1. Anger and Coronary Heart Disease: Epidemiologic Evidence from the Atherosclerosis Risk in Communities (ARIC) Study Janice E. Williams, PhD, MPH Centers for Disease Control and Prevention

2. The ARIC Study Two research arms –Cohort –Community morbidity/mortality surveillance

3. Types of Anger Anger experience –Transitory state (state anger) –Stable and general predisposition to experience anger (trait anger)

4. Types of Anger Anger expression –Anger in –Anger out –Anger control

5. Trait Anger Subtypes –Temperament –Reaction

6. Anger and CHD Studies Have employed the following study designs to provide evidence of an association – cross-sectional – prospective – laboratory/clinical

7. Anger and CHD: ARIC Study Relationship of overall trait anger and subtypes to –CHD (revascularization procedures, silent MI, acute MI/fatal CHD)

8. Methods 13,000 black and white men and women, aged 48 - 67, free of clinically manifest CHD Completed Spielberger Trait Anger Scale

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

10. 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.

11. 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.

12. 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.

13. Spielberger Trait Anger Scale (continued) I feel infuriated when I do a good job and get a poor evaluation.

14. Trait Anger-Temperament Subscale I am quick tempered. I have a fiery temper. I am a hotheaded person. I fly off the handle.

15. 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.

16. 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.

17. Spielberger Trait Anger Scale Coding –1) Almost never –2) Sometimes –3) Often –4) Almost always

18. Statistical Analyses Means and percentages to describe the population by CHD risk factors. -2 log likelihood tests to assess interactions of covariates with anger.

19. 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.

20. Covariates Age Race Gender Education Waist-to-hip ratio LDL-and HDL-cholesterol Drinking Smoking Diabetes

21. 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

22. Multivariate-adjusted hazard ratios (95% C.I.) for the association between overall trait anger and CHD risk _ _ _ _ _ _ _ _

23. Multivariate-adjusted hazard ratios (95% C.I.) for the association between trait anger-temperament and CHD risk _ _ _ _ _ _ _ _

24. Multivariate-adjusted hazard ratios (95% C.I.) for the association between trait anger-reaction and CHD risk _ _ _ _

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

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

27. S ummary No statistically significant association was observed between trait anger-reaction and CHD.

28. 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.

29. 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.

30. The Mechanism Direct pathophysiological effects via heightened sympathetic arousal and neuroendocrine activation.