Anger proneness predicts coronary heart disease risk: prospective analysis from the atherosclerosis risk in communities (ARIC) study

Association of perceived inequality, relative deprivation and loneliness with the trajectory of anger in university students

OBJECTIVE

To examine the trajectory of anger and its psychosocial predictors (i.e., perceived social inequality, relative deprivation, and loneliness) as well as its association with anxiety and depression.

PARTICIPANTS/METHOD

Students (N = 365) completed an online survey three times over a one-year period.

RESULTS

Three trajectories of anger were identified by growth mixture modeling: low/stable (i.e., a low and stable anger over time; 88.0%), low/increasing (i.e., a low level of anger with an increasing trend; 6.7%), and moderate/decreasing class (i.e., a moderate level of anger with a decreasing trend; 5.3%). A greater perception of relative deprivation, but not of perceived social inequality, was associated with the low/increasing class. A greater level of loneliness was associated with the moderate/decreasing class. Symptoms of depression and anxiety were higher in the moderate/decreasing and low/increasing class than in the low/stable class.

CONCLUSIONS

These results suggest that interventions targeted at anger may benefit from addressing perceptions of relative deprivation and loneliness.

Patient and healthcare professionals' perceived barriers and facilitators to the implementation of psychosocial screening in cardiac practice: A Delphi study

BACKGROUND

Psychosocial risk factors contribute to the incidence and progression of coronary heart disease (CHD). Psychosocial screening may identify individuals who are at risk and aid them with getting appropriate care. To successfully implement psychosocial screening in the cardiology practice, the current study aims to identify key barriers and facilitators to its implementation and evaluate their perceived importance among health care professionals (HCPs) and patients.

METHODS

We took a modified 3-round Delphi study approach to gain insight into key determinants that could either impede or ease implementation. Round 1 gathered data from HCPs (n = 9; cardiologists, medical psychologists, cardiac nurses) and CHD patients (n = 21), which we transcribed verbatim, coded, and processed into unique determinants. In rounds 2 and 3, participants were asked to select the most relevant determinants and rank them based on importance. Subsequently, determinants were classified by implementation level.

RESULTS

Patients were generally more positive towards screening. HCP barriers included time-constraints, disruption of primary activities, and limited knowledge on psychosocial risk and screening, while patient barriers were commonly related to accessibility and patient characteristics (e.g., health literacy, motivation). Facilitators of both groups mainly pertained to the use of the screener and follow-up care, such as increasing the accessibility and the benefits of the screener.

CONCLUSION

Barriers may be targeted by enhancing the effects of the facilitators. Increasing the accessibility to the screener and interventions, improving information provision, and appointing a contact person to oversee the screening process may ease the screening and care process for both patients and HCPs.

Implications of Social Disadvantage Score in Cardiovascular Outcomes and Risk Assessment: Findings From the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Social determinants of health contribute to disparate cardiovascular outcomes, yet they have not been operationalized into the current paradigm of cardiovascular risk assessment.

METHODS

Data from the Multi-Ethnic Study of Atherosclerosis, which includes participants from 6 US field centers, were used to create an index of baseline Social Disadvantage Score (SDS) to explore its association with incident atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality and impact on ASCVD risk prediction. SDS, which ranges from 0 to 4, was calculated by tallying the following social factors: (1) household income less than the federal poverty level; (2) educational attainment less than a high school diploma; (3) single-living status; and (4) experience of lifetime discrimination. Cox models were used to examine the association between SDS and each outcome with adjustment for traditional cardiovascular risk factors. Changes in the discrimination and reclassification of ASCVD risk by incorporating SDS into the pooled cohort equations were examined.

RESULTS

A total of 6434 participants (mean age, 61.9±10.2 years; female 52.8%; non-white 60.9%) had available SDS 1733 (26.9%) with SDS 0; 2614 (40.6%) with SDS 1; 1515 (23.5%) with SDS 2; and 572 (8.9%) with SDS ≥3. In total, 775 incident ASCVD events and 1573 deaths were observed over a median follow-up of 17.0 years. Increasing SDS was significantly associated with incident ASCVD and all-cause mortality after adjusting for traditional risk factors (ASCVD: per unit increase in SDS hazard ratio, 1.15 [95% CI, 1.07-1.24]; mortality: per unit increase in SDS hazard ratio, 1.13 [95% CI, 1.08-1.19]). Adding SDS to pooled cohort equations components in a Cox model for 10-year ASCVD risk prediction did not significantly improve discrimination (P=0.208) or reclassification (P=0.112).

CONCLUSIONS

Although SDS is independently associated with incident ASCVD and all-cause mortality, it does not improve 10-year ASCVD risk prediction beyond pooled cohort equations.

The relationships between trait anger, forgiveness, and subjective well-being during the COVID-19 pandemic: a moderated mediating model under lockdown situation

Although previous studies have found relationships between anger, forgiveness, and well-being, none have examined whether forgiveness mediates the relationship between trait anger and subjective well-being. To address this gap, this study constructed and tested a relevant moderated mediating model. We also considered the moderating effects of the COVID-19 lockdown situation, which has indirectly deteriorated well-being. The participants included 1,274 individuals who were recruited in April 2022. In sum, the results showed negative relationships between the trait anger and forgiveness and well-being, with a positive association between forgiveness and well-being. Moreover, forgiveness mediated the association between trait anger and subjective well-being, whereas the lockdown situation regulated the effects of trait anger on forgiveness and subjective well-being; specifically, forgiveness and well-being were more susceptible to trait anger among individuals under the lockdown situation. These findings suggest that forgiveness mediates the relationship between trait anger and well-being, while trait anger negatively predicts forgiveness and subjective well-being. Furthermore, the lockdown situation increases the negative predictive effects of anger on forgiveness and subjective well-being.

Supplementary information

The online version contains supplementary material available at 10.1007/s12144-023-04500-9.

Information needs, approaches, and case studies in human health risk communication

This article uses ten case studies to illustrate the information needs, various communication approaches, and the communicator's role in explaining environmental health risks from a variety of hazards, to a variety of audiences, over time frames from days to years, using in person consultation, lectures, zooms, and email formats. Events often had a long history before the communication began and may have had a long tail afterward. Audiences may be public officials, companies, workers, communities, or individuals. Each individual may have their own understanding or mental model regarding the hazard, exposure, and risk. The communicator's role or intention may be to reassure an audience that has unrealistic exaggerated concerns or fears or to protect a client if the fears are realistic. Or it may be altruistic to inform a complacent audience to take the risks it faces more seriously. Although risk assessment research has advanced the techniques for communicating abstruse probabilities to audiences with low numeracy, in my experience, audiences are unimpressed by precise-sounding probability numbers, and are more interested in whether exposure is occurring or may occur and how to stop it. Often audiences have reason to be outraged and may be more concerned about punishing wrong doers than about the hazard itself, particularly when the exposure is past and cannot be undone. Thus, there is a difference between discussing the riskiness of a situation (risk communication) and what you are going to do about the situation (risk management). Risk communication is successful when the audience responds as intended, calming down or taking action. These case studies are drawn from a large number of risk communication experiences that I and my Rutgers colleagues have engaged in over the past four decades. Through the 20th century, New Jersey was the most densely industrialized State in United States. New Jersey experienced growth of the chemical and petrochemical industries and the unfortunately profligate disposal of toxic wastes. Having the most Superfund sites of any state is a dubious distinction, but New Jersey also has the most experience in evaluating and responding to these hazards.

Anger frequency and risk of cardiovascular morbidity and mortality

Aims

Anger may increase the risk of cardiovascular diseases (CVDs) but previous findings are inconclusive and large prospective studies are needed. We investigated whether frequency of strong anger is associated with the incidence of specific CVDs and CVD mortality, and if sex, age, and cardiometabolic risk factors modify these associations.

Methods and results

We used data from a population-based cohort of 47 077 Swedish adults (56–94 years of age) who completed questionnaires regarding their experience of anger, lifestyle habits, and health characteristics. Participants were followed for incident cardiovascular outcomes and death up to 9 years through linkage to the Swedish National Patient and Death Registers. Hazard ratios and confidence intervals adjusted for potential confounders were assessed.

In multivariable analyses, frequent episodes of strong anger were associated with an increased risk of heart failure, atrial fibrillation, and CVD mortality [hazard ratios (95% confidence intervals) = 1.19 (1.04–1.37), 1.16 (1.06–1.28), and 1.23 (1.09–1.40), respectively]. The link between anger frequency and heart failure was more pronounced in men and participants with a history of diabetes. No evidence of an independent association of anger frequency with risk of myocardial infarction, aortic valve stenosis, and abdominal aortic aneurysm was found.

Conclusion

Our findings indicate that anger may contribute to the development of specific CVDs and CVD mortality, especially heart failure in men and in those with diabetes.

When Anger Remains Unspoken: Anger and Accelerated Epigenetic Aging Among Stress-Exposed Black Americans

OBJECTIVE

Race-related lifetime stress exposure (LSE) including racial discrimination, trauma, and stressful life events have been shown to contribute to racial health disparities. However, little is known about associations between race-related stressors and premature biological aging that confer the risk of adverse health outcomes. Even less is known about the mechanisms through which race-related stressors may be associated with accelerated aging. Early evidence suggests psychological processes such as anger, and particularly the internalization of anger, may play a role.

METHODS

In a community sample of predominantly low-income Black adults (n = 219; age = 45.91 [12.33] years; 64% female), the present study examined the association of race-related LSE (as defined by exposure to racial discrimination, trauma, and stressful life events) and epigenetic age acceleration through anger expression.

RESULTS

Internalized and externalized anger expression were each significantly associated with LSE and age acceleration. Although LSE was not directly associated with age acceleration (ΔR2 = 0.001, p = .64), we found that greater LSE was indirectly associated with age acceleration through increases in internalized, but not externalized, anger (indirect effect: β = 0.03, standard error = 0.02, 95% confidence interval = 0.003 to 0.08; total effect: β = 0.02, 95% confidence interval = -0.25 to 0.31).

CONCLUSIONS

These results suggest race-related LSE may elicit the internalization of anger, which, along with the externalization of anger, may initiate detrimental epigenetic alterations that confer the risk of adverse health outcomes. These findings lay the groundwork for longitudinal studies of the association between race-related stress and racial health disparities.

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.

Psychosocial factors and subsequent risk of hospitalizations with peripheral artery disease: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND AND AIMS

Psychosocial factors are associated with increased risk of cardiovascular disease (CVD). However, associations with peripheral artery disease (PAD) remain uncharacterized. We aimed to compare associations of psychosocial factors with the risk of PAD and two other major atherosclerotic CVD: coronary heart disease (CHD) and ischemic stroke, in the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS

In 11,104 participants (mean age 56.7 [SD 5.7] years) without a clinical history of PAD and CHD/stroke at baseline (1990-1992), we evaluated four psychosocial domains: depressive/fatigue symptoms by the Maastricht Questionnaire, social support by the Interpersonal Evaluation List, social networks by the Lubben Scale, and trait anger by the Spielberger Scale. PAD was defined as hospitalizations with diagnosis or related procedures. CHD included adjudicated coronary heart disease and stroke included ischemic stroke.

RESULTS

We observed 397 PAD and 1940 CHD/stroke events during a median follow-up of 23.1 years. Higher depressive/fatigue symptoms and less social support were significantly associated with incident PAD (adjusted hazard ratios for top vs. bottom quartile 1.65 [95%CI, 1.25-2.19] and 1.40 [1.05-1.87], respectively). When these factors were simultaneously modeled, only depressive/fatigue symptoms remained significant. Incident CHD/stroke was not associated with either of depressive/fatigue symptoms or social support. Social networks and trait anger were not independently associated with PAD or CHD/stroke.

CONCLUSIONS

Depressive/fatigue symptoms and social support (especially the former) were independently associated with the risk of hospitalizations with PAD but not CHD/stroke in the general population. Our results support the importance of depressive/fatigue symptoms in vascular health and suggest the need of including PAD when studying the impact of psychosocial factors on CVD.

Psychological factors and cardiac repolarization instability during anger in implantable cardioverter defibrillator patients

Background

Evidence indicates that emotions such as anger are associated with increased incidence of sudden cardiac death, but the biological mechanisms remain unclear. We tested the hypothesis that, in patients with sudden death vulnerability, anger would be associated with arrhythmic vulnerability, indexed by cardiac repolarization instability.

Methods

Patients with coronary artery disease (CAD) and an implantable cardioverter defibrillator (ICD; n = 41) and healthy controls (n = 26) gave an anger‐inducing speech (anger recall), rated their current (state) anger, and completed measures of trait (chronic) levels of Anger and Hostility. Repolarization instability was measured using QT Variability Index (QTVI) at resting baseline and during anger recall using continuous ECG.

Results

ICD patients had significantly higher QTVI at baseline and during anger recall compared with controls, indicating greater arrhythmic vulnerability overall. QTVI increased from baseline to anger recall to a similar extent in both groups. In ICD patients but not controls, during anger recall, self‐rated anger was related to QTVI (r = .44, p = .007). Trait (chronic) Anger Expression (r = .26, p = .04), Anger Control (r = −.26, p = .04), and Hostility (r = .25, p = .05) were each associated with the change in QTVI from baseline to anger recall (ΔQTVI). Moderation analyses evaluated whether psychological trait associations with ΔQTVI were specific to the ICD group. Results indicated that Hostility scores predicted ΔQTVI from baseline to anger recall in ICD patients (β = 0.07, p = .01), but not in controls.

Conclusions

Anger increases repolarization lability, but in patients with CAD and arrhythmic vulnerability, chronic and acute anger interact to trigger cardiac repolarization lability associated with susceptibility to malignant arrhythmias.

Association Between Anger and Mortality in Women and Men: A Prospective Cohort Study in a Japanese Community

Background: Anger is a common problem in society, and anger's relationship with mortality, in particular with cardiovascular mortality, has been studied mainly in male western population. There are no prospective studies in Japan, about the association between anger and mortality. Materials and Methods: This study examined the association of anger with all-cause and cause-specific mortality in a Japanese community. Data came from the Takayama Study, which recruited residents aged ≥35 years in 1992 from Takayama City in Gifu, Japan. The current study used information on anger that was obtained from the second survey in 2002. A total of 11,902 healthy participants aged ≥45 years completed a self-administered questionnaire. Anger was assessed using the Spielberger Trait Anger Scale. Results: The main causes of deaths during the follow-up period from 2002 to 2013 were 460 for neoplasm, 254 for cardiovascular, and 435 for other causes. After adjusting for potential confounders, we found a significant positive association between the trait anger score and the risk of cardiovascular mortality for women, with a hazard ratio for high versus low score of trait anger of 1.81 (95% confidence interval 0.91-3.63, p for trend = 0.04), but not for men. Conclusions: Data suggest that for Japanese women, high trait anger score may be associated with an increased risk of cardiovascular mortality. Potential gender differences in the association between trait anger and mortality should be further studied from the cultural context.

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.

Personality Traits in Patients with Myocardial Infarction with Nonobstructive Coronary Arteries

OBJECTIVE

The purpose of this study was to describe type A behavior pattern and trait anger in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) and compare them with patients with coronary heart disease and healthy controls. Type A behavior pattern and anger have been linked to coronary heart disease in previous studies. This is the first study to assess type A behavior pattern and trait anger in MINOCA patients.

METHODS

One hundred MINOCA patients, consecutively recruited during 2007-2011 at 5 coronary care units in Stockholm, were matched for sex and age to 100 coronary heart disease patients and 100 healthy controls. All participants completed the Bortner Rating Scale to quantify type A behavior pattern and the Spielberger Trait Anger Scale to quantify anger 3 months after the acute event.

RESULTS

MINOCA patients' Bortner Rating Scale score was 70.9 ± 10.8 (mean ± SD) and Spielberger Trait Anger Scale score was 14 (12-17) (median; interquartile range). Coronary heart disease patients' Bortner Rating Scale score was 70.5 ± 10.2 and Spielberger Trait Anger Scale score was 14 (12-17). Healthy controls' Bortner Rating Scale score was 71.9 ± 9.1 and Spielberger Trait Anger Scale score was 13 (11-16).

CONCLUSION

We found no significant differences in Bortner Rating Scale score and Spielberger Trait Anger Scale score among MINOCA, coronary heart disease patients, and healthy controls, regardless of whether total scores, subscales, or cutoffs were used to classify type A behavior pattern and trait anger. However, we cannot exclude the existence of an occasional episode of anger or mental stress in relation to the coronary event. This is the first study to assess type A behavior pattern and trait anger in patients with MINOCA, and future studies need to confirm the current findings before any firm conclusions can be made.

Psychosocial Factors Associated with Subclinical Atherosclerosis in South Asians: The MASALA Study

South Asians have the highest rates of premature atherosclerotic cardiovascular disease amongst all ethnic groups in the world; however this risk cannot be fully explained by traditional risk factors. Participants from the Mediators of Atherosclerosis in South Asians Living in America Study were included in this cross-sectional analysis. The purpose of this study was to investigate the association of psychosocial factors (including anger, anxiety, depressive symptoms, current and chronic stress, and everyday hassles) with carotid intima-media thickness (CIMT). Three multivariate models were examined to evaluate the association between the psychosocial factors and CIMT. Findings suggest that the impact of psychosocial factors on subclinical atherosclerosis is differential for South Asian men and women. For men, anxiety and depression were associated; while for women, stress was associated with common carotid intima media thickness, independent of traditional CVD risk factors, diet and physical activity.

An Investigation of Treatment Engagement Among Returning Veterans With Problematic Anger

Anger is a commonly reported problem among returning veterans, yet little attention has been devoted to studying treatment engagement among veterans who report anger problems but do not have posttraumatic stress disorder (PTSD). This study compares Iraq-Afghanistan veterans with anger/no PTSD (n = 159) to others reporting significant PTSD symptoms (n = 285) and those reporting neither anger nor PTSD (n = 716) on rates of treatment utilization, perceived barriers to treatment, and preferences for care. Relative to the PTSD group, the anger/no-PTSD group was significantly less likely to have received mental health treatment in the last year, despite endorsing barriers to treatment at a lower rate. Furthermore, the anger/no-PTSD group endorsed fewer preferences than the PTSD group. Results suggest that the anger/no-PTSD group is a unique subgroup that may be less likely to identify a need for treatment. Implications are discussed.

Association of anger proneness, depression and low social support with peripheral arterial disease: the Atherosclerosis Risk in Communities Study

There is mounting evidence to suggest that psychosocial factors, including anger proneness, depression and social isolation, are risk factors for cardiovascular disease. Nevertheless, evidence relating these factors to peripheral arterial disease (PAD) and intermittent claudication remains sparse. Using data from the Atherosclerosis Risk in Communities Study, we analyzed the relationship of psychosocial variables (Spielberger anger score, depression score from the Maastricht questionnaire, and a perceived social support scale) at study visit 2 with incident PAD (ankle-brachial index ≤0.9; a hospital discharge diagnosis of PAD, leg amputation, or leg revascularization procedures; or intermittent claudication). In 12 965 middle-aged adults with no prior history of PAD, 854 developed PAD over a mean follow-up time of 9.7 years, yielding an incidence rate of 6.8 per 1000 person years. A modest, monotonic dose-response, positive association between anger proneness and incident PAD was observed in a multivariable model: relative risk (RR) = 1.15 (95% confidence interval (CI) 0.99-1.38) in the moderate anger group and RR = 1.38 (95% CI 1.08-1.76) in the high anger group, compared with the low anger group. When compared with a low level of depressive symptoms, moderate and high levels of depressive symptoms were also associated with greater incident PAD, with multivariable RRs of 1.20 (95% CI 0.99-1.45) and 1.44 (95% CI 1.19-1.74) respectively. There was no association of perceived level of social support with the occurrence of PAD. Anger proneness and depressive symptoms may be associated with the occur-rence of PAD, as for other atherosclerotic syndromes. These findings may warrant confirmation in further studies and, if causal, could serve as a unique target for a PAD prevention trial.

Hispanic and Female College Students: Evidence for Increased Risk for Cardiac Disease

This article describes subjective and objective risks for cardiovascular disease and the relationship to anger and spirituality among 104 predominately Hispanic college freshman women. Findings indicated a population at risk for metabolic syndrome, hypertension, and diabetes and identified students requiring medical and anger management interventions. Associations between anger, spirituality, and weight suggest a need for further study. University health services are strategically positioned to reach students with lifestyle modification information for cardiac risk reduction.

Anger Experience and Anger Inhibition in Sub-Populations of African American and European American Older Adults and Relation to Circulatory Disease

This study examined ethnic differences in the link between anger experience and anger inhibition and that of circulatory disease (CD). To ascertain the effects of anger inhibition in older persons, health data from groups of African American, African Caribbean, Eastern European and European American adults were collected. Experienced anger and anger inhibition were significant predictors of CD only for the African American group and the relation between experienced anger and CD was mediated by anger inhibition. The data suggest that cultural factors play a role in the development of an angerinhibitory style and that this trait may pose a serious risk factor for circulatory disease.

The Effect of Hostility Reduction on Autonomic Control of the Heart and Vasculature: A Randomized Controlled Trial

OBJECTIVE

Hostility is associated with coronary artery disease. One candidate mechanism may be autonomic nervous system (ANS) dysregulation. In this study, we report the effect of cognitive behavioral treatment on ANS regulation.

METHODS

Participants were 158 healthy young adults, high in hostility measured by the Cook-Medley Hostility and Spielberger Trait Anger scales. Participants were also interviewed using the Interpersonal Hostility Assessment Technique. They were randomized to a 12-week cognitive behavioral treatment program for reducing hostility or a wait-list control group. The outcome measures were preejection period, low-frequency blood pressure variability, and high-frequency heart rate variability measured at rest and in response to and recovery from cognitive and orthostatic challenge. Linear-mixed models were used to examine group by session and group by session by period interactions while controlling for sex and age. Contrasts of differential group and session effects were used to examine reactivity and recovery from challenge.

RESULTS

After Bonferroni correction, two-way and three-way interactions failed to achieve significance for preejection period, low-frequency blood pressure variability, or high-frequency heart rate variability (p > .002), indicating that hostility reduction treatment failed to influence ANS indices.

CONCLUSIONS

Reduction in anger and hostility failed to alter ANS activity at rest or in response to or recovery from challenge. These findings raise questions about whether autonomic dysregulation represents a pathophysiological link between hostility and heart disease.

Trait anger but not anxiety predicts incident type 2 diabetes: The Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVE

Prior studies have shown a bidirectional association between depression and type 2 diabetes mellitus (T2DM); however, the prospective associations of anger and anxiety with T2DM have not been established. We hypothesized that trait anger and anxiety would predict incident T2DM, independently of depressive symptoms.

RESEARCH DESIGN AND METHODS

In the Multi-ethnic Study of Atherosclerosis (MESA), we prospectively examined the association of trait anger and trait anxiety (assessed via the Spielberger Trait Anger and Anxiety Scales, respectively) with incident T2DM over 11.4 years in 5598 White, Black, Hispanic, and Chinese participants (53.2% women, mean age 61.6 years) at baseline without prevalent T2DM or cardiovascular disease. We used Cox proportional hazards models to calculate the hazard ratios (HR) of incident T2DM by previously defined anger category (low, moderate, high), and anxiety quartile, as there were no previously defined categories.

RESULTS

High total trait anger was associated with incident T2DM (HR 1.50; 95% CI 1.08-2.07) relative to low total trait anger. The association was attenuated following adjustment for waist circumference (HR 1.32; 95% CI 0.94-1.86). Higher anger reaction was also associated with incident T2DM (HR=1.07; 95% CI 1.03-1.11) that remained significant after adjusting for potential confounders/explanatory factors. In contrast, trait anxiety did not predict incident T2DM.

CONCLUSIONS

High total trait anger and anger reaction are potential modifiable risk factors for T2DM. Further research is needed to explore the mechanisms of the anger-diabetes relationship and to develop preventive interventions.

Measuring Hostile Interpretation Bias: The WSAP-Hostility Scale

Hostile interpretation biases are central to the development and maintenance of anger, yet have been inconsistently assessed. The Word Sentence Association Paradigm (WSAP) was used to develop a new measure of hostile interpretation biases, the WSAP-Hostility. Study 1 examined the factor structure and internal consistency of the WSAP-Hostility, as well as its relationship with trait anger. Study 2 provided convergent and divergent validity data by examining its associations with trait anger, aggression, depression, and anxiety. Study 3 examined the relationship between WSAP-Hostility and another measure of hostile interpretation biases, as well as another word sentence association measure, in a sample of community participants. Study 4 also used a sample of community participants to offer further evidence of convergent validity. Across the studies, the WSAP-Hostility demonstrated convergent and divergent validity and internal consistency, supporting its use as a measure of hostile interpretation biases.

Management of Coronary Artery Disease in South Asian Populations: Why and How to Prevent and Treat Differently

The South Asian (SA) population constitutes one of the largest ethnic groups in the world. Several studies that compared host and migrant populations around the world indicate that SAs have a higher risk of developing cardiovascular disease (CVD) than their native-born counterparts. Herein, we review the literature to address the role of the screening tools, scoring systems, and guidelines for primary, secondary, and tertiary prevention in these populations. Management based on screening for the CVD risk factors in a high-risk population such as SAs can improve health care outcomes. There are many scoring tools for calculating 10-year CVD risk; however, each scoring system has its limitations in this particular ethnicity. Further work is needed to establish a unique scoring and guidelines in SAs.

Ischemic heart disease in women: a focus on risk factors

Heart disease remains a major contributor to morbidity and mortality in women in the United States and worldwide. This review highlights known and emerging risk factors for ischemic heart disease (IHD) in women. Traditional Framingham risk factors such as hypertension, hyperlipidemia, diabetes, smoking, as well as lifestyle habits such as unhealthy diet and sedentary lifestyle are all modifiable. Health care providers should be aware of emerging cardiac risk factors in women such as adverse pregnancy outcomes, systemic autoimmune disorders, obstructive sleep apnea, and radiation-induced heart disease; psychosocial factors such as mental stress, depression, anxiety, low socioeconomic status, and work and marital stress play an important role in IHD in women. Appropriate recognition and management of an array of risk factors is imperative given the growing burden of IHD and need to deliver cost-effective, quality care for women.

Anger proneness, gender, and the risk of heart failure

BACKGROUND

Evidence regarding the association of anger proneness with incidence of heart failure is lacking.

METHODS AND RESULTS

Anger proneness was ascertained among 13,171 black and white participants of the Atherosclerosis Risk in Communities (ARIC) study cohort with the use of the Spielberger Trait Anger Scale. Incident heart failure events, defined as occurrence of ICD-9-CM code 428.x, were ascertained from participants' medical records during follow-up in the years 1990-2010. Relative hazard of heart failure across categories of trait anger was estimated with the use of Cox proportional hazard models. Study participants (mean age 56.9 [SD 5.7] years) experienced 1,985 incident HF events during 18.5 (SD 4.9) years of follow-up. Incidence of HF was greater among those with high, as compared to those with low or moderate trait anger, with higher incidence observed for men than for women. The relative hazard of incident HF was modestly high among those with high trait anger, compared with those with low or moderate trait anger (age-adjusted hazard ratio for men: 1.44 (95% confidence interval [CI] 1.23-1.69). Adjustment for comorbidities and depressive symptoms attenuated the estimated age-adjusted relative hazard in men to 1.26 (95% CI 1.00-1.60).

CONCLUSIONS

Assessment of anger proneness may be necessary in successful prevention and clinical management of heart failure, especially in men.

Impact of anger on the health-related quality of life of multiple sclerosis patients

Background:

There is evidence of the presence of a disturbed pattern of anger in multiple sclerosis (MS). Emotion changes, including anger, are thought to influence health-related quality of life (HRQoL). However, although deleterious consequences of anger on physical health have been well reported, there are no studies that have analysed the effects of anger on the HRQoL in patients with MS. Our purpose was to assess the extent to which anger impacts on the HRQoL of a cohort of MS patients.

Methods:

One hundred and fifty-seven consecutive MS patients were enrolled in the study. Participants were administered affective trait measures (Beck Depression Inventory, Beck Anxiety Inventory) and anger measures (the Spanish adapted version of the State-Trait Anger Expression Inventory-2). HRQoL was quantified using the Functional Assessment of MS.

Results:

Linear regression analyses revealed that even after controlling for socio-demographic and clinical variables, higher levels of anger expression-in (tendency to handle anger by keeping it inside) independently predicted worse overall HRQoL of MS patients (β = −0.15, p = 0.04). We further found that this relationship was moderated by gender, showing that anger expression-in is a more influential predictor of the HRQoL in women with MS.

Conclusion:

The present study provides evidence that anger negatively affects the HRQoL of MS patients. Our results may have implications for those involved in treating emotional complications of MS and especially regarding psychotherapeutic interventions to improve HRQoL of MS patients.

Effect of anger and trait forgiveness on cardiovascular risk in young adult females

High trait anger is linked to adverse cardiovascular outcomes. A potential antidote to the cardiotoxic influence of anger is trait forgiveness (TF), as it has shown associations with improved blood pressure (BP) and cardiovagal tone regulation in cardiac patients. However, it has yet to be determined if anger and forgiveness independently predict cardiovascular parameters. Trait anger (State-Trait Anger Expression Inventory-2) and TF (Tendency to Forgive Scale) were evaluated in 308 (M = 21.11years ± SD = 2.52) healthy female volunteers allocated to 3 related, yet distinct, studies. Hierarchical multiple regressions tested the incremental contribution of TF after accounting for anger. Study 1 assessed autonomic modulation through beat-to-beat BP and spectral analysis to examine sympathovagal balance and baroreflex functioning. Study 2 used tonometry and pulse wave analysis for aortic hemodynamics. Study 3 assessed 24-hour ambulatory BP and ambulatory arterial stiffness index. Hierarchical models demonstrated that anger was significantly associated with increased sympathovagal tone, increased hemodynamic indices, high ambulatory BPs, and attenuated BP variability and baroreflex. In contrast, TF was associated with more favorable hemodynamic effects (i.e., decreased ventricular work and myocardial oxygen consumption). In conclusion, these results demonstrate divergent cardiovascular effects of anger and forgiveness, such that anger is associated with a more cardiotoxic autonomic and hemodynamic profile, whereas TF is associated with a more cardioprotective profile. These findings suggest that interventions aimed at decreasing anger while increasing forgiveness may be clinically relevant.

Association of depressive symptoms, trait anxiety, and perceived stress with subclinical atherosclerosis: results from the Chicago Healthy Aging Study (CHAS)

OBJECTIVE

Examine the association between multiple psychological factors (depressive symptoms, trait anxiety, perceived stress) and subclinical atherosclerosis in older age.

METHOD

This cross-sectional study included 1101 adults ages 65-84 from the Chicago Healthy Aging Study (CHAS - 2007-2010). Previously validated self-report instruments were used to assess psychological factors. Non-invasive methods were used to assess subclinical atherosclerosis in two regions of the body, i.e., ankle-brachial blood pressure index (ABI) and coronary artery calcification (CAC). Multivariate logistic regression was used to examine the association between each psychological measure and subclinical atherosclerosis, after the adjustment for socio-demographic factors, sleep quality, young adulthood/early middle age and late-life CVD risk status, and psychological ill-being as appropriate.

RESULTS

The burden of major cardiovascular disease risk factors did not significantly differ across tertiles of psychological factors. In multivariate adjusted models, trait anxiety was associated with calcification: those in the second tertile were significantly more likely to have CAC >0 compared to those in the lowest anxiety tertile [OR=1.68; 95% CI=1.09-2.58], but no significant difference was observed for Tertile III of trait anxiety [OR=1.31; 95% CI=0.75-2.27]. No association was seen between psychological measures and ABI.

CONCLUSION

Of several psychological factors, only trait anxiety was significantly associated with CAC.

Psychosocial correlates of atrial natriuretic peptide: a marker of vascular health

BACKGROUND

Psychosocial factors have been associated with cardiovascular outcomes, but few studies have examined the association between psychosocial function and natriuretic peptides.

PURPOSE

The purpose of this study is to determine the predictive value of hostility, anger, and social support in relation to atrial natriuretic peptide (ANP), a marker of vascular health, among middle-aged men.

METHODS

One hundred twenty-one men (mean age = 39.8 years, SD = 4.1) underwent assessments of ANP and completed the Cook-Medley Hostility Scale, the Spielberger State-Trait Anger Scale, and the Interview Schedule for Social Interaction.

RESULTS

Higher levels of hostility (β = 0.22 [95 % CI 0.04, 0.40], P = 0.032) and trait anger (β = 0.18 [95 % CI 0.01, 0.37], P = 0.044) were associated with greater ANP levels. In contrast, higher perceived social support was also associated with lower ANP levels, (β = -0.19 [95 % CI -0.05, -0.41], P = 0.010).

CONCLUSIONS

Psychosocial factors, including hostility, anger, and social support, are associated with varying ANP levels among middle-aged men, independent of cardiovascular and behavioral risk factors.

Genome-wide association study of proneness to anger

Background

Community samples suggest that approximately 1 in 20 children and adults exhibit clinically significant anger, hostility, and aggression. Individuals with dysregulated emotional control have a greater lifetime burden of psychiatric morbidity, severe impairment in role functioning, and premature mortality due to cardiovascular disease.

Methods

With publically available data secured from dbGaP, we conducted a genome-wide association study of proneness to anger using the Spielberger State-Trait Anger Scale in the Atherosclerosis Risk in Communities (ARIC) study (n = 8,747).

Results

Subjects were, on average, 54 (range 45–64) years old at baseline enrollment, 47% (n = 4,117) were male, and all were of European descent by self-report. The mean Angry Temperament and Angry Reaction scores were 5.8±1.8 and 7.6±2.2. We observed a nominally significant finding (p = 2.9E-08, λ = 1.027 - corrected p_gc = 2.2E-07, λ = 1.0015) on chromosome 6q21 in the gene coding for the non-receptor protein-tyrosine kinase, Fyn.

Conclusions

Fyn interacts with NDMA receptors and inositol-1,4,5-trisphosphate (IP3)-gated channels to regulate calcium influx and intracellular release in the post-synaptic density. These results suggest that signaling pathways regulating intracellular calcium homeostasis, which are relevant to memory, learning, and neuronal survival, may in part underlie the expression of Angry Temperament.

Psychosocial and cardiac outcomes of yoga for ICD patients: a randomized clinical control trial

BACKGROUND

Because as many as 46% of implantable cardioverter defibrillator (ICD) patients experience clinical symptoms of shock anxiety, this randomized controlled study evaluated the efficacy of adapted yoga (vs usual care) in reducing clinical psychosocial risks shown to impact morbidity and mortality in ICD recipients.

METHODS

Forty-six participants were randomized to a control group or an 8-week adapted yoga group that followed a standardized protocol with weekly classes and home practice. Medical and psychosocial data were collected at baseline and follow-up, then compared and analyzed.

RESULTS

Total shock anxiety decreased for the yoga group and increased for the control group, t(4.43, 36), P < 0.0001, with significant differences between these changes. Similarly, consequential anxiety decreased for the yoga group but increased for the control group t(2.86,36) P = 0.007. Compared to the control, the yoga group had greater overall self-compassion, t(-2.84,37), P = 0.007, and greater mindfulness, t(-2.10,37) P = 0.04, at the end of the study. Exploratory analyses utilizing a linear model (R(2) = 0.98) of observed device-treated ventricular (DTV) events revealed that the expected number of DTV events in the yoga group was significantly lower than in the control group (P < 0.0001). Compared to the control, the yoga group had a 32% lower risk of experiencing device-related firings at end of follow-up.

CONCLUSIONS

Our study demonstrated psychosocial benefits from a program of adapted yoga (vs usual care) for ICD recipients. These data support continued research to better understand the role of complementary medicine to address ICD-specific stress in cardiac outcomes.

Effects of interpretation training on hostile attribution bias and reactivity to interpersonal insult

Research suggests that individuals high in anger have a bias for attributing hostile intentions to ambiguous situations. The current study tested whether this interpretation bias can be altered to influence anger reactivity to an interpersonal insult using a single-session cognitive bias modification program. One hundred thirty-five undergraduate students were randomized to receive positive training, negative training, or a control condition. Anger reactivity to insult was then assessed. Positive training led to significantly greater increases in positive interpretation bias relative to the negative group, though these increases were only marginally greater than the control group. Negative training led to increased negative interpretation bias relative to other groups. During the insult, participants in the positive condition reported less anger than those in the control condition. Observers rated participants in the positive condition as less irritated than those in the negative condition and more amused than the other two conditions. Though mediation of effects via bias modification was not demonstrated, among the positive condition posttraining interpretation bias was correlated with self-reported anger, suggesting that positive training reduced anger reactivity by influencing interpretation biases. Findings suggest that positive interpretation training may be a promising treatment for reducing anger. However, the current study was conducted with a non-treatment-seeking student sample; further research with a treatment-seeking sample with problematic anger is necessary.

Choices: anger and anger management in rehabilitative care

BACKGROUND AND PURPOSE

Violent acts are on rise and rehabilitation providers as caregivers may encounter anger on a daily basis. The purpose of this article is to discuss anger and describe anger management strategies based on behavioral interventions grounded in Choice Theory.

CHOICE THEORY

Applying choice theory to anger is the belief that people are internally, not externally motivated, and that outside events do not make people do anything. Thus, what drives people's anger behaviors are internally developed notions of what is important and satisfying for them.

CLINICAL RELEVANCE AND CONCLUSION

Anger becomes a choice along with its management. Choosing strategies to manage anger are key to reducing the potential for angry emotions to escalate to the point of aggressive and violent acts that threaten caregivers and clients safety. Anger-free environments promote mental/physical health and establish elements of safe living and working environments in a variety of rehabilitative care settings.

Culture moderates the cardiovascular consequences of anger regulation strategy

PURPOSE

This research examined cultural differences in experiential and cardiovascular outcomes of three anger regulation strategies (expression, suppression and reappraisal).

METHODS

Forty-five Chinese and 45 Caucasian females participated in a laboratory experiment in which role play was used to induce anger. During this role play participants were instructed to either express or suppress their feelings or engage in cognitive reappraisal. Emotional experience was measured before and after the role play. Cardiovascular indices were measured continuously during the experiment.

RESULTS

Significant interactions were obtained such that Caucasians showed stronger cardiovascular responses to suppression than expression of anger whereas the opposite was true for Chinese.

CONCLUSIONS

These results demonstrate that physiological consequences of emotion regulation strategies vary by cultural background. Possible reasons as well as implications of these findings are discussed.

Anger, adiposity, and glucose control in nondiabetic adults: findings from MIDUS II

Anger has been linked to cardiovascular disease, but few studies have examined the relationship between anger and type 2 diabetes. The aim was to investigate associations among different indicators of anger expression, adiposity, and nondiabetic glucose metabolism in a national survey of adults. Participants were 939 adults without diabetes in the Midlife in the US study (MIDUS II). Glucose metabolism was characterized by fasting glucose, insulin, insulin resistance, and glycosylated hemoglobin (HbA1c). Spielberger's Anger Expression inventory was used to measure suppressed anger (anger-in), expressed anger (anger-out), and controlled anger (anger-control). We investigated the relationship between anger and glucose metabolism, and whether anger amplified the adverse relationship between body weight distribution (body mass index = BMI and waist-to-hip ratio = WHR) and glucose metabolism. Multivariate-adjusted analyses revealed an association between anger-out and both insulin and insulin resistance. As predicted, anger-in amplified the relationships between BMI and insulin and insulin resistance, while anger-out amplified the association between WHR and insulin and insulin resistance. Low anger-control was associated with higher glucose. None of the three anger measures was significantly associated with HbA1c. Our findings extend previous research on anger as a potential risk factor for type 2 diabetes by demonstrating that anger expression is associated with clinical indicators of glycemic control, especially among those with pre-existing risk due to obesity and high central adiposity.

Mathematical modeling the neuroregulation of blood pressure using a cognitive top-down approach

Background:

The body′s physiological stability is maintained by the influence of the autonomic nervous system upon the dynamic interaction of multiple systems. These physiological systems, their nature and structure, and the factors which influence their function have been poorly defined. A greater understanding of such physiological systems leads to an understanding of the synchronised function of organs in each neural network i.e. there is a fundamental relationship involving sensory input and/or sense perception, neural function and neural networks, and cellular and molecular biology. Such an approach compares with the bottom-up systems biology approach in which there may be an almost infinite degree of biochemical complexity to be taken into account.

Aims:

The purpose of this article is to discuss a novel cognitive, top-down, mathematical model of the physiological systems, in particular its application to the neuroregulation of blood pressure.

Results:

This article highlights the influence of sensori-visual input upon the function of the autonomic nervous system and the coherent function of the various organ networks i.e. the relationship which exists between visual perception and pathology.

Conclusions:

The application of Grakov′s model may lead to a greater understanding of the fundamental role played by light e.g. regulating acidity, levels of Magnesium, activation of enzymes, and the various factors which contribute to the regulation of blood pressure. It indicates that the body′s regulation of blood pressure does not reside in any one neural or visceral component but instead is a measure of the brain′s best efforts to maintain its physiological stability.

Associations of anger, anxiety, and depressive symptoms with carotid arterial wall thickness: the multi-ethnic study of atherosclerosis

OBJECTIVE

Carotid arterial wall thickness, measured as intima-media thickness (IMT), is an early subclinical indicator of cardiovascular disease. Few studies have investigated the association of psychological factors with IMT across multiple ethnic groups and by sex.

METHODS

We included 6561 men and women (2541 whites, 1790 African Americans, 1436 Hispanics, and 794 Chinese) aged 45 to 84 years who took part in the first examination of the Multi-Ethnic Study of Atherosclerosis. Associations of trait anger, trait anxiety, and depressive symptoms with mean values of common carotid artery (CCA) and internal carotid artery (ICA) IMTs were investigated using multivariable regression and logistic models.

RESULTS

In age-, sex-, and race/ethnicity-adjusted analyses, the trait anger score was positively associated with CCA and ICA IMTs (mean differences per 1-standard deviation increment of trait anger score were 0.014 [95% confidence interval {CI} = 0.003-0.025, p = .01] and 0.054 [95% CI = 0.017-0.090, p = .004] for CCA and ICA IMTs, respectively). Anger was also associated with the presence of carotid plaque (age-, sex-, and race/ethnicity-adjusted odds ratio per 1-standard deviation increase in trait anger = 1.27 [95% CI = 1.06-1.52]). The associations of the anger score with thicker IMT were attenuated after adjustment for covariates but remained statistically significant. Associations were stronger in men than in women and in whites than in other race/ethnic groups, but heterogeneity was only marginally statistically significant by race/ethnicity. There was no association of depressive symptoms or trait anxiety with IMT.

CONCLUSIONS

Only one of the three measures examined was associated with IMT, and the patterns seemed to be heterogeneous across race/ethnic groups.

Associations between dimensional personality measures and preclinical atherosclerosis: the cardiovascular risk in Young Finns study

OBJECTIVE

To assess how multidimensional personality-trait theories, such as the Psychobiological Model of Temperament and Character, and the Five-factor Model of Personality, are associated with subclinical atherosclerosis as indicated by carotid intima-media thickness (IMT). The analysis was designed to tolerate non-linear development in which the same personality profiles can have multiple final outcomes and different antecedent profiles can have the same final outcome.

METHODS

605 men and 844 women (average age 31.6year, s.d.=5.0, range=24-39) provided data on IMT and traits of the psychobiological model, 725 men and 1011 women were assessed for IMT and the five-factor model (age 37.7year, s.d.=5.0, range=30-45). Robust multidimensional Hotelling's T(2) statistic was used to detect personality differences between participants with high IMT and others. Model-based clustering method further explored the effect.

RESULTS

Those with a high level of subclinical atherosclerosis within the sample (highest IMT-decile) had a combined higher persistence (i.e., were perseverative or perfectionistic), more disorganized (schizotypal) character, and more antisocial temperamental configuration than others (P=0.019). No effect was found for the five-factor model (P=0.978). Traditional methods that did not account for multidimensionality and nonlinearity did not detect an association.

CONCLUSION

Psychological well-being may have positive effects on health that reduce atherosclerosis in the population as a whole. Increased subclinical atherosclerosis was associated with a profile that combines known risk factors, such as cynical distrust and hostile tendencies. More frequent use of statistical procedures that can cope with non-linear interactions in complex psychobiological systems may facilitate scientific advances in health promotion.

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.

Anxiety disorders, hypertension, and cardiovascular risk: a review

Hypertension, coronary heart disease (CHD), and anxiety disorders all cause substantial morbidity to patients and costs to the healthcare system. Associations between these diseases have been hypothesized and studied for decades. In particular, psychosocial stressors associated with anxiety disorders raise autonomic arousal via the hypothalamic-pituitary axis which increases circulating catecholamines. This heightened arousal is associated with an increased risk of hypertension and a pro-inflammatory state and, consequently, development of coronary heart disease. This association holds across the spectrum of anxiety disorders (generalized anxiety, posttraumatic stress disorder, panic disorder, and obsessive compulsive disorder) and also when controlling for comorbid conditions such as depression and physical ailments. Multiple cross sectional studies reveal a positive association between anxiety and hypertension. These associations are bidirectional, with those with hypertension being more likely to have anxiety and those with anxiety being more likely to have hypertension. However, a few studies have shown no association. Longitudinal studies point to an increased risk of development of hypertension in patients who suffer from anxiety. More convincing studies show links between anxiety symptoms and disorders, including panic disorder and PTSD, and cardiovascular outcomes. Drawing broad conclusions from these studies is challenging, however, given the multiplicity of scales used to measure anxiety disorders. Anxiety, hypertension, and CHD are common conditions seen in primary care, and anxiety may be an important predictor of future CHD outcomes. Better recognition of the association of these conditions and the possible roles of each in development of the other should alert primary care providers to be vigilant in monitoring and treating anxiety, hypertension, and CHD.