Anger and Coronary Heart Disease:

Epidemiologic Evidence from the Atherosclerosis Risk in

Communities (ARIC) Study

Janice E. Williams, PhD, MPHCenters for Disease Control and

Prevention

The ARIC Study

• Two research arms

–Cohort

–Community morbidity/mortality surveillance

Types of Anger

• Anger experience

–Transitory state (state anger)

–Stable and general predisposition to experience anger (trait anger)

Types of Anger

• Anger expression

–Anger in

–Anger out

–Anger control

Trait Anger

• Subtypes–Temperament

–Reaction

Anger and CHD Studies

• Have employed the following study designs to provide evidence of an association– cross-sectional– prospective– laboratory/clinical

Anger and CHD: ARIC Study

• Relationship of overall trait anger and subtypes to

–CHD (revascularization procedures, silent MI, acute MI/fatal CHD)

Methods

• 13,000 black and white men and women, aged 48 - 67, free of clinically manifest CHD

• Completed Spielberger Trait Anger Scale

Methods

• Followed from 1990 - 1995 for the occurrence of CHD (revascularization procedures, silent MI, acute MI/fatal CHD)

Spielberger Trait Anger Scale

• I am quick tempered.

• I have a fiery temper.

• I am a hotheaded person.

• I get angry when I am slowed down by others’ mistakes.

Spielberger Trait Anger Scale (continued)

• I feel annoyed when I am not given recognition for doing good work.

• I fly off the handle.• When I get angry, I say nasty

things.

Spielberger Trait Anger Scale (continued)

• It makes me furious when I am criticized in front of others.

• When I get frustrated, I feel like hitting someone.

Spielberger Trait Anger Scale (continued)

• I feel infuriated when I do a good job and get a poor evaluation.

Trait Anger-Temperament Subscale

• I am quick tempered.

• I have a fiery temper.

• I am a hotheaded person.

• I fly off the handle.

Trait Anger - Reaction Subscale

• I get angry when I am slowed down by others’ mistakes.

• I feel annoyed when I am not given recognition for doing good work.

Trait Anger - Reaction Subscale (continued)

• It makes me furious when I am criticized in front of others.

• I feel infuriated when I do a good job and get a poor evaluation.

Spielberger Trait Anger Scale

• Coding

–1) Almost never

–2) Sometimes

–3) Often

–4) Almost always

Statistical Analyses

• Means and percentages to describe the population by CHD risk factors.

• -2 log likelihood tests to assess interactions of covariates with anger.

Statistical Analyses (continued)

• Proportional hazards regression models to assess anger-CHD association.

• Kaplan-Meier product limit method to assess probabilities of CHD event-free survival.

Covariates

•Age •Race •Gender •Education •Waist-to-hip ratio •LDL-and HDL-cholesterol

•Drinking •Smoking •Diabetes

Results

• Compared to their low-anger counterparts, persons high in trait anger were more likely to:– be smokers and drinkers– be heavier – have less formal education

Multivariate-adjusted hazard ratios (95% C.I.) for the association between

overall trait anger and CHD risk

_

__

__

_

_

_0

1

2

3

4

5

Normo Hyper Normo Hyper

Multivariate-adjusted hazard ratios (95% C.I.) for the association between

trait anger-temperament and CHD risk

0

1

2

3

4

5

Normo Hyper Normo Hyper

_

_ __

_

_ _

_

Multivariate-adjusted hazard ratios (95% C.I.) for the association between

trait anger-reaction and CHD risk

0

1

2

3

4

5

Full Cohort Full Cohort

__

_

_

Summary

• Overall trait anger was positively associated with risk of both combined CHD and of “hard” events (acute MI/fatal CHD) among normotensive individuals.

Summary

• Similarly, trait anger-temperament was positively associated with combined CHD and with “hard” events (acute MI/fatal CHD) among normotensive individuals.

Summary

• No statistically significant association was observed between trait anger-reaction and CHD.

Conclusions

• A fiery temper predisposes middle-aged normotensive persons to a greater risk of CHD than anger aroused in reaction to frustration, criticism, or unfair treatment.

The Mechanism

• High-anger persons, compared to their low-anger counterparts, may be more likely to engage in unhealthy behaviors that place them at risk for CHD.

The Mechanism

• Direct pathophysiological effects via heightened sympathetic arousal and neuroendocrine activation.