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Eric Van De Graaff, M.D.

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.



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7 Responses to Anger Management

  1. Arie says:

    This article makes you wonder why the Incredible Hulk hasn’t toppled over from a heart attack years ago.

  2. Tom Medinger says:

    My wife always tells me when I am very angry, that I will get a stroke! Does anger cause or increase hypertension? Is so, there would be a link between anger and the risk of heart attack.

  3. Eric Van De Graaff, M.D. says:

    Tom,

    Surprisingly, the evidence linking anger to hypertension is rather scant. One review study (which looked at 15 research trials on the subject) revealed no definitive association between anger and elevated BP. (see this reference at http://www.ncbi.nlm.nih.gov/pubmed/14593850)

    Having said that, I think your days on this earth will be vastly extended if you do your best to listen to your wife regardless of any scientific evidence on the subject.

    Thanks for the comment.

    Dr. VDG

  4. Joel says:

    So what does this say about your patients? Are your patients surlier than most and do they yell and throw things at you?

  5. Eric Van De Graaff, M.D. says:

    Joel,

    Good point. What you are bringing up is the issue of selection bias. If calm people are less likely to see the inside of a cardiologist’s office then we can assume that heart patients are more likely to fall into the “hostile” category. I am fortunate to have a population of patients in my practice who seem to defy these odds, as they are overwhelmingly pleasant and well-adjusted people who throw things at me only when I deserve it.

    Dr. VDG

  6. Christina R. says:

    “Your article is quite interesting.” If Cardiologist blames Angry as a link to High BP, then those people who are claim-contentful, will Never come consult a Cardiologist/ recognize their true heart trouble symptoms and Never go to an ER to get help. It’s like a female comes into an ER with “CARDIAC related” symptoms; they misdiagnosis them for Stomach problems, send them home and the have an Heart Attack and die.
    “I’ve experienced enough to say, I’ve been told I am too young to experience symptoms.” But yet, most recent testing on my heart indicate underlying problems that should be fully investigated by a EP-Cardiologist. I also have a strong family history for heart. And Yes, Anger is highly developed over time to cause me to decide on IGNORING my symptoms and go on with my life.

  7. Normally I don’t read post on blogs, but I would like to say that this write-up very pressured me to check out and do so! Your writing style has been surprised me. Thank you, very great post.

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