Anger / Distress and Heart Disease by Anthony Ocana

Chuck is a 59 year-old helicopter pilot, self-described as a type A personality, who works in the forestry industry on Vancouver Island. He was just released from hospital after having a heart attack last week. His father died early of heart disease and his wife wonders if Chuck’s depression and bad temper is increasing his risk of a another cardiac event. 

Studies show that people with depression are approximately three times more likely than the general population to suffer from coronary artery disease (CAD). Depression is also considered as a significant risk factor for coronary artery disease. Tennant C, McLean L. The impact of emotions on coronary heart disease risk. J Cardiovasc Risk 2001 Jun;8(3):175-83
In these patients, the presence of major depressive disorder was the best single predictor of cardiac events during the 12 months following diagnosis. Significantly, the risk of death 6-months after a heart attack has been shown to be higher in depressed patients than in non-depressed patients. Sheps DS, Sheffield D. Depression, anxiety, and the cardiovascular system: the cardiologist's perspective. J Clin Psychiatry 2001;62 Suppl 8:12-6; discussion 17-8. 

Five years ago, if you would have told a group of cardiologists that coronary heart disease was a psychosomatic illness, they would have laughed you right out of the room. However, the evidence linking emotional disturbances to coronary heart disease is now robust.  

While the classic Type A behavior pattern is no longer considered to predict cardiac deaths, specific emotional components of the type A behavior, such as anger, irritation, impatience and hostility increasingly appear to have an impact on both the slow development of coronary artery disease (CAD) and the incidence of sudden heart attacks. Ketterer MW, Denollet J, Goldberg AD, McCullough PA, John S, Farha AJ, Clark V, Keteyian S, Chapp J, Thayer B, Deveshwar S. The big mush: psychometric measures are confounded and non-independent in their association with age at initial diagnosis of Ischaemic Coronary Heart Disease J Cardiovasc Risk 2002 Feb;9(1):41-8. 

Chang PP, Ford DE, Meoni LA, Wang NY, Klag MJ. Anger in young men and subsequent premature cardiovascular disease: the precursors study. Arch Intern Med 2002 Apr 22;162(8):901-6. 

Besides the known physical stresses that can trigger heart attacks in untrained persons such as heavy exertion, sexual activity, cocaine use and poor air quality and. Emotional disturbances can be just as toxic. Emotional disturbances may originate from interaction between the individual and the environment, or from within the individual. External stressors include earthquakes, financial pressures and job strain. Internal distress may manifest itself as sadness, anxiety, anger, or hostility. All have been shown in prospective studies to have adverse effects on the development of coronary artery disease. 

High depression scores were associated with a nearly three-fold risk of smoking and approximately four times greater risk of being overweight and having high low-density lipoprotein cholesterol concentration, even after adjustment for other variables. Rutledge T, Reis SE, Olson M, Owens J, Kelsey SF, Pepine CJ, Reichek N, Rogers WJ, Merz CN, Sopko G, Cornell CE, Matthews KA. Psychosocial variables are associated with atherosclerosis risk factors among women with chest pain: the WISE study. Psychosom Med 2001 Mar-Apr;63(2):282-8. 

The short-term effects of acute stress can precipitate the onset of acute myocardial infarction and other cardiovascular events. Mittleman MA. Epidemiologic perspective on the role of psychosocial factors. Ital Heart J 2001 Dec;2(12):887-9.
After the Hanshin-Awaji earthquake in Japan, there were increases of blood pressure and deaths from myocardial infarction that persisted for several months. Ogawa K, Tsuji I, Shiono K, Hisamichi S Increased acute myocardial infarction mortality following the 1995 Great Hanshin-Awaji earthquake in Japan. Int J Epidemiol 2000 Jun;29(3):449-55. 

Job strain, defined as a combination of low control, low reward and high demands at work, has been associated with increased coronary heart disease outcomes. Netterstrom B, Nielsen FE, Kristensen TS, Bach E, Moller L. Relation between job strain and myocardial infarction: a case-control study. Occup Environ Med 1999 May;56(5):339-42. 

A common link between external stressors and internal distress is the perceived loss of control over one's environment. Pickering TG Mental stress as a causal factor in the development of hypertension and cardiovascular disease. Curr Hypertens Rep 2001 Jun;3(3):249-54.  

The Initial studies on stress and heart disease were mostly done on men, but newer studies show that  women reporting high levels of mental stress were more than twice as likely to die from stroke and heart disease than women reporting low stress levels, over the following 8 years, even when they did not have other risk factors, according to Dr. Hiroyaso Iso and colleagues from the University of Tsukuba in Ibaraki-ken, Japan, in the August 13th issue of Circulation: Journal of the American Heart Association.

The strongest association is between anger and heart attacks.  Researchers found that heart attack risk was two times greater during the two hours after an angry episode Moller J, Hallqvist J, Diderichsen F, Theorell T, Reuterwall C, Ahlbom A. Do episodes of anger trigger myocardial infarction? A case-crossover analysis in the Stockholm Heart Epidemiology Program (SHEEP). Psychosom Med 1999 Nov-Dec;61(6):842-9.

In another study, researchers found that fatal heart attacks were two to three times more likely in those with the highest anger scores. Williams JE, Paton CC, Siegler IC, Eigenbrodt ML, Nieto FJ, Tyroler HA Anger proneness predicts coronary heart disease risk: back of the from the atherosclerosis risk in communities (ARIC) study. Circulation 2000 May 2;101(17):2034-9 .

This may occur by many different mechanisms simultaneously: 

Anger increases muscle tension and stress hormones by a factor of eight through emotional or physical stress as part of the fight or flight reaction. This increases blood pressure and makes the blood stickier and more likely to clot. Hevey D, McGee HM, Fitzgerald D, Horgan JH. Acute psychological stress decreases plasma tissue plasminogen activator (tPA) and tissue plasminogen activator/plasminogen activator inhibitor-1 (tPA/PAI-1) complexes in cardiac patients. Eur J Appl Physiol 2000 Nov;83(4 -5):344-8 . 

A recent study, found that over time anger increased the likelihood of thickening of the arteries in middle-aged women. This is likely a secondary effect of anger increasing blood pressure and homocysteine. Homocysteine is an intermediary chemical that our body usually detoxifies (see other article). It is now known that homocysteine damages the lining of arteries and impairs their ability to dilate when needed. 

You might ask, “Is the risk related to being angry in response to stress or having an angry personality?”. A recent study suggests that a strong, angry temperament rather than anger in reaction to criticism, frustration, or unfair treatment places normotensive, middle-aged persons at increased risk for cardiac events and may confer a CAD risk similar to that of hypertension. Williams JE, Nieto FJ, Sanford CP, Tyroler HA. Effects of an angry temperament on coronary heart disease risk: The Atherosclerosis Risk in Communities Study. Am J Epidemiol 2001 Aug 1;154(3):230-5.

 
Chuck, like his father, had an explosive temper.  This begs the question is anger hereditary or learned? It is probably both hereditary and learned. Interestingly, scientists have recently isolated the abnormal gene that causes angry people to have difficulty with self soothing and depression. Fumeron F, Betoulle D, Nicaud V, Evans A, Kee F, Ruidavets JB, Arveiler D, Luc G, Cambien F. Serotonin transporter gene polymorphism and myocardial infarction: Etude Cas-Temoins de l'Infarctus du Myocarde (ECTIM). Circulation 2002 Jun 25;105(25):2943-5.

 Currently, much of medicine is practiced under the assumption that the head and the heart are separate entities. Luckily, Chuck’s cardiologist noticed his lack of interest, social withdrawal and increasingly dark moods while he was still in hospital and made sure that Chuck’s discharge instructions included a referral to a multidisciplinary cardiac rehabilitation program.  While the emphasis in most current cardiac rehabilitation programs is on physical exercise and dietary management, there is a growing tendency by rehabilitation programs to go beyond diet and exercise towards psycho-education aimed at teaching patients how to monitor and manage the "toxic" aspects of negative emotions. Donker FJ. Cardiac rehabilitation: a review of current developments. Clin Psychol Rev 2000 Oct;20(7):923-43.

 Even though he still finds himself triggered to anger, Chuck has cultured an increased awareness of the usual irritations and frustrations that set him off and as a result, he has been able to decrease the intensity and duration of his rage.

 With some luck, the current research findings and the positive outcomes experienced by people like Chuck, will stimulate the growing trend toward the integration of mental health and cardiology. This has been a good thing for Chuck. It’s also good for society. We can no longer afford to do it any other way.