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CLINICAL RESEARCH: PSYCHOLOGICAL FACTORS AND CAD

The Association of Anger and Hostility With Future Coronary Heart Disease

A Meta-Analytic Review of Prospective Evidence

Psychobiology Group, Department of Epidemiology and Public Health, University College London, London, United Kingdom

Manuscript received July 14, 2008; revised manuscript received November 25, 2008, accepted November 25, 2008.

^_* Reprint requests and correspondence: Dr. Yoichi Chida, Psychobiology Group, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, United Kingdom (Email: y.chida{at}ucl.ac.uk).

Objectives: This review aimed to evaluate the association between anger and hostility and coronary heart disease (CHD) in prospective cohort studies using quantitative methods.

Background: The harmful effect of anger and hostility on CHD has been widely asserted, but previous reviews have been inconclusive.

Methods: We searched general bibliographic databases: MEDLINE, PsycINFO, Web of Science, and PubMed up to November 2008. Two reviewers independently extracted data on study characteristics, quality, and estimates of associations.

Results: There were 25 studies (21 articles) investigating CHD outcomes in initially healthy populations and 19 studies (18 articles) of samples with existing CHD. Anger and hostility were associated with increased CHD events in the healthy population studies (combined hazard ratio [HR]: 1.19; 95% confidence interval [CI]: 1.05 to 1.35, p = 0.008) and with poor prognosis in the CHD population studies (HR: 1.24; 95% CI: 1.08 to 1.42, p = 0.002). There were indications of publication bias in these reports, although the fail-safe numbers were 2,020 and 750 for healthy and disease population studies, respectively. Intriguingly, the harmful effect of anger and hostility on CHD events in the healthy populations was greater in men than women. In studies of participants with CHD at baseline that controlled fully for basal disease status and treatment, the association of anger and hostility with poor prognosis persisted.

Conclusions: The current review suggests that anger and hostility are associated with CHD outcomes both in healthy and CHD populations. Besides conventional physical and pharmacological interventions, this supports the use of psychological management focusing on anger and hostility in the prevention and treatment of CHD.

Key Words: aggression • CHD-prone personality • hostility • meta-analysis • prospective study

Abbreviations and Acronyms   AX = Spielberger anger expression scale   CHD = coronary heart disease   CI = confidence interval   CMHS = Cook-Medley hostility scale   HR = hazard ratio   MMPI = Minnesota Multiphasic Personality Inventory   RR = relative risk   TAS = Spielberger trait anger scale

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