Covariation of psychological attributes and incident coronary heart disease in U.S. Air Force veterans of the Vietnam war

Independent Associations Between Trait-Anger, Depressive Symptoms and Preclinical Atherosclerotic Progression

BACKGROUND

Previous research from our group found that recent depressive symptoms were associated with 3-year change in carotid intima-media thickness (CA-IMT), a biomarker of cardiovascular disease risk, in an initially healthy sample of older adults. Trait measures of anxiety, anger, and hostility did not predict 3-year CA-IMT progression in that report.

PURPOSE

The current study sought to reexamine these associations at a 6-year follow-up point.

METHODS

Two-hundred seventy-eight participants (151 males, mean age = 60.68 years) from the original sample completed an additional IMT reading 6 years following the initial baseline assessment.

RESULTS

Though not significant at 3-years, trait-anger emerged as a predictor of IMT progression at the 6-year point. When examined in separate regression models, both depression and trait-anger (but not anxiety or hostility) predicted 6-year IMT change (b = .017, p = .002; b = .029, p = .01, respectively). When examined concurrently, both depression and anger were independently associated with 6-year IMT progression (b = .016, p = .010, b = .028, p = .022, respectively). Exploratory analyses suggest that the relative contributions of anger and depression may differ for males and females.

CONCLUSIONS

The use of sequential follow-ups is relatively unique in this literature, and our results suggest a need for further research on the timing and duration of psychosocial risk exposures in early stages of cardiovascular disease.

The personality meta-trait of stability and carotid artery atherosclerosis

BACKGROUND

Several personality traits increase the risk for atherosclerotic cardiovascular disease. Because many of these traits are correlated, their associations with disease risk could reflect shared variance, rather than unique contributions of each trait. We examined a higher-order personality trait of Stability as related to preclinical atherosclerosis and tested whether any such relationship might be explained by correlated variation in cardiometabolic risk factors.

METHOD

Among 798 community volunteers, lower-order traits of Neuroticism, Agreeableness, and Conscientiousness were modeled as latent variables (from self- and informant ratings) and used to estimate the second-order factor, Stability. Cardiometabolic risk was similarly modeled from indicators of glycemic control, blood pressure, adiposity, and lipids. Carotid artery atherosclerosis was measured as intima-media thickness (IMT) by duplex ultrasonography.

RESULT

A structural equation model incorporating direct and indirect effects showed lower Stability associated with greater IMT, and this relationship was accounted for by the indirect pathway via cardiometabolic risk. Secondary analyses showed that: (1) Neuroticism, Agreeableness, and Conscientiousness were unrelated to IMT independent of Stability; and (2) Stability predicted variation in IMT when estimated from informant-, but not self-rated, traits.

CONCLUSION

Personality traits may associate with atherosclerotic burden through their shared, rather than unique, variance, as reflected in Stability.

Cardiovascular therapeutics: A new potential for anxiety treatment?

Besides the well‐recognized risk factors, novel conditions increasing cardiovascular morbidity and mortality are emerging. Undesirable emotions and behavior such as anxiety and depression, appear to participate in worsening cardiovascular pathologies. On the other hand, deteriorating conditions of the heart and vasculature result in disturbed mental and emotional health. The pathophysiological background of this bidirectional interplay could reside in an inappropriate activation of vegetative neurohormonal and other humoral systems in both cardiovascular and psychological disturbances. This results in circulus vitiosus potentiating mental and circulatory disorders. Thus, it appears to be of utmost importance to examine the alteration of emotions, cognition, and behavior in cardiovascular patients. In terms of this consideration, recognizing the potential of principal cardiovascular drugs to interact with the mental state in patients with heart or vasculature disturbances is unavoidable, to optimize their therapeutic benefit. In general, beta‐blockers, central sympatholytics, ACE inhibitors, ARBs, aldosterone receptor blockers, sacubitril/valsartan, and fibrates are considered to exert anxiolytic effect in animal experiments and clinical settings. Statins and some beta‐blockers appear to have an equivocal impact on mood and anxiety and ivabradine expressed neutral psychological impact. It seems reasonable to suppose that the knowledge of a patient's mood, cognition, and behavior, along with applying careful consideration of the choice of the particular cardiovascular drug and respecting its potential psychological benefit or harm might improve the individualized approach to the treatment of cardiovascular disorders.

The emotional heart: prospective associations of anger, depression, and anxiety as risk factors for myocardial infarction in a 22-year follow-up of a working cohort of middle-aged men

Aim

The study aim was to further clarify the relationship between psychological factors and myocardial infarction (MI) by simultaneously examining anger, depression, and anxiety as risk factors for incident MI in a healthy working sample.

Subject and method

Baseline measurements of psychological variables were assessed through a self-reported questionnaire in a healthy cohort of 968 middle-aged men working at the Volvo Corporation. Single-item questions assessed depression and anxiety. Anger was assessed by the Trait Anger subscale of the Spielberger State-Trait Anger Expression Inventory. The endpoint was incident MI verified by national registers or medical records with follow up after 22 years. The main outcome was computed through logistic regression, reported as odds ratios. Additional correlation analyses were performed between psychological variables and coronary risk factors.

Results

None of the psychological variables was significantly associated with the outcome; thus, the results failed to show an association between anger, depression, or anxiety and incident MI in this sample. There were some significant, but weak, correlations between psychological factors and negative health behaviors. Other components of traditional risk scoring instruments did not correlate with the psychological factors.

Conclusion

A cohort restricted to middle-age healthy men limits applicability. However, our failure to replicate earlier results of population samples suggests a need for further research on associations between psychological factors and MI in healthy samples.

Sex- and Gender-Stratified Risks of Psychological Factors for Incident Ischemic Heart Disease: Systematic Review and Meta-Analysis

Background

Psychological factors are associated with an increased risk of developing ischemic heart disease (IHD). Women more often report psychological factors, and sex and gender differences are present in IHD. In this meta‐analysis we examine the risks of psychological factors for IHD incidence in women and men. We hypothesize that a broad range of psychological factors are related to a higher risk for incident IHD, with a higher risk for women.

Methods and Results

PubMed, EMBASE, and PsycINFO were searched for studies assessing the risk between psychological factors and incident IHD. Psychological factors included depression, anxiety or panic disorder, social support, hostility, anger, personality (type D), type A behavior pattern, posttraumatic stress disorder, and psychological distress. In the primary analyses, 62 studies (77 separate reports) that included 2 145 679 women and 3 119 879 men and reported confounder‐adjusted hazard ratios or relative risks were included. Pooled effect confounder‐adjusted estimates from random‐effects models showed that psychological factors (all combined) were associated with incident IHD in women (hazard ratio: 1.22; 95% CI, 1.14–1.30) and men (hazard ratio: 1.25; 95% CI, 1.19–1.31). No sex and gender differences were found for these pooled effect estimates (P=0.547).

Conclusions

Psychological factors are associated with incident IHD in both women and men, but no significant differences were observed between women and men. IHD is predominantly being studied as obstructive coronary artery disease, which is more prevalent in men. Data are needed on psychological predictors and other manifestations of IHD such as coronary microvascular disease, which is more common in women.

Association of psychosocial traits with coronary artery calcium development and progression: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Coronary artery calcium (CAC) is a well-established quantifiable risk factor for cardiovascular disease (CVD). We examined the association of anger, hostility, anxiety, and depression with the development and progression of CAC.

METHODS

We studied the association of these psychosocial traits with CAC among participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Anger was measured using the Spielberger Trait Anger questionnaire, hostility using a modified Cook-Medley Hostility questionnaire, anxiety using the Spielberger Trait Scale, and depression using the Center for Epidemiological Studies Depression Scale (CES-D). Among the subsample of participants with CAC = 0 at the beginning of the study period, Poisson regression models were used to determine the relative risk of developing CAC>0 over the study period. In the subsample that developed CAC>0, we used linear regression models to estimate the average increase in CAC associated with a unit increase in psychosocial trait.

RESULTS

Median time of follow-up was 9.4 years (range 8.0-11.4 years). Cross-sectional analyses at baseline revealed no association of any of the psychosocial traits with the presence or magnitude of CAC (anger: RR 0.98, p < 0.01; hostility: RR 1.01, p = 0.25; anxiety: RR 0.99, p < 0.01; depression: RR 0.99, p < 0.01 [not statistically significant after adjustment for covariates]). No association was detected between the traits and development of CAC (anger: RR 0.99, p = 0.23; hostility: RR 1.01, p = 0.68, anxiety: RR 1.00, p = 0.49; depression: RR 1.00, p = 0.51). We also found no association between any of the traits and progression of CAC (anger: beta -3.21, p = 0.08; hostility: beta 2.28, p = 0.43; anxiety: 3.45, p = 0.02 [not statistically significant after adjustment for covariates]; depression: beta -1.46, p = 0.11).

CONCLUSIONS

We found no association between anger, hostility, anxiety, or depression and CAC, suggesting these personality traits are not independent risk factors for CVD.

Anger, hostility and risk of stroke: a meta-analysis of cohort studies

OBJECTIVE

A growing number of studies have been conducted on the relationship between anger and hostility and the risk of stroke, and their conclusions are not consistent. Accordingly, we performed a meta-analysis to evaluate the relationship between anger and hostility and the risk of stroke.

METHODS

We searched the PubMed and Embase databases for cohort studies, focusing on the relationship between anger and hostility and risk of stroke. Then studies were selected according to the inclusion and exclusion criteria. Study results were pooled using a random effects model.

RESULTS

Ten studies from seven articles involving 52,277 participants were included in this meta-analysis. No significant association was found between anger and hostility level and risk of stroke (hazard ratio 1.08; 95% confidence interval 0.79-1.47). However, a positive association was seen when people with high socioeconomic status were excluded (hazard ratio 1.30; 95% confidence interval 1.06-1.59).

CONCLUSION

A higher level of anger and hostility is not associated with elevated risk of stroke. However, the association is positive among people with lower socioeconomic status.

Psychosocial Factors in the Relationship between Socioeconomic Status and Cardiometabolic Risk: the HCHS/SOL Sociocultural Ancillary Study

BACKGROUND

U.S. Hispanics/Latinos display a high prevalence of metabolic syndrome (MetSyn), a group of co-occurring cardiometabolic risk factors (abdominal obesity, impaired fasting glucose, dyslipidemia, elevated blood pressure) associated with higher cardiovascular disease and mortality risk. Low socioeconomic status (SES) is associated with higher risk for MetSyn in Hispanics/Latinos, and psychosocial factors may play a role in this relationship.

PURPOSE

This cross-sectional study examined psychosocial factors in the association of SES and MetSyn components in 4,996 Hispanic/Latino adults from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study.

METHODS

MetSyn components were measured at the baseline examination. Participants completed interviews to determine psychosocial risks (e.g., depression) and resources (e.g., social support) within 9 months of baseline (< 4 months in 72.6% of participants). Confirmatory factor analysis (CFA) and structural equation modeling (SEM) were used to identify latent constructs and examine associations.

RESULTS

Participant mean age was 41.7 years (SE = 0.4) and 62.7% were female. CFA identified single latent factors for SES and psychosocial indicators, and three factors for MetSyn [blood pressure, lipids, metabolic factors]. SEMs showed that lower SES was related to MetSyn factors indirectly through higher psychosocial risk/lower resources (Y-Bχ² (df = 420) = 4412.90, p < .05, RMSEA = .042, SRMR = .051). A statistically significant effect consistent with mediation was found from lower SES to higher metabolic risk (glucose/waist circumference) via psychosocial risk/resource variables (Mackinnon's 95% asymmetric CI = -0.13 to -0.02).

CONCLUSIONS

SES is related to metabolic variables indirectly through psychosocial factors in U.S. Hispanics/Latinos of diverse ancestries.

Personality Traits and Adaptive HIV Disease Management: Relationships with Engagement in Care and Condomless Anal Intercourse Among Highly Sexually Active Sexual Minority Men Living with HIV

PURPOSE

The purpose of this study was to identify systematic relationships between personality domains and engagement in HIV care and secondary HIV prevention among sexual minority men living with HIV.

METHODS

This cross-sectional study examined the relationships between general personality traits of the Five-Factor Model of personality (e.g., Neuroticism and Conscientiousness) and engagement in medical care and condomless anal intercourse among a sample of highly sexually active sexual minority men living with HIV (N = 60).

RESULTS

Conscientiousness (B = -0.01, P < 0.05), Openness (B = -0.03, P < 0.05), and Extraversion (B = -0.03, P < 0.001) were each associated with engaging in fewer episodes of condomless anal intercourse and Conscientiousness alone was significantly related to having fewer sexual partners (B = -0.04, P < 0.001). Conscientiousness (odds ratio [OR] = 1.07, confidence interval [CI]: 1.01-1.13) and Extraversion (OR = 1.13, CI: 1.04-1.22) were both associated significantly with prevention service use. Conscientiousness alone was related to engagement in HIV medical case management (B = -0.11, P < 0.05), whereas both Conscientiousness (B = 0.41, P < 0.0001) and Neuroticism (B = -0.64, P < 0.001) were associated with perceived health. Furthermore, compared with the normative sample for the NEO-Personality Inventory-Revised, men in our sample scored significantly higher on Neuroticism and significantly lower on Conscientiousness (Ps < 0.05).

CONCLUSION

These findings suggest that enduring individual differences may account, in part, for some of the high levels of condomless anal intercourse reported by this group, as well as engagement in and use of prevention services. We suggest strategies for engaging this group in secondary HIV prevention programs and initiatives.

Toxic Affect: Are Anger, Anxiety, and Depression Independent Risk Factors for Cardiovascular Disease?

Three negative affective dispositions—anger, anxiety, and depression—are hypothesized to increase physical disease risk and have been the subject of epidemiological studies. However, the overlap among the major negative affective dispositions, and the superordinate construct of trait negative affectivity (NA) are only beginning to be tested. Presented here is a narrative review of recent prospective studies that simultaneously tested anger, anxiety, depression, and trait NA as risk factors for cardiac outcomes. Anxiety and depression emerged as independent risk factors for premature heart disease in population studies of persons nominally healthy at baseline, and for recurrence/mortality among patients with existing heart disease. General trait NA also was a cardiac risk factor in population samples.

Meta-Analysis of Anxiety as a Risk Factor for Cardiovascular Disease

Whether anxiety is a risk factor for a range of cardiovascular diseases is unclear. We aimed to determine the association between anxiety and a range of cardiovascular diseases. MEDLINE and EMBASE were searched for cohort studies that included participants with and without anxiety, including subjects with anxiety, worry, posttraumatic stress disorder, phobic anxiety, and panic disorder. We examined the association of anxiety with cardiovascular mortality, major cardiovascular events (defined as the composite of cardiovascular death, stroke, coronary heart disease, and heart failure), stroke, coronary heart disease, heart failure, and atrial fibrillation. We identified 46 cohort studies containing 2,017,276 participants and 222,253 subjects with anxiety. Anxiety was associated with a significantly elevated risk of cardiovascular mortality (relative risk [RR] 1.41, CI 1.13 to 1.76), coronary heart disease (RR 1.41, CI 1.23 to 1.61), stroke (RR 1.71, CI 1.18 to 2.50), and heart failure (RR 1.35, CI 1.11 to 1.64). Anxiety was not significantly associated with major cardiovascular events or atrial fibrillation although CIs were wide. Phobic anxiety was associated with a higher risk of coronary heart disease than other anxiety disorders, and posttraumatic stress disorder was associated with a higher risk of stroke. Results were broadly consistent in sensitivity analyses. Anxiety disorders are associated with an elevated risk of a range of different cardiovascular events, including stroke, coronary heart disease, heart failure, and cardiovascular death. Whether these associations are causal is unclear.

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

BACKGROUND

Anxiety has been associated with new-onset cardiovascular disease (CVD), but the quality of this relationship is unclear. Only if anxiety is a causal, independent cardiovascular risk factor might it be a target for CVD prevention.

AIMS

To determine and examine the independent association and causality between anxiety and incident CVD.

METHOD

PubMed, EMBASE and PsycINFO databases were searched up to October 2013. A review of Hill's criteria for causality and random effects meta-analysis were conducted of prospective, population-based studies examining anxiety and incident CVD in people free from CVD at baseline.

RESULTS

The meta-analysis comprised 37 papers (n = 1 565 699). The follow-up ranged from 1 to 24 years. Anxiety was associated with a 52% increased incidence of CVD (hazard ratio = 1.52, 95% CI 1.36-1.71). The risk seemed independent of traditional risk factors and depression. The evaluation of Hill's criteria largely argued in favour of causality.

CONCLUSIONS

Anxiety may be of interest for CVD prevention. Future research should examine biological and behavioural underpinnings of the association in order to identify targets for intervention.

Panic disorder and incident coronary heart disease: a systematic review and meta-analysis protocol

BACKGROUND

The clinical presentation of panic disorder and panic attack overlaps many symptoms typically experienced in coronary heart disease (CHD). Etiological links between panic disorder and CHD are controversial and remain largely tenuous. This systematic review aims to pool together data regarding panic disorder with respect to incident CHD or myocardial infarction.

METHODS/DESIGN

Electronic databases (MEDLINE, EMBASE, PsycINFO and SCOPUS) will be searched using a search strategy exploding the topics for CHD and panic disorder. Authors and reference lists of included studies will also be contacted to identify additional published and unpublished studies. Eligibility criteria are as follows:

POPULATION

persons without CHD who meet criteria for panic disorder, panic attack, anxiety neurosis or elevated panic disorder symptoms; Comparison: persons without CHD who do not meet criteria for panic disorder, panic attack, anxiety neurosis or elevated panic disorder symptoms;

OUTCOME

verified fatal and non-fatal CHD at follow-up; including coronary revascularization procedure, coronary artery disease, and myocardial infarction. Studies adopting self-report CHD will be ineligible. Screening will be undertaken by two independent reviewers with disagreements resolved through discussion. Data extraction will include original data specified as hazard ratios, risk ratios, and original cell data if available. Risk of bias assessment will be undertaken by two independent reviewers. Meta-analytic methods will be used to synthesize the data collected relating to the CHD outcomes with Cochrane Review Manager 5.3.

DISCUSSION

This systematic review aims to clarify whether panic disorder is associated with elevated risk for subsequent CHD. An evaluation of the etiological links between panic disorder with incident CHD might inform evidence-based clinical practice and policy concerning triaging chest pain patients, diagnostic assessment, and psychiatric intervention with panic disorder patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014014891 .

Identification of hypertensive patients with dominant affective temperaments might improve the psychopathological and cardiovascular risk stratification: a pilot, case-control study

BACKGROUND

Although mood disorders and cardiovascular diseases have widely studied psychosomatic connections, data concerning the influence of the psychopathologically important affective temperaments in hypertension are scarce. To define a possibly higher cardiovascular risk subpopulation we investigated in well-treated hypertensive patients with dominant affective temperaments (DOM) and in well-treated hypertensive patients without dominant temperaments the level of depression and anxiety, arterial stiffness and serum Brain-derived Neurotrophic Factor (seBDNF).

METHODS

175 hypertensive patients, free of the history of psychiatric diseases, completed the TEMPS-A, Beck Depression Inventory and Hamilton Anxiety Scale questionnaires in two primary care practices. Of those 175 patients, 24 DOM patients and 24 hypertensive controls (matched in age, sex and the presence of diabetes) were selected for measurements of arterial stiffness and seBDNF level.

RESULTS

Beck and Hamilton scores in DOM patients were higher compared with controls. Pulse wave velocity and augmentation index did not differ between the groups while in the DOM patients decreased brachial systolic and diastolic and central diastolic blood pressures were found compared with controls. SeBDNF was lower in the DOM group than in the controls (22.4 ± 7.2 vs. 27.3 ± 7.8 ng/mL, p < 0.05).

CONCLUSIONS

Although similar arterial stiffness parameters were found in DOM patients, their increased depression and anxiety scores, the decreased brachial and central diastolic blood pressures as well as the decreased seBDNF might refer to their higher vulnerability regarding the development not only of major mood disorders, but also of cardiovascular complications. These data suggest that the evaluation of affective temperaments should get more attention both with regard to psychopathology and cardiovascular health management.

Personality traits and circadian blood pressure patterns: a 7-year prospective study

OBJECTIVE

A nighttime dip in blood pressure is associated with decreased risk of cardiovascular morbidity and mortality. We examined whether personality traits predict nighttime dipping blood pressure.

METHODS

A community-based sample of 2848 adults from Sardinia (Italy) completed the Revised NEO Personality Inventory and 7 years later were examined with 24-hour ambulatory blood pressure monitoring. The primary analyses examined the associations of personality traits with continuous and categorical measures of mean arterial, systolic, and diastolic blood pressure nighttime dipping.

RESULTS

Agreeableness and conscientiousness were associated with more nocturnal blood pressure dipping (β = .05 [p = .025] and β = .07 [p < .001], respectively) and lower systolic blood pressure at night (β = -.05 [p = .018] and β = -.03 [p = .072], respectively). Nondippers were particularly more impulsive (p = .009), less trusting (p = .004), and less self-disciplined (p = .001), but there was no significant association between nocturnal dipping blood pressure and trait anxiety (p = .78) or depression (p = .59). The associations were stronger when comparing extreme dippers (nighttime drop ≥ 20%) to reverse dippers (nighttime increase in blood pressure). Indeed, scoring 1 standard deviation higher on conscientiousness was associated with approximately 40% reduced risk of reverse dipping (odds ratio = 1.43, confidence interval = 1.08-1.91).

CONCLUSIONS

We found evidence that reduced nighttime blood pressure dipping is associated with antagonism and impulsivity-related traits but not with measures of emotional vulnerability. The strongest associations were found with conscientiousness, a trait that may have a broad impact on cardiovascular health.

Anxiety, anger, and mortality risk among survivors of myocardial infarction

BACKGROUND

Although there is evidence that anxiety and anger are associated with a higher risk of cardiovascular events, studies examining the relationship between these stressors and prognosis following myocardial infarction have been mixed.

METHODS

We conducted a prospective cohort study of 1968 participants (average age 60.2 years, 30.6% women) in the Determinants of Myocardial Infarction Onset Study recruited at the time of admission for myocardial infarction between 1989 and 1996. We used the state anxiety and anger subscales of the State-Trait Personality Inventory. Participants were followed for all-cause mortality through December 31, 2007 using the National Death Index. We constructed multivariable Cox proportional hazards models adjusted for demographic, behavioral, and clinical confounders and calculated hazard ratios (HR) and 95% confidence intervals (CI) to examine the relationship between high levels of anxiety and anger and all-cause mortality.

RESULTS

Over 10 years of follow-up, 525 participants died. Compared with those scoring lower, an anxiety score >90(th) percentile was associated with a 1.31-times (95% CI, 0.93-1.84) higher mortality rate. The association was apparent in the first 3 years (HR 1.78; 95% CI 1.08-2.93), but not thereafter. Likewise, an anger score >90(th) percentile was associated with a 1.25-times (95% CI, 0.87-1.80) higher mortality rate. The association was higher in the first 3 years (HR 1.58; 95% CI, 0.91-2.74) than in subsequent years, but it was not statistically significant during either follow-up period.

CONCLUSIONS

In this study of myocardial infarction survivors, a high level of anxiety was associated with all-cause mortality, with the strongest association in the first 3 years of follow-up.

An anxious heart: anxiety and the onset of cardiovascular diseases

The public health burden of cardiovascular disease (CVD) is high both in terms of economic and social costs. Key modifiable factors identified for CVD prevention include health behaviors and health risk factors (e.g., cholesterol, blood pressure). However, a substantial body of research has also identified stress, anxiety, and depression as potentially modifiable CVD risk factors. Here we focus on the role of anxiety in the development of CVD and consider its potential as a key target for primordial prevention strategies. First, we highlight important findings and summarize the latest research on anxiety and incident CVD. We also review and summarize the findings to date on subclinical CVD outcomes and briefly consider mechanisms by which anxiety may influence CVD. We identify key issues and consider how these issues may inform our understanding of the anxiety-CVD relationship. Finally, we briefly discuss the clinical implications of this work, with specific recommendations for providers.

Combining personality traits with traditional risk factors for coronary stenosis: an artificial neural networks solution in patients with computed tomography detected coronary artery disease

Background. Coronary artery disease (CAD) is a complex, multifactorial disease in which personality seems to play a role but with no definition in combination with other risk factors. Objective. To explore the nonlinear and simultaneous pathways between traditional and personality traits risk factors and coronary stenosis by Artificial Neural Networks (ANN) data mining analysis. Method. Seventy-five subjects were examined for traditional cardiac risk factors and personality traits. Analyses were based on a new data mining method using a particular artificial adaptive system, the autocontractive map (AutoCM). Results. Several traditional Cardiovascular Risk Factors (CRF) present significant relations with coronary artery plaque (CAP) presence or severity. Moreover, anger turns out to be the main factor of personality for CAP in connection with numbers of traditional risk factors. Hidden connection map showed that anger, hostility, and the Type D personality subscale social inhibition are the core factors related to the traditional cardiovascular risk factors (CRF) specifically by hypertension. Discussion. This study shows a nonlinear and simultaneous pathway between traditional risk factors and personality traits associated with coronary stenosis in CAD patients without history of cardiovascular disease. In particular, anger seems to be the main personality factor for CAP in addition to traditional risk factors.

Combining psychosocial data to improve prediction of cardiovascular disease risk factors and events: The National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation study

BACKGROUND

There is overlap among psychosocial predictors of cardiovascular disease (CVD). The usefulness of combining psychosocial variables as risk markers for CVD needs investigation.

METHODS

Participants were 493 women in the NHLBI WISE study. Multivariate combination of Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Social Network Index (SNI), and Cook-Medley hostility subscales was evaluated, and principal components analysis also conducted. Relationships of composite psychosocial risk markers to CVD events and risk factors were assessed.

RESULTS

The multivariate block of SNI, Cook-Medley Hostile Affect subscale, STAI, and BDI predicted CVD events (χ(2) = 27.8, df = 6, p < .001). Scalewise factor analysis revealed 2 factors: negative affectivity (NA) and hostility (explained variance, 45.6% and 17.1%, respectively). NA was associated with BMI (β [SE] = 0.18 [0.09], p = .04), hostility with metabolic syndrome (exp(β) = 0.60 [0.28], p = .04). Both factors were associated with blood pressure (BP): NA with SBP (β = 2.53 [1.04], p = .02) and DBP (β = 1.66 [0.60], p = .02); hostility with SBP (β = 2.72 [1.13], p = .02) and DBP (β = 1.83 [0.65], p = .005). Neither factor predicted CVD events. Original scales predicted CVD events: lower SNI (HR = 0.74, CI = 0.57-0.96), lower Hostile Affect (HR = 0.80, CI = 0.56-1.03), and higher BDI (HR = 1.33, CI = 1.08-1.74).

CONCLUSIONS

In women with suspected ischemia, multivariate combination of psychosocial risk markers predicts CVD events; derived psychosocial factors were associated with CVD risk factors but not events. Measuring common variance among psychosocial variables may be a useful research strategy.

Latent constructs in psychosocial factors associated with cardiovascular disease: an examination by race and sex

This study examines race and sex differences in the latent structure of 10 psychosocial measures and the association of identified factors with self-reported history of coronary heart disease (CHD). Participants were 4,128 older adults from the Chicago Health and Aging Project. Exploratory factor analysis (EFA) with oblique geomin rotation was used to identify latent factors among the psychosocial measures. Multi-group comparisons of the EFA model were conducted using exploratory structural equation modeling to test for measurement invariance across race and sex subgroups. A factor-based scale score was created for invariant factor(s). Logistic regression was used to test the relationship between the factor score(s) and CHD adjusting for relevant confounders. Effect modification of the relationship by race-sex subgroup was tested. A two-factor model fit the data well (comparative fit index = 0.986; Tucker-Lewis index = 0.969; root mean square error of approximation = 0.039). Depressive symptoms, neuroticism, perceived stress, and low life satisfaction loaded on Factor I. Social engagement, spirituality, social networks, and extraversion loaded on Factor II. Only Factor I, re-named distress, showed measurement invariance across subgroups. Distress was associated with a 37% increased odds of self-reported CHD (odds ratio: 1.37; 95% confidence intervals: 1.25, 1.50; p-value < 0.0001). This effect did not differ by race or sex (interaction p-value = 0.43). This study identified two underlying latent constructs among a large range of psychosocial variables; only one, distress, was validly measured across race-sex subgroups. This construct was robustly related to prevalent CHD, highlighting the potential importance of latent constructs as predictors of cardiovascular disease.

Observed hostility and the risk of incident ischemic heart disease: a prospective population study from the 1995 Canadian Nova Scotia Health Survey

OBJECTIVES

The aim of this study was to examine the relation between hostility and incident ischemic heart disease (IHD) and to determine whether observed hostility is superior to patient-reported hostility for the prediction of IHD in a large, prospective observational study.

BACKGROUND

Some studies have found that hostile patients have an increased risk of incident IHD. However, no studies have compared methods of hostility assessment or considered important psychosocial and cardiovascular risk factors as confounders. Furthermore, it is unknown whether all expressions of hostility carry equal risk or whether certain manifestations are more cardiotoxic.

METHODS

We assessed the independent relationship between baseline observed hostility and 10-year incident IHD in 1,749 adults of the population-based Canadian Nova Scotia Health Survey.

RESULTS

There were 149 (8.5%) incident IHD events (140 nonfatal, 9 fatal) during the 15,295 person-years of observation (9.74 events/1,000 person-years). Participants with any observed hostility had a greater risk of incident IHD than those without (p = 0.02); no such relation was found for patient-reported hostility. Those with any observed hostility had a significantly greater risk of incident IHD (hazard ratio: 2.06, 95% confidence interval: 1.04 to 4.08, p = 0.04), after adjusting for cardiovascular (age, sex, Framingham Risk Score) and psychosocial (depression, positive affect, patient-reported hostility, and anger) risk factors.

CONCLUSIONS

The presence of any observed hostility at baseline was associated with a 2-fold increased risk of incident IHD over 10 years of follow-up. Compared with patient-reported measures, observed hostility is a superior predictor of IHD.

The association between anxiety and C-reactive protein (CRP) levels: results from the Northern Finland 1966 birth cohort study

BACKGROUND

Anxiety frequently accompanies low-grade inflammation-associated conditions like depression, insulin resistance, coronary heart disease and metabolic syndrome. The association between anxiety and low-grade inflammation is, unlike between depression and low-grade inflammation, a very sparsely studied area in general populations. The aim of the present study was to investigate whether anxiety symptoms as well as comorbid anxiety and depressive symptoms are associated with low-grade inflammation at population level.

METHODS

The general population-based Northern Finland 1966 Birth Cohort was followed until age 31 (n=2688 males and 2837 females), when the highly sensitive CRP concentrations were measured. Anxiety and depressive symptoms were defined by Hopkins Symptom Checklist-25 (HSCL-25).

RESULTS

After adjusting for confounders, logistic regression analyses showed that anxiety symptoms alone increased the probability for elevated hs-CRP levels (>3.0mg/L) in males over two-fold (2.19 CI 95% 1.08-4.46), while comorbid anxiety and depressive symptoms caused a 1.7-fold (1.76 CI 95% 1.13-2.74) increase in the probability for elevated hs-CRP levels (1.0-3.0mg/L).

CONCLUSIONS

Our results support the hypothesis that anxiety as well as comorbid anxiety and depression can be associated with an increased risk for low-grade inflammation in males at population level.

Anxiety and risk of incident coronary heart disease: a meta-analysis

OBJECTIVES

The purpose of this study was to assess the association between anxiety and risk of coronary heart disease (CHD).

BACKGROUND

Less research has focused on the association of anxiety with incident CHD in contrast to other negative emotions, such as depression.

METHODS

A meta-analysis of references derived from PubMed, EMBASE, and PsycINFO (1980 to May 2009) was performed without language restrictions. End points were cardiac death, myocardial infarction (MI), and cardiac events. The authors selected prospective studies of (nonpsychiatric) cohorts of initially healthy persons in which anxiety was assessed at baseline.

RESULTS

Twenty studies reporting on incident CHD comprised 249,846 persons with a mean follow-up period of 11.2 years. Anxious persons were at risk of CHD (hazard ratio [HR] random: 1.26; 95% confidence interval [CI]: 1.15 to 1.38; p < 0.0001) and cardiac death (HR: 1.48; 95% CI: 1.14 to 1.92; p = 0.003), independent of demographic variables, biological risk factors, and health behaviors. There was a nonsignificant trend for an association between anxiety and nonfatal MI (HR: 1.43; 95% CI: 0.85 to 2.40; p = 0.180). Subgroup analyses did not show any significant differences regarding study characteristics, with significant associations for different types of anxiety, short- and long-term follow-up, and both men and women.

CONCLUSIONS

Anxiety seemed to be an independent risk factor for incident CHD and cardiac mortality. Future research should examine the association between anxiety and CHD with valid and reliable anxiety measures and focus on the mechanisms through which anxiety might affect CHD.

Associations of depressive symptoms, trait hostility, and gender with C-reactive protein and interleukin-6 response after emotion recall

OBJECTIVE

To examine the effects of depressive symptoms and hostility on changes in C-reactive protein (CRP) and interleukin (IL)-6 in response to an acute laboratory stressor. Depressive symptoms moderate the effect of trait hostility on circulating levels of CRP and IL-6.

METHODS

The study included 307 men and 218 women, affording the opportunity to examine moderation by gender. Regression analyses were performed to examine depressive symptoms, hostility ratings, gender, and their interactions as predictors of CRP and IL-6 response to an emotion recall task. Analyses were adjusted for age, race, body mass index, and prerecall task levels of either CRP or IL-6.

RESULTS

The product term for Depressive Symptoms x Hostility x Gender was not significantly related to CRP nor IL-6 response. However, Depressive Symptoms x Hostility did interact to predict CRP response (p = .002); those with the combination of high symptoms of depression and hostility had the largest CRP response. The Depressive Symptoms x Gender interaction was also a predictor of both CRP (p = .001) and IL-6 (p = .04) response; for each inflammatory marker, depressive symptoms were significantly associated with higher CRP response in women, as compared with men. Hostility did not moderate depressive symptoms, nor gender for IL-6.

CONCLUSIONS

Our findings extend prior research by suggesting that, broadly speaking, depression is related to inflammatory markers; however, this relationship seems complex. Depression seems to be related to inflammation more strongly among hostile individuals and more strongly among women than among men.

Social isolation and depression predict 12-month outcomes in the "waiting for a new heart study"

BACKGROUND

Identification of modifiable psychosocial characteristics related to survival of heart transplant (HTx) candidates is needed to prevent clinical deterioration and improve prognosis.

METHODS

A multi-site, prospective study was conducted with 318 HTx candidates (18% female, 82% male; 53 +/- 11 years of age) newly listed at 17 hospitals in Germany and Austria. Baseline demographic and psychosocial characteristics were assessed by questionnaires. Indicators of disease severity (Heart Failure Survival Score, creatinine, cardiac index) and 12-month outcomes (death, high-urgency HTx, elective HTx, de-listing due to deterioration or improvement) were provided by Eurotransplant.

RESULTS

By 12 months, 33 patients died, 83 received an urgent HTx, 30 underwent an elective HTx, and 9 were de-listed due to clinical deterioration and 17 due to improvement. All measures of disease severity predicted outcomes. Controlling for disease severity, the number of social contacts contributed significantly to outcomes, favoring those who improved. Comparing socially isolated patients (<4 social contacts/month) who also had depression scores in the clinical range (high psychosocial risk group; n = 37) to those with >10 social contacts/month without depression (low psychosocial risk group; n = 47) revealed significant differences in the distribution of outcome frequencies (chi-square = 11.2, df = 4, p < 0.04). The high psychosocial risk group was more likely to have died/deteriorated and less likely to have improved than the low psychosocial risk group.

CONCLUSIONS

Regardless of disease severity, socially isolated HTx candidates who are also depressed may be at increased risk for clinical deterioration and mortality, indicating a need for psychosocial intervention.

Psychological predictors of prognosis in chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is an increasingly prevalent condition with high mortality and morbidity rates. This review examines the role of depression, anxiety, and social support on prognosis in CHF.

METHOD AND RESULTS

Prospective studies that examined mortality as an outcome, and assessed depression, anxiety, or social support as associates were included. Methodological qualities were evaluated. In total, 25 studies were identified. Concerning depression, 6 of 15 studies of inpatients, 10 of 11 studies of outpatients, and 1 study of a mixed sample found associations between depression and prognosis, with greater associations rendered by depressive symptomatology in outpatients. Anxiety was not associated with prognosis in one inpatient study and one outpatient study. There was a univariable trend in one outpatient study for anxiety to be associated with prognosis. In two of six studies of inpatients and in two of four studies of outpatients, social support was associated with prognosis. On the basis of methodological quality, studies on depression showed mixed results, no conclusions could be drawn for anxiety because this association was not investigated soundly, and the quality of the social network was not associated with outcome.

CONCLUSION

Evidence suggests that depressive symptoms and social support might be associated with prognosis in CHF outpatients, independently of biomedical risk factors. With respect to anxiety, no conclusions can be drawn. Future studies are warranted to disentangle associations with psychological factors.

Self-reported symptoms of sleep disturbance and inflammation, coagulation, insulin resistance and psychosocial distress: evidence for gender disparity

Self-reported ratings of sleep quality and symptoms of poor sleep have been linked to increased risk of coronary heart disease (CHD), Type 2 diabetes and hypertension with recent evidence suggesting stronger associations in women. At this time, the mechanisms of action that underlie these gender-specific associations are incompletely defined. The current study examined whether gender moderates the relation of subjective sleep and sleep-related symptoms to indices of inflammation, coagulation, insulin resistance (IR) and psychosocial distress, factors associated with increased risk of cardiovascular and metabolic disorders. Subjects were 210 healthy men and women without a history of sleep disorders. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality and frequency of sleep symptoms. In multivariate-adjusted models, overall poor sleep quality, more frequent problems falling asleep (>2 night/week) and longer periods to fall asleep (>30 min) were associated with greater psychosocial distress, higher fasting insulin, fibrinogen and inflammatory biomarkers, but only for women. The data suggest that subjective ratings of poor sleep, greater frequency of sleep-related symptoms, and longer period of time to fall asleep are associated with a mosaic of biobehavioral mechanisms in women and that these gender-specific associations have direct implications to recent observations suggesting gender differences in the association between symptoms of poor sleep and cardiovascular disease.

Bridging human and animal research: a comparative approach to studies of personality and health

This article evaluates a comparative approach to personality and health research. We (1) review evidence showing that personality exists and can be measured in animals, (2) illustrate the benefits of animal studies for human personality research, (3) illustrate the benefits of human studies for animal personality research, and (4) provide guidelines for making cross-species comparisons. We conclude that a comparative approach can provide unique insights into personality psychology, especially into research on personality, immunity, and health.

Anxiety disorders and comorbid medical illness

OBJECTIVE

To provide an overview of the role of anxiety disorders in medical illness.

METHOD

The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed.

RESULTS

A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care.

CONCLUSIONS

Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.

Multiple sources of psychosocial disadvantage and risk of coronary heart disease

OBJECTIVES

To examine the co-occurrence of multiple sources of psychosocial disadvantage in association with risk of incident coronary heart disease (CHD). It was hypothesized that increased co-occurring psychosocial disadvantage would be associated with increased risk of CHD in a monotonic fashion. While both social and psychological disadvantage are associated with increased risk of CHD, indicators of psychosocial disadvantage are traditionally examined individually in relationship to CHD. However, multiple sources of psychosocial disadvantage tend to co-occur.

METHODS

Hypotheses were examined using data from the First National Health and Nutrition Examination Survey and its follow-up studies (n = 6913). Indicators of psychosocial disadvantage (education, income, employment, single parenting, marital status, depressive and anxious symptoms) and covariates were derived from baseline interviews and incident CHD from hospital records/death certificates collected over 22 years of follow-up. Hypotheses were evaluated using Cox proportional hazards models.

RESULTS

Results indicated that greater co-occurrence of psychosocial disadvantage conferred increased CHD risk. Relative to no disadvantage, one indicator of psychosocial disadvantage (relative risk (RR) = 1.28; 95% confidence interval (CI) = 1.10-1.48), two to three indicators of psychosocial disadvantage (RR = 1.56; 95% CI = 1.33-1.84), and four or more indicators of psychosocial disadvantage (RR = 2.63; 95% CI = 2.01-3.44) were associated with increased risk of incident CHD. Results persisted in covariate-adjusted models. A significant interaction by gender was observed such that the co-occurrence of psychosocial risk and its association with incident CHD were stronger among women than among men.

CONCLUSIONS

Results indicate the importance of considering patterns of co-occurring psychosocial risk factors in relationship to CHD.