Coronary Heart Disease 345physician management of hypothetical patients with chest
pain. Physicians were given six experimental factors
(race, gender, age, type of chest pain, coronary risk factors,
and thallium stress test results) and asked whether they rec-
ommend a cardiac catheterization for each patient. The in-
vestigators found race was an independent predictor of
catheterization referral. A physician•s subconscious bias may
cause this disparity, thus it is important to train physicians on
issues such as racial stereotypes and how they effect diag-
noses and referrals.
Summary
There is evidence that both acute and chronic stress may ei-
ther promote the development of or trigger CHD events. Key
chronic risk factors include job strain, low social support, and
lack of economic resources (i.e., low socioeconomic status).
Recent evidence also suggests that anger is an emotion that
may potentially trigger cardiac events such as myocardial in-
farction and ischemia. Two other very important variables,
race and gender, have gained much attention as data mounts
that both may play complex roles in the development of car-
diac disease.
Individual Characteristics as CAD Risk Factors
In addition to environmental and social variables, several
speci“c individual behavioral traits have been studied as pos-
sible CHD risk factors. These include hostility and Type A
behavior, and depression and related traits.
Type ABehavior: Current Status
In 1959, cardiologists Friedman and Rosenman identi“ed a
•coronary-proneŽ personality type characterized by hostility,
an overly competitive drive, impatience, and vigorous speech
characteristics. They termed this Type A behavior pattern (as
opposed to Type B, a behavior pattern with a relatively easy-
going style of coping). Friedman and Rosenman (1974) de-
veloped a structured interview to measure Type A behavior
based on observable behaviors and the manner in which
subjects responded to questions. This objective interview
showed a stronger relationship to risk of developing coronary
disease as opposed to previously used scales which relied
heavily on a subjects• self-report of their own behavior
(Matthews & Haynes, 1986).
Interest in Type A behavior accelerated after the Western
Collaborative Group Study (WCGS), which tracked over
3,000 men for 8.5 years (Rosenman et al., 1975). The re-
searchers found that Type A behavior was associated with a
twofold increased risk of developing CAD and a “vefold in-
creased risk of recurrent MI. In the 1980 Framingham Heart
Study, Haynes, Feinleib, and Kannel (1980) found Type A be-
havior to be a predictor of coronary disease among men in
white collar occupations and in women working outside of
the home.
Since the 1980s, however, most studies have not been able
to verify a relationship between Type A behavior and CAD
risk. The Multiple Risk Factor Intervention Trial (MRFIT)
was primarily designed to assess whether interventions to
modify coronary risk factors such as high cholesterol levels,
smoking, and high blood pressure in high-risk men would
reduce the likelihood of coronary disease in these individu-
als. Type A behavior was measured in over 3,000 of the
participants who were then followed for seven years. The re-
searchers found no relationships between the behavior pat-
tern and incidence of a “rst heart attack (Shekelle, Hulley, &
Neaton, 1985), which has clearly cast doubt on the validity of
initial studies that found positive relationship between Type
A behavior and coronary disease. Many researchers now be-
lieve that not all components of Type A behavior are patho-
genic, but rather speci“c personality traits such as hostility
and anger may be associated with coronary disease.Anger and HostilityResearch suggests that hostility and anger, which are both
major components of Type A behavior that have been fre-
quently correlated with coronary disease risk. A reanalysis of
data from the WCGS described earlier showed that •potential
for hostility,Ž vigorous speech, and reports of frequent
anger and irritation were the strongest predictors of coronary
disease (Matthews, Glass, Rosenman, & Bortner, 1977).
Likewise, the MRFIT study, which did not “nd that Type A
behavior was predictive of coronary disease, found an associ-
ation of hostility with coronary disease risk (Dembroski,
MacDougall, Costa, & Grandits, 1989).
Hostility is a broad concept that encompasses traits such as
anger (an emotion), and cynicism and mistrust (attitudes). It is
also important to note the difference between the experience
of hostility, a subjective process including angry feelings or
cynical thoughts, and the expression of hostility, a more ob-
servable component which includes acts of verbal or physical
aggression (Siegman, 1994). These overt, expressive aspects
of hostility have generally been found to have a greater corre-
lation with coronary heart disease, including con“rmed my-
ocardial infarction (Miller, Smith, Turner, Guijarro, & Hallet,
1996) even after controlling for other risk factors.
The Cook and Medley Hostility Inventory (Cook &
Medley, 1954), which measures hostile attitudes such as