Anger and Coronary Heart Disease: Epidemiologic Evidence from the Atherosclerosis Risk in Communities (ARIC) Study
Janice E. Williams, PhD, MPH Centers for Disease Control and Prevention
The ARIC Study
• Two research arms –Cohort –Community morbidity/mortality surveillance
Types of Anger
• Anger experience –Transitory state (state anger) –Stable and general predisposition to experience anger (trait anger)
Types of Anger
• Anger expression –Anger in –Anger out –Anger control
Trait Anger
• Subtypes
–Temperament –Reaction
Anger and CHD Studies
• Have employed the following study designs to provide evidence of an association
– cross-sectional – prospective – laboratory/clinical
Anger and CHD: ARIC Study
• Relationship of overall trait anger and subtypes to –CHD (revascularization procedures, silent MI, acute MI/fatal CHD)
Methods
• 13,000 black and white men and women, aged 48 - 67, free of clinically manifest CHD • Completed Spielberger Trait Anger Scale
Methods
• Followed from 1990 - 1995 for the occurrence of CHD (revascularization procedures, silent MI, acute MI/fatal CHD)
Spielberger Trait Anger Scale
• I am quick tempered. • I have a fiery temper. • I am a hotheaded person. • I get angry when I am slowed down by others’ mistakes.
Spielberger Trait Anger Scale
(continued) • I feel annoyed when I am not given recognition for doing good work. • I fly off the handle. • When I get angry, I say nasty things.
Spielberger Trait Anger Scale
(continued)
• It makes me furious when I am criticized in front of others. • When I get frustrated, I feel like hitting someone.
Spielberger Trait Anger Scale
(continued) • I feel infuriated when I do a good job and get a poor evaluation.
Trait Anger-Temperament Subscale
• I am quick tempered. • I have a fiery temper. • I am a hotheaded person. • I fly off the handle.
Trait Anger - Reaction Subscale
• I get angry when I am slowed down by others’ mistakes. • I feel annoyed when I am not given recognition for doing good work.
Trait Anger - Reaction Subscale
(continued) • It makes me furious when I am criticized in front of others. • I feel infuriated when I do a good job and get a poor evaluation.
Spielberger Trait Anger Scale
• Coding –1) Almost never –2) Sometimes –3) Often –4) Almost always
Statistical Analyses
• Means and percentages to describe the population by CHD risk factors. • -2 log likelihood tests to assess interactions of covariates with anger.
Statistical Analyses (continued)
• Proportional hazards regression models to assess anger-CHD association. • Kaplan-Meier product limit method to assess probabilities of CHD event-free survival.
Covariates
• Age • Drinking • Race • Smoking • Gender • Diabetes • Education • Waist-to-hip ratio • LDL-and HDL-cholesterol
Results
• Compared to their low-anger counterparts, persons high in trait anger were more likely to: – be smokers and drinkers – be heavier – have less formal education
Multivariate-adjusted hazard ratios (95% C.I.) for the association between overall trait anger and CHD risk
5 4 3 2 1 0 Normo Hyper Normo Hyper
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Multivariate-adjusted hazard ratios (95% C.I.) for the association between trait anger-temperament and CHD risk
5 4 3 2 1 0 Normo Hyper Normo Hyper
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Multivariate-adjusted hazard ratios (95% C.I.) for the association between trait anger-reaction and CHD risk
5 4 3 2 1 0 Full Cohort Full Cohort
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Summary
• Overall trait anger was positively associated with risk of both combined CHD and of “hard” events (acute MI/fatal CHD) among normotensive individuals.
Summary
• Similarly, trait angertemperament was positively associated with combined CHD and with “hard” events (acute MI/fatal CHD) among normotensive individuals.
Summary
• No statistically significant association was observed between trait anger-reaction and CHD.
Conclusions
• A fiery temper predisposes middle-aged normotensive persons to a greater risk of CHD than anger aroused in reaction to frustration, criticism, or unfair treatment.
The Mechanism
• High-anger persons, compared to their low-anger counterparts, may be more likely to engage in unhealthy behaviors that place them at risk for CHD.
The Mechanism
• Direct pathophysiological effects via heightened sympathetic arousal and neuroendocrine activation.