (along with lots of other things commonly found in a thesaurus). Based on the person’s surliness level the expert nurses placed each in one of four categories ranging from “non-hostile” to “please-put-down-the-sharp-object angry.” They took pains to note that pregnant women were excluded from the study—I guess they couldn’t think of a category above “criminally enraged.”

A total of 1,749 subjects completed the assessment and the researchers combed through the volunteers’ records over the next 10 years looking for evidence of heart disease. At baseline, the characteristics of the group were fairly predictable. Angrier people tended to be younger, were more likely to smoke, and were more commonly male (who knew?). They then correlated the risk of heart disease to the subjects’ baseline anger level to come up with the conclusion that hostile people were twice as likely to end up in the ER clutching their chest.

What does this mean for us? Before we can get to that we have to look at the study’s limitations. Most glaring was the relative distribution of the populations that made up the trial. Out of the 1,749 people enrolled only 177 came away from their interview with the label “non-hostile.” The remaining 90% of people—those who were ultimately found to be at increased cardiovascular risk—were defined as having some degree of hostility. In other words, unless you are in the small fraction of truly peaceful, Zen-like people you’re pretty much toast (yet another reason to pursue a career in the library sciences). Further, the hostility interview was a one-time assessment and may not have reflected the ongoing mood of the subjects. To put this in perspective I would challenge the investigators to perform the same interviews in Lincoln, Nebraska the day after the Huskers’ Big Ten debut and see what they come up with (of course that wouldn’t work since a well-run study needs at least one or two non-hostile control subjects).

The precise mechanism that links hostility to heart attacks is still a mystery. In a well-written essay accompanying the research paper, Dr. Mary Whooley of San Francisco (another place you wouldn’t expect to find an expert on hostility) reminds us that this personality trait is also associated with poor health behaviors such as physical inactivity, dietary indiscretion, higher body mass index, and smoking—factors known to be complicit in the development of coronary disease. She also postulates that elevated levels of adrenalin might be the culprit but cautions that studies of this linkage have been far from conclusive (in one report, 158 “hostile volunteers” underwent 12 weeks of cognitive therapy without any reduction in their cardiac adrenalin activity).

Can you lower your risk of heart attack by training yourself to be less hostile? No one knows, but it’s certainly possible. Many years ago two cardiologists, Drs. Friedman and Rosenman, identified a “coronary prone behavior pattern” that they called “type A” personality. They tested their theory linking personality to coronary risk by performing a prospective study where they randomized a group of high-strung heart attack survivors to receive behavioral counseling and compared their outcomes to another group that underwent no such therapy. After nearly five years of sessions on the couch, the group that managed to reign in their type A-ness fared better with fewer heart attacks and longer lives (getting nearly a thousand type A personalities to set aside their taxing daily schedules to enroll in a study of soothing discussions about their childhood must have been a feat in itself).

Since then, numerous papers have been published linking aggressive and competitive behavior to early heart attacks, but we have yet to see a large research trial that settles the question of whether the hostile 90% of us can achieve the same low risk as the peaceful 10%.

Until then I suppose the best advice is to do your best to rid yourself of anger, hostility, surliness, irritability, antagonism etc. Even if it isn’t the magic bullet to cure heart disease it certainly can’t hurt to be at peace with the universe. For those of us in Nebraska, a life devoid of surliness might just be the prescription we need to survive another college football season.

Eric Van De Graaff, MD
Eric Van De Graaff, MD

Eric Van De Graaff, MD is a Heart & Vascular Specialist at CHI Health Clinic.

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