London, UK - Anger and hostility were associated with a 19% increase in coronary heart disease (CHD) events in healthy individuals and a 24% increase in risk among those with preexisting CHD, researchers report in the first large, systematic meta-analysis to show significant links between those two mind states and CHD [1].
"The harmful effect of anger and hostility has been widely asserted, but previous reviews have been inconclusive," Dr Yoichi Chida and Dr Andrew Steptoe (both from University College London, UK) write in their review published in the March 17, 2009 issue of the Journal of the American College of Cardiology.
"Intriguingly, the harmful effect of anger and hostility on CHD events in the healthy populations was greater in men than women," the researchers write. In the healthy-population studies, the researchers found a strong association between anger and hostility and CHD in men (HR 1.22, p<0.001),>
"Previous meta-analyses failed to show significant associations of anger and hostility with CHD," Chida told heartwire. Chida added that this report includes several studies published since the last major meta-analytical review.
Chida's review included 21 articles (71 606 individuals) on CHD outcomes in healthy populations and 18 articles (n=8120) of people with preexisting CHD, from studies conducted in Australasia, Europe, and America. Anger and hostility were associated with increased CHD events in the healthy-population studies, with a combined HR of 1.19 (p=0.008), and those emotions were associated with poor prognosis in the population with existing CHD (HR 1.24, p=0.002). In the studies of individuals with baseline CHD, the poor prognosis associated with anger and hostility persisted after researchers fully controlled for basal disease status and treatment, the article states.
Although the body of research investigating the association between anger and hostility and CHD has grown during the past 25 years, several reviews of the literature have produced different findings, possibly because some looked at individual facets of the overall construct, such as hostility alone. Another possible confounder could be the inclusion of cross-sectional, retrospective, and prospective studies in previous reviews, the researchers write in their analysis, which was limited to prospective cohort investigations.
The analysis found that CHD risk appeared to be mediated through high-risk behaviors, with the association between anger/hostility and CHD becoming no longer significant after full adjustment for behavioral factors such as smoking, physical activity, body-mass index, or socioeconomic status.
Small but notable risk
In an accompanying editorial [2], Dr Johan Denollet and Dr Susanne S Pedersen (both from Tilburg University, the Netherlands) point out that while the overall size of the associations between anger and hostility and subsequent CHD reported by Chida et al might seem small, it appears notable when compared with the 11% increased risk associated with von Willebrand factor in the Reykjavik Study [3].
"This meta-analytic review is of high scientific quality and provides us with a reliable estimate of the risk associated with anger/hostility," Denollet told heartwire. "This review has important clinical implications, because it supports the notion that adverse psychological factors do matter in the development and progression of CHD. Moreover, these findings indicate that psychological factors, in this case anger/hostility, start to show their adverse effect after a couple of years, suggesting that these factors are especially of importance in the long run and that more long-term follow-up studies are needed."
Symptoms of anger/hostility should be taken seriously. "Clinicians may consider referring their coronary patients with high levels of anger for behavioral intervention," he said in the interview with heartwire.
Regarding the findings that the association between anger/hostility and CHD appears mediated by lifestyle behaviors and socioeconomic status, Denollet told heartwire, "I think that a number of these unhealthy lifestyles—smoking, overeating—may reflect attempts to downregulate feelings of tension associated with anger/hostility. Socioeconomic status may reflect a vulnerability factor for increased levels of anger/hostility."
One important direction for future research would be the role of emotion-regulation strategies that might moderate the effects of anger and hostility.
"There is some evidence that suppression of anger increases the risk of hypertension and coronary disease and that inhibition of emotion and behavior in general may further increase the risk of stress-related CHD. Future research should more often focus on the interplay between negative emotions and emotion-regulation strategies as a determinant of major coronary events," Denollet said.
"I think we need to be careful to not simply conclude that 'anger is bad for the heart.' After all, anger is a natural emotion that can be very adaptive (eg, as a warning signal), provided that this negative emotion is regulated and used in a socially meaningful and adaptive way," he added.
| Chida receives support from the Kanae Foundation for the Promotion of Medical Science and the Medical Research Council. Steptoe receives support from the British Heart Foundation. Denollet and Pedersen report no disclosures. |
- Chida Y, Steptoe A. The association of anger and hostility with future Coronary Heart Disease. J Am Coll Cardiol 2009; 53:936-946. DOI:10.1016/j.jacc.2008.11.044.
- Denollet J, Pedersen SS. Anger, depression, and anxiety in cardiac patients. J Am Coll Cardiol 2009; 53:947-9.
- Danesh J, Wheeler JG, Hirschfield GM, et al. C-reactive protein and other circulating markers of inflammation in the prediction of coronary heart disease. New Engl J Med 2004; 350:1387-97.
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