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Impact of social support, cynical hostility and anger expression on progression of coronary atherosclerosis
Abstract
This prospective cohort study of patients with coronary artery disease (CAD) sought to determine the impact of social support, anger expression and cynical hostility on progression of coronary atherosclerosis as shown by angiography.
Low social support, high levels of expressed anger and cynical hostility are correlated to increased CAD morbidity and mortality. However, the impact of these factors, alone or together, on progression of human coronary atherosclerosis is unknown.
Of 223 patients with CAD documented by standardized angiography at baseline, 162 had a second angiogram after two years. An expert panel who had no knowledge of the patients' characteristics evaluated the films pairwise to determine disease progression. At baseline, all patients were asked to answer three self-report questionnaires: questions concerning emotional social support, the State-Trait-Anger-Expression Inventory (STAXI) and the Cook-Medley cynical hostility scale. Each patient's clinical and laboratory status was followed.
Questionnaires and angiographic follow-up data were available for 150 patients. Bivariate analysis of the psychological variables showed a higher risk of progression only for patients who scored high on STAXI anger-out or low on social support. In the multivariate analysis, when adjusting for confounding variables and examining the interaction between psychological variables, only patients with both high anger-out and low social support were at highly increased risk for progression (odds ratio 30, confidence interval [CI] 5.5 to 165.1; RR 3.19).
Patients with CAD and low emotional social support who express anger outwardly are at a highly increased risk of disease progression, independent of medication or other risk factors.
... A study conducted with 223 patients and published in 2000 sought to identify whether social support, furious expression, and anger were associated with increased CAD morbidity and death. Each patient was given three self-report questionnaires to complete, including emotional and social support items, the State-Trait-Anger-Expression Inventory, and the Cook-Medley scale of negative thoughts about people who are not suitable (Angerer et al. 2000). The patients were observed for a total of 2 years. ...
... After 2 years, 162 of the 223 patients underwent an angiographic follow-up, which was deemed adequate. According to the study's outcome, patients with CAD and limited emotional and social support who express their anger openly might face a significant risk of disease progression (Angerer et al. 2000). ...
Anger is a basic human emotion associated with unpleasant feelings, memories, and behaviors. Anger contributes to a vicious cycle in the lives of affected humans, leading to numerous social, economic, and health concerns. Anger was recognized as a problem and distinguished from “normal anger” back in the eighteenth century. A generalized emotional turmoil was addressed by setting a standard of “love, as opposed to anger.” This was mainly to save the most emotional and dependent members of society, women (wives), and children. A school of thought believed anger and its manifestation was a paranormal activity, and angry people were accused of being demons. Anger is a dependent variable mainly influenced by internal and external factors. Internal factors give rise to anger associated with individual problems, like past experiences, emotional traumas, distorted thinking patterns, brain physiology, and accidental injuries affecting the central neural system (CNS). At the same time, external factors constitute everything that surrounds an individual, except the person itself, including people, friends, co-workers, spouse, and workplace. It is evenly hard to control internal or external factors causing anger; however, one can seek help and manage the expression of anger.
... A study conducted with 223 patients and published in 2000 sought to identify whether social support, furious expression, and anger were associated with increased CAD morbidity and death. Each patient was given three self-report questionnaires to complete, including emotional and social support items, the State-Trait-Anger-Expression Inventory, and the Cook-Medley scale of negative thoughts about people who are not suitable (Angerer et al. 2000). The patients were observed for a total of 2 years. ...
... After 2 years, 162 of the 223 patients underwent an angiographic follow-up, which was deemed adequate. According to the study's outcome, patients with CAD and limited emotional and social support who express their anger openly might face a significant risk of disease progression (Angerer et al. 2000). ...
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are medically unexplained disorders that occur with somatic or psychiatric symptoms presenting during the luteal phase of the menstrual cycle, ending within a few days after the onset of menstruation. Worldwide, the prevalence of PMS is remarkably high, and its causes are still unclear and are multifactorial. This chapter aims to understand better the etiopathogenesis, clinical features, diagnosis, contemporary, and integrative holistic approaches of PMS management. A thorough literature survey from various scientific databases such as Web of Science, ScienceDirect, PubMed, Google Scholar, Scopus, and other databases was retrieved for the evidence connected to premenstrual syndrome, and PMDD was undertaken. The biochemical changes of PMS involve sex steroids, neurotransmitters such as cholecystokinin GABA, serotonin, and regulation of the renin-angiotensin-aldosterone system, genetic vulnerabilities, diet, and lifestyle. The most common symptoms of PMS are affective symptoms (anger outburst, anxiety, depression, confusion, irritability, social withdrawal) or somatic symptoms (headache, breast tenderness, abdominal bloating, and swelling of extremities) that affect the quality of life negatively. Its diagnosis is based on the time of appearance and the type of symptoms in the menstrual cycle. The initial step embraces lifestyle changes and diet regulation, teaching women self-screening, creating awareness about PMS, and methods of coping with stress. Complementary alternative therapies and cognitive behavioral therapy are implemented in the second step. The third step is initiated with pharmacological treatment if the problem continues, and in the fourth step, surgical treatment is applied.
... A study conducted with 223 patients and published in 2000 sought to identify whether social support, furious expression, and anger were associated with increased CAD morbidity and death. Each patient was given three self-report questionnaires to complete, including emotional and social support items, the State-Trait-Anger-Expression Inventory, and the Cook-Medley scale of negative thoughts about people who are not suitable (Angerer et al. 2000). The patients were observed for a total of 2 years. ...
... After 2 years, 162 of the 223 patients underwent an angiographic follow-up, which was deemed adequate. According to the study's outcome, patients with CAD and limited emotional and social support who express their anger openly might face a significant risk of disease progression (Angerer et al. 2000). ...
... Perceived social support (PSS)-the perception of being cared for, esteemed, and part of a mutually supportive social network 11 -is crucial for anger management. High PSS has been suggested to mitigate elevated anger 12,13 and systolic blood pressure, 14 progression of coronary atherosclerosis, 15 and increased body mass index (BMI) and low-density lipoprotein cholesterol to high-density lipoprotein cholesterol (LDL-C=HDL-C) ratio 16 related to anger or hostility. PSS may relieve anger and reduce the risk of stroke associated with anger. ...
... among those with high PSS and high anger expression. 15 A cross-sectional study of 304 male and 367 female healthy Finnish adults aged 18-30 years indicated that PSS weakened the association between anger and atherosclerotic risk factors. PSS significantly interacted with anger relative to BMI and LDL-C=HDL-C ratio in women (P = 0.026 and P = 0.032, respectively). ...
Background: Anger has been suggested as a risk factor for stroke. Perceived social support (PSS) may relieve anger, thus reducing the risk of stroke; however, evidence supporting this is limited. We aimed to examine whether PSS modifies the risk of stroke associated with anger expression.
Methods: A cohort study was conducted among 1,806 community residents aged 40–74 years who received a cardiovascular risk survey including anger expression in 1997. A Cox proportional hazards model was applied to the participants with low and high PSS to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of the risks of total stroke and its subtypes based on total anger expression after adjusting for known stroke risk factors.
Results: The median follow-up duration was 18.8 years, with 51 incident strokes. Among the participants with low PSS, anger expression had a positive association with the total stroke risk: The multivariable HR per SD increment of total anger expression was 1.43 (95% CI, 1.13-1.82). In contrast, no association was identified among those with high PSS. The corresponding HR was 0.83 (95% CI, 0.49-1.40), with a significant interaction between low and high PSS (p = 0.037). Similar associations regarding the risk of ischemic stroke were found.
Conclusions: We found an increased risk of stroke associated with anger expression among the participants with low PSS, but not among those with high PSS. Our results suggest that PSS might mitigate the risk of stroke associated with anger.
... A perceived lack of social support has been implicated as a risk factor for the development and progression of cardiovascular disease (5, 11,12). Social support may influence the seeking of appropriate treatment (10) and is associated with greater quality of life and better physical health (13). ...
Introduction. The aim of the study was to assess the extent to which psychosocial factors (social support and coping strategies) may have a protective role against depression in patients with peripheral arterial disease (PAD). Methods. The design of the study was transversal and included 37 patients with PAD with critical ischemia (32 men, 5 women, mean age = 62.41). They were administered Center for Epidemiologic Studies Depression Scale, Duke-UNC Functional Social Support Questionnaire and COPE inventory. Results. Depressive symptoms were found at 28.6% of the patients. There were low scores of perceived social support at 32.4% of the patients. Depression correlated (p<.001) positively with mental disengagement (r=.791), denial (r=.672), behavioral disengagement (r=.760), restraint (r=.075) and negatively with social support (r= -.879) and positive reinterpretation (r=-.844), active coping (r=-.776), use of emotional support (r=-.624). Discussion. PAD patients experience depression. Is highlighted the buffer role of social support and of active coping strategies in facing a chronic disease. Conclusions. Recognition and evaluation for depression in patients with PAD followed by identifying psychosocial interventions may be useful in improving outcomes of these patients.
... In one cross-sectional study using the 2007-08 National Health and Nutrition Examination Survey (NHANES), lack of social support was associated with poor LS7 metrics (Kieu et al., 2020), while a review study reported that individuals with better social relationships were more likely to achieve or maintain ideal CVH (Cabeza de Baca et al., 2018). Other studies have also shown that low social support was associated with a greater risk of adverse CVD outcomes (Angerer et al., 2000;Barth et al., 2010;Berkman et al., 1992;Blazer, 1982;Freak-Poli et al., 2021;Ikeda et al., 2008;Rozanski et al., 1999;Uchino et al., 2018). Conversely, in one study using MESA data, higher social support was not associated with incident CVD, and cross-sectional studies among Black and Hispanic/Latino adults showed that higher levels of social support were not associated with individual LS7 metrics (e.g., BMI, Table 1 Characteristics of measures at JHS, MASALA, and MESA Exam 1 comparing the included and excluded participants (i.e., participants with no CVH outcome measured at Exam 1). ...
Purpose
Social support may have benefits on cardiovascular health (CVH). CVH is evaluated using seven important metrics (Life's Simple 7; LS7) established by the American Heart Association (e.g., smoking, diet). However, evidence from longitudinal studies is limited and inconsistent. The objective of this study is to examine the longitudinal relationship between social support and CVH, and assess whether psychosocial risks (e.g., anger and stress) modify the relationship in a racially/ethnically diverse population.
Methods
Participants from three harmonized cohort studies – Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America, and Multi-Ethnic Study of Atherosclerosis – were included. Repeated-measures modified Poisson regression models were used to examine the overall relationship between social support (in tertiles) and CVH (LS7 metric), and to assess for effect modification by psychosocial risk.
Results
Among 7724 participants, those with high (versus low) social support had an adjusted prevalence ratio (aPR) and 95% confidence interval (CI) for ideal or intermediate (versus poor) CVH of 0.99 (0.96–1.03). For medium (versus low) social support, the aPR (95% CI) was 1.01 (0.98–1.05). There was evidence for modification by employment and anger. Those with medium (versus low) social support had an aPR (95% CI) of 1.04 (0.99–1.10) among unemployed or low anger participants. Corresponding results for employed or high anger participants were 0.99 (0.94–1.03) and 0.97 (0.91–1.03), respectively.
Conclusion
Overall, we observed no strong evidence for an association between social support and CVH. However, some psychosocial risks may be modifiers. Prospective studies are needed to assess the social support-CVH relationship by psychosocial risks in racially/ethnically diverse populations.
... В недавних исследованиях также были выявлены корреляции между показателями враждебности и смертности у больных с ССЗ. В исследовании P. Angerer было показано, что у лиц с ИБС и внешним проявлением гнева, низкой эмоциональной, социальной поддержкой, повышается риск прогрессирования коронарного атеросклероза [20]. Кроме того, у пациентов с ИМ были обнаружены более высокие показатели враждебности по сравнению с группой здоровых лиц контрольной группы [21]. ...
The review presents the main aspects of the relationship between psychoemotional factors, hostility, anger and cardiovascular diseases. The first chapter describes the main historical stages in the study of this problem, starting from the Middle Ages and ending with fundamental research of the 19-20 centuries. In the second part, the authors demonstrated that hostility/anger are a risk factor for the CVD development and affect the prognosis and course of CVD (hypertension, ischemic heart disease, various cardiac arrhythmias, etc.). In the third chapter, there were studies that found that high rates of hostility/ anger reduced the effectiveness of cardiovascular therapy. In the fourth part, there are the main correlation mechanisms of negative emotions, hostility/anger and the cardiovascular system, carried out through the relationships with the activation of the hypothalamic-pituitary-adrenal, autonomic nervous system, platelet activation, with the changes in the risk factors characteristics etc. In the final chapter, the authors suggested prospects for further study of the problem, probably associated with the assessment of behavioral interventions, pharmacological or complex effects on the severity of hostility/anger to reduce CVD mortality in individuals with high rates of hostility / anger.
... The lack of social support among PAD patients after revascularisation was related to a decrease in quality of life and a decrease in walking ability (Remes et al., 2010). Another study showed that patients who were receiving low social support had increased progression of coronary atherosclerosis (Angerer et al., 2000). PAD patients who have received good social support have better surgery results (Wongkongkam et al., 2019). ...
Aim
The purpose of this study is a comparative analysis of the degree of disease acceptance and social support in patients with peripheral vascular diseases and other medical conditions treated in surgery ward.
Design
A cross-sectional study.
Methods
This cross-sectional study compares disease acceptance and social support in a group of 212 patients with peripheral vascular diseases and other conditions treated in surgery ward. A standardized Acceptance of Illness Scale (AIS) and Social Support Scale were used to collect the research data.
Results
Overall, on the AIS, 14% of patients with surgical diseases and 34% of patients with vascular diseases had a low disease acceptance rate. A high level of support was demonstrated in 41% of study participants with surgically treated diseases and in 17% of participants with vascular diseases.
... It is defined as a cynical, antagonistic, resentful attitude toward others, with negative interactions characterized by sarcasm, impatience, irritability or negativism, 2 and it has been linked with cardiovascular disease since the 1950s. 1,3 Investigators continue to focus on specific pathways and relationships between hostility and coronary artery disease (CAD). [4][5][6] Many inconsistencies in research findings have emerged, generating the need for additional research using robust datasets. ...
Background:
Hostility is associated with greater risk for cardiac disease, cardiac events and dysrhythmias. Investigators have reported equivocal findings regarding the association of hostility with acute coronary syndrome (ACS) recurrence and mortality. Given mixed results on the relationship between hostility and cardiovascular outcomes, further research is critical.
Aims:
The aim of our study was to determine whether hostility was a predictor of ACS recurrence and mortality.
Methods:
We performed a secondary analysis of data (N = 2321) from a large randomized clinical trial of an intervention designed to reduce pre-hospital delay among patients who were experiencing ACS. Hostility was measured at baseline with the Multiple Adjective Affect Checklist (MAACL) and patients were followed for 24 months for evaluation of ACS recurrence and all-cause mortality. We used Cox proportional hazards modeling to determine whether hostility was predictive of time to ACS recurrence or all-cause mortality.
Results:
The majority of patients were married (73%), Caucasian (97%), men (68%), and had a mean age of 67 ± 11 years. Fifty-seven percent of participants scored as hostile based on the established MAACL cut point (mean score = 7.56 ± 3.8). Hostility was an independent predictor of all-cause mortality (p = < 0.039), but was not a predictor of ACS recurrence (p = 0.792).
Conclusion:
Hostility is common in patients with ACS and its relationship to clinical outcomes is important to the design of future interventions to improve long-term ACS mortality.
... For example, the social environment between neighbors affects the psychological and social functions of adults [50]. In one study, it was found that a lower amount of social support led to a higher amount of cynical hostility [51]. Our results showed that the better the environment was, the lower cynical hostility became. ...
Cynical hostility in the workplace has been studied. However, there is still no complete study examining how cynical hostility affects work performance. We examined how work environment impacts presenteeism through the mediation of cynical hostility and how chronic work discrimination moderates the relationship between work environment and cynical hostility among ageing workforces. The psychosocial vulnerability model supplies theoretical support for our model. We analyzed data from a sample of 2926 aging workforces from the Health and Retirement Study. Structural equation modeling (SEM) was used to examine the relationships with a moderated mediation model. In the final SEM model, our results showed that work environment was directly negatively associated with presenteeism. Moreover, cynical hostility was significantly inversely correlated with work environment and positively correlated with presenteeism. We found that the significant indirect effect between work environment and presenteeism can be significantly mediated by cynical hostility. In addition, cynical hostility is more likely to be affected by work environment among ageing workforces with lower levels of chronic work discrimination than those with higher levels. Enterprise, government, and employees themselves should be aware of the impact of presenteeism on ageing workforces with high levels of cynical hostility.
... El SCA es una enfermedad muy compleja con enormes consecuencias psicológicas para la persona, siendo la ansiedad y la depresión algunas de las variables más estudiadas (Farquhar, Stonerock y Blumenthal, 2018;Rutledge, Redwine, Linke y Mills, 2013). A pesar de estos estudios y de las guías cardiológicas de actuación quedan interrogantes (Elosua, 2014;Whelton et al., 2018), principalmente acerca de las relaciones existentes entre las diferentes variables psicológicas implicadas en un SCA (Angerer et al., 2000). ...
Actualmente existen interrogantes acerca del estado psicológico tras un Síndrome Coronario Agudo (SCA). El primer objetivo, a partir de un estudio piloto compuesto por hombres y mujeres, fue evaluar los cambios en las creencias respecto a la utilidad del ejercicio como herramienta de salud psicológica y física. El segundo, a partir de un segundo estudio formado por mujeres, consistió en comparar los cambios en variables psicológicas y su ajuste a la enfermedad así como observar diferencias, tras su paso por un programa de rehabilitación cardiaca que incluye ejercicio físico. Se evaluaron 37 pacientes de ambos sexos en el estudio 1 (m = 59.38 años de edad (dt = 9.80)) y 28 mujeres en el estudio 2 (m = 62.68 años de edad (dt = 10.6)) que presentaron un SCA y a las que se les había realizado un cateterismo diagnóstico con intención terapéutica dentro de los 3 primeros días. Los resultados del estudio piloto indican un cambio en las creencias respecto al ejercicio tras su paso por el programa. Además, el estudio 2, señala que a los 3 meses se muestran cambios intrasujetos en expresión de ira, ajuste a la enfermedad, cuidado de la salud, ámbito profesional, distrés y salud mental.
... Based on the proportion of cases and controls with low social support (39.3 and 60.7, respectively) found in a previous study in a comparable setting, [22] the sample size estimated for the present study was 150 in each group with Annals of Clinical Cardiology ¦ Volume 1 ¦ Issue 1 ¦ January-December 2019 90% confidence interval (CI) and 80% power. Therefore, a total of 150 cases and 150 controls were included in the study. ...
... At first glance, these results appear at odds with research demonstrating the benefits of close others for physical and mental health (Reblin & Uchino, 2008;Robles et al., 2014;Uchino, 2006). However, most prior work has examined social support and health within a general context, or has focused on what happens after acutely stressful health events when patients and support providers are managing ongoing care in their daily environments (Angerer et al., 2000;Wang, Mittleman, & Orth-Gomer, 2005). In contrast, being in an ED and experiencing the acute phase of ACS evaluation and treatment can be distressing for both patients and their close others (Dalteg, Benzein, Fridlund, & Malm, 2011;Edmondson et al., 2014;Edmondson et al., 2013). ...
Objective:
Relationship quality is one of the most consistent psychosocial predictors of physical and mental health. Yet, little research examines relationship types or support within the immediate context of acute health events. We tested the unexplored role that close others play in patients' experience of threat during evaluation for acute coronary syndrome (ACS) in the Emergency Department (ED), as well as the indirect effect of close others on ACS-induced posttraumatic stress disorder (PTSD).
Method:
Participants were 871 patients evaluated for ACS at an urban academic ED (60.86 years old; 54.08% male; 56.37% Hispanic, 19.86% Black, 16.65% White). Threat perceptions were assessed in-ED and median 3 days later. ACS-induced PTSD was assessed median 41 days later using the PTSD checklist cued to a specific stressor. Non-overlapping categories were created representing close others in the ED (i.e., spouse/significant other, child), non-close others (e.g., neighbor), or no one.
Results:
Patients who brought close others recalled experiencing greater threat in the ED: vs. no one, b = 0.11, p = .072; vs. non-close others, b = 0.16, p = .030. There was no direct effect of close others on ACS-induced PTSD; however, recalled threat mediated the effect of close others on development of ACS-induced PTSD, ps < .05.
Conclusions:
Close others were associated with recalling greater threat during ED evaluation, which predicted ACS-induced PTSD. ACS-induced PTSD is associated with medication nonadherence, event recurrence, and mortality, highlighting the need to develop a greater understanding of the impact stressful medical environments have on patients and close others.
... 20 Another study revealed that patients who perceived having low social support had increased 2-year progression of coronary atherosclerosis, as confirmed by coronary angiography. 21 Many studies have demonstrated that depression is related to poor prognosis in patients with established CAD and PAD. Grenon et al 22 reported that depressive symptoms were significantly associated with the prevalence of PAD among patients with CAD at baseline, and modifiable cardiovascular risk factors are partly responsible for this association. ...
Functional recovery, described by walking ability, is one of the significant outcomes for patients with peripheral arterial disease (PAD) after lower extremity bypass. Little is known about associated factors that help to improve this outcome. The purpose of this study was to examine factors associated with functional recovery among patients with PAD after lower extremity bypass, such as postoperative period, social support, and depression. Data were collected in a University Hospital in Bangkok, Thailand. A sample of 77 patients with PAD receiving lower extremity bypass treatment was recruited into the study. The interview questionnaires consisted of demographic characteristics, Medical Outcome Study social survey, Thai Geriatric Depression Scale, and Walking Impairment Questionnaire. Reliability of each instrument was 0.97, 0.87, and 0.92, respectively. Pearson's correlation was performed to identify the factors associated with functional recovery. The mean values of age, postoperative period, and walking ability score were 63.92 years (standard deviation [SD] = 11.21), 4.19 years (SD = 3.52), and 62.52 (SD = 13.83). Functional recovery and social support were significantly associated with depression (r = –0.272, P <.05; r = –0.463, P <.01, respectively). The postoperative period was also significantly associated with social support (r = 0.247, P <.03).In conclusion, psychological factors were significantly related to functional recovery among patients with PAD after lower extremity bypass. Therefore, health-care providers should consider these factors during discharge planning, and screening depression score as baseline should be performed.
... Preliminary evidence for a role of social support on the development of cardiovascular disease can be found in studies utilizing imaging techniques. Several of these studies have shown that social support predicts less underlying atherosclerosis (Angerer, Siebert, et al., 2000;Wang, Mittleman, & Orth-Gomer, 2005). For instance, women with established coronary artery disease who were low in emotional support showed faster disease progression as indexed by angiography over a subsequent 3-year period (Wang, Mittleman, & Orth-Gomer, 2005). ...
Social support is defined as the perceived or actual receipt of social resources (e.g., tangible, emotional) and is one of the most reliable predictors of disease morbidity and mortality. In this chapter, the evidence linking social support to disease is reviewed along with the presentation of a theoretical model which highlights the social, psychological, behavioral, and biological pathways potentially responsible for such links. Important unresolved issues are also raised such as the distinction between perceived and received support, the importance of modeling antecedent processes and change over time, and cultural/technological influences on support processes. Studies attempting to utilize the epidemiological evidence to produce effective support intervention that impact health are also reviewed. Finally, the future of social support research/interventions along with their policy implications is discussed and highlights the tremendous progress in the field and potential impact of social support to help individuals live healthier and happier lives.
... As such, it could be that those high in mastery might use ICTs to increase their health literacy or recruit social network resources to enact positive changes in their lives (Drewelies, Chopik, Hoppmann, Smith, & Gerstorf, 2016;Infurna, Rivers, Reich, & Zautra, 2015;Mancuso, 2008;Schulz & Nakamoto, 2013;Sudore et al., 2006). Likewise, optimism (i.e., a generalized expectation that good things will happen) and cynical hostility (i.e., a general cynicism and mistrust of interpersonal relationships) could be linked to ICT use primarily through the possibility of forming and maintaining close relationships (Angerer et al., 2000;Brummett et al., 2000;Kim, Chopik, & Smith, 2014;Srivastava, McGonigal, Richards, Butler, & Gross, 2006). Although these mechanisms are speculatory, it is likely that there are multiple pathways linking individual difference constructs to ICT use that vary depending on the construct being considered (e.g., need for cognition v. mastery/ optimism) and the aspect of ICT use examined. ...
Given the benefits of information and communication technology (ICT) use in older adulthood, a natural question is which individual difference characteristics predict ICT use and adoption. Research has provided mixed findings drawn from studies that generally focus on a narrow set of ICTs, a narrow set of individual difference constructs, and younger adults. Using data from the 2012 wave of the Health and Retirement Study, we examined 17 individual difference predictors of ICT use among older adults. Need for cognition, perceived mastery, and optimism positively predicted ICT use after controlling for all the constructs simultaneously; cynical hostility also emerged as a negative predictor of ICT use. Further, viewing more benefits of ICT use explained why those high in need for cognition used more ICTs. Directions for future research include examining the processes that link individual differences to ICT use and its subsequent benefits during the second half of life.
... [1][2][3][4] Since Berkman and Syme's seminal paper established the association between social networks and survival, 1 several studies have confirmed this association in a range of populations. 3 5 6 In addition to a lower risk of mortality, greater social integration has been linked with improved subjective well-being 7 8 and immune function 9 10 and reduced risk of depression, 11 disability, 12 13 cardiovascular disease 14 15 and ischaemic heart disease. 16 While there is a general consensus that social networks have a positive effect on survival and other health outcomes, the specific nature of this association remains poorly understood. ...
Having a larger social network has beneficial effects on health and survival in adults, but few studies have evaluated the role of network diversity, in addition to network size. We aim to determine whether social network diversity is associated with mortality, physical function, and disability in a population of older black and white adults. We used data from the Chicago Health and Aging Project, a longitudinal, population-based study of adults aged 65 years and older. We estimated hazard ratios (HRs) of mortality using Cox proportional hazards models (N=6,595), mean difference (b) in physical function using generalized estimating equations (N=4,304), odds ratios (ORs) of disability onset using logistic regression (N=5,318), and relative risk (RR) of disability progression using Poisson regression (N=5,318), associated with network diversity. Models were adjusted for age, gender, race, education, marital status, and health-related variables. In adjusted models, elderly with more diverse social networks had a lower risk of mortality (HR=0.76; 95% CI = 0.62–0.92) and higher physical function at baseline (b=0.85; p<.001) compared to elderly with less diverse networks. Increased diversity in social networks was also associated with lower odds of disability onset (OR=0.58; 95% CI = 0.36–0.91) but not with progression of disability. Social networks are particularly important for older adults as they face the greatest threats to their health, and depend on their network relationships, more than younger individuals, to meet their needs. Increasing diversity, and not just increasing size, of social networks may be essential for improving health and survival among the elderly.
... [22] Moreover, it was reported that disease progression was higher among those individuals who had CAD and also had poor social support. [23] Denollet et al. found that mortality was 4 times higher in 6-10-year follow-up among patients with CAD who had type D personality. [24] Another study reported that the level of tumor necrosis factor alpha, which is one of the independent predictors of mortality among patients with chronic heart failure, was higher among patients with type D personality characteristics. ...
Objective:
The role of psychosocial risk factors is becoming increasingly important in the etiology of acute coronary syndrome (ACS). The purpose of this study was to assess an association between the personality types of young patients with ACS and the prevalence and severity of coronary artery disease (CAD).
Methods:
Patients younger than 45 years of age who presented with ACS and who underwent coronary angiography in the period from 2012 to 2016 were included in the study. The coronary angiography records of the patients were examined and their Gensini score (GS) was calculated; GS ≥20 was considered to be severe CAD. The Eysenck Personality Questionnaire-Revised Short Form scales were used to measure psychoticism, extraversion, lying, and neuroticism.
Results:
A total of 139 patients were included in the study. The median psychoticism score of patients with GS <20 was found to be significantly higher than that of patients with GS ≥20 [1.0 (25th and 75th percentile: 0.0-2.0) vs. 1.0 (25th and 75th percentile: 0.0-1.0); p=0.015]. The median psychoticism score was 1.0 (25th and 75th percentile: 1.0-2.0) in the unstable angina pectoris group, 0.5 (25th and 75th percentile: 0.0-1.0) in the ST segment elevation myocardial infarction group, and 1.0 (25th and 75th percentile: 0.0-1.0) in the non-ST segment elevation myocardial infarction group (p=0.004).
Conclusion:
The presence of psychoticism characteristics in patients who present with ACS is associated with less severe CAD.
... The STAXI has high internal consistency and high test-retest reliability in Asian populations (Bishop and Quah 1998). Because T-Anger and Anger-Out denote an outward direction of one's anger (Angerer et al. 2000) and are thought to be related to hostility, the present study analyzed the relationships of the scores on these subscales with the identified brain regions. ...
Anger typically manifests for only a short period of time, whereas hostility is present for a longer duration. However, both of these emotions are associated with an increased likelihood of psychological problems. The nodes within the neural networks that underlie hostility remain unclear. We presumed that specific nodes might include the anterior midcingulate cortex (aMCC), which seems to be essential for the cognitive aspects of hostility. Thus, the present study first evaluated the associations between regional gray matter density (rGMD) and hostility in 777 healthy young students (433 men and 344 women; 20.7 ± 1.8 years of age) using magnetic resonance imaging and the hostile behaviors subscale (HBS) of the Coronary-prone Type Scale (CTS) for Japanese populations. The HBS scores were positively correlated with rGMD in the aMCC and in widespread frontal regions from the dorsomedial/dorsolateral prefrontal cortices to the lateral premotor cortex at the whole-brain level. No significant correlation was observed between rGMD and the conjunction of HBS and Trait Anger/Anger-Out scores. Furthermore, no significant interaction effects of sex and HBS scores on rGMD were revealed, although the HBS scores of males were significantly higher than those of females. The present findings indicate that the neural correlates of hostility appear to be more distinct in rGMD than those of anger due to differences and duration.
Electronic supplementary material
The online version of this article (doi:10.1007/s00429-016-1200-6) contains supplementary material, which is available to authorized users.
“Good works are continually being undone by the tons of hatred and anger poured out on the world” – Swami Vivekananda. Anger is a social emotion that impacts a large number of people. Most people have known what it is like to be the enraged actor, a bystander to another’s wrath, or the subject of another’s rage. Observing the core of this emotion, any anger explosion can be characterized mainly as a joint event. Anger heightens the tension, whereas wrath heightens it. Its expressiveness has the power to bring life to the dead and remote. While there is no doubt that excessive, persistent, and misdirected anger may be emotionally and socially detrimental, there is also no doubt that anger can drive and organize movements against everyday injustices if it is directed in the proper direction. This chapter concentrates on the primary social motifs of anger, including a hierarchical study of anger-related factors like age, gender, workplace, medical conditions, family, and social environment.
Thema dieses Kapitels ist unsere evolutionäre „Bestimmung“: Die Programme, die in uns liegen und Anteil haben an unseren Bedürfnissen, werden beleuchtet und unserem tatsächlichen „Tun“ gegenübergestellt. Eine kritische Auseinandersetzung mit dem ungebremsten Sitzkonsum geht einem Plädoyer für das Training der „freundlichen Ausdauer“ und der sozialen Eingebundenheit „Gemeinsam ist besser als einsam“ voraus. Praktische Tipps für die Umsetzung schließen das Kapitel ab.
Objectives: Examine the social influence of adult children on the cardiovascular-related health behaviors of older South Asian (SA) immigrants to inform lifestyle interventions.
Design: This mixed-methods study used data from an ancillary study of social networks (2014–2018) in the Mediators of Atherosclerosis in South Asians Living in America cohort. Phase 1 was a quantitative analysis of self-reported diet and physical activity among SA adults (n = 448, mean age = 58 years, SD 8.4) who named at least one adult child to their social network. The Alternative Healthy Eating Index (AHEI) was used to measure parents’ diet; higher numbers indicate a healthier diet (range 0–110). Phase 2 was a thematic content analysis of in-depth qualitative interviews from a subsample of these parents (n = 23, mean age = 55, SD 7.6).
Results: Parents with an adult child in their network who consumed uncooked vegetables daily had mean parental AHEI score 1.5 points higher (adjusted p-value = 0.03) than those who had a child in the network who ate uncooked vegetables less often. When at least one adult child in their network ate fresh fruit daily compared to less frequently or when at least one child ate non-SA food daily compared to less frequently, mean parental AHEI scores were higher by 2.0 (adjusted p-value = 0.01) and 1.6 (adjusted p-value = 0.03) points respectively. Parents with an adult child in their network who exercised at least weekly were more likely to meet guideline-recommended physical activity levels than parents with children who exercised less often (76% v. 56%, adjusted p-value = 0.02). Adult children provided social support and were seen as ‘role models’ for healthy behavior, especially when adopting Western health behaviors.
Conclusion: Positive role modeling and support from adult children were important facilitators of healthy behavior change in older SA immigrants and can inform health behavior interventions for SA adults.
In 1902, a paper published in The Lancet pointed to the fact that ‘abnormal physical conditions in children’ could be caused by diseases of the central nervous system (CNS). This conclusion was based on observations of children developing hyperactive, antisocial behaviour after encephalitis (Still, 1902). Kahn and Cohen further discussed the clinical picture in 1934, introducing the concept ‘organic driveness’ (Kahn & Cohen, 1934). Bradley (1937) reported clinical efficacy of CNS stimulants in hyperactive children a few years later. The concept of minimal brain dysfunction (MBD) was used for many years to describe children with hyperactivity and attention problems. However, this concept was used differently both between and within countries, thus making comparison of research reports problematic and clinical evaluations different. Accordingly, the MBD concept has been abandoned in clinical practice and research, whereas Attention Deficit Hyperactivity Disorder (ADHD) has become the internationally accepted term and diagnosis for the group of children described as MBD or hyperactive in older publications (APA, 1994). Hyperactivity is regarded as a predominant symptom in ADHD children, but the relative importance of this symptom has been discussed extensively over the years. In The Diagnostic and Statistical Manual-III of The American Psychiatric Association (DSM-III), the syndrome was subdivided into attention deficit disorder with or without hyperactivity. The DSM-III revision broke this down into ADHD only, thus demanding that hyperactivity should be present in order to diagnose ADHD. In the DSM-IV (APA, 1994), the sub-division reappeared (predominantly inattentive, predominantly hyperactive or both).
Sexual functioning in men and women encompasses behaviours, physiological responses and subjective states of awareness. These phenomena are influenced by personal and relationship histories as well as cultural expectations. A linear sexual response cycle was hypothesized by Masters and Johnson (1966), in which desire precedes initiation of sexual activity, followed by arousal, orgasm and resolution. The psychosexual diagnostic categories of the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders (DSM) (third edition and onwards) are based on this model. In general, a sexual dysfunction is a physiological response and/or state of awareness contrary to these expectations for normative sexual functioning. This chapter will summarize issues relating to sexual dysfunctions including prevalence, risk factors and treatments. Sexual dysfunctions in men Definitions and prevalence Erectile dysfunction (ED) has been defined as ‘the persistent inability to attain and maintain a penile erection adequate for sexual performance’ (NIH Consensus Panel, 1993). Knowledge of the epidemiology of this condition has been facilitated by two large population/community based studies, the National Health and Social Life Survey (NHSLS) (Laumann et al., 1999) and the Massachusetts Male Aging Study (MMAS) (Feldman et al., 1994). In the NHSLS study, the percentage of men reporting difficulties maintaining or achieving an erection ranged from 7% for those aged 18–29 to 18% for those aged 50–59. In the MMAS baseline study, complete ED was reported by less than 10%, moderate by 25% and mild by 17%.
A longstanding puzzle within psychology and psychosomatic medicine concerns the relationship between the expression of emotions and physical health. Descartes and Shakespeare suggested that not expressing powerful emotions could be unhealthy. Similarly, William James (1890) and Franz Alexander (1950) forcefully argued that inhibiting the expression of strong emotions over time could result in physical health problems through basic biological stress-related channels (see ‘Psychoneuroimmunology’ and ‘Psychosomatics’). Despite these early hypotheses, there is still no overwhelming evidence to support the idea that the suppression of emotional expression is unhealthy and, conversely, that the open expression of emotions is beneficial. Emotional expression has been viewed by our culture somewhat ambivalently. On the one hand, emotional expression is often viewed as rather uncivilized, as ‘giving in’ to passion (King & Emmons, 1990, p. 864). On the other hand, it is assumed that emotions usually should be let out, that the healthy end to an emotional response is emotional expression. This view is especially common in the psychological literature. From Breuer and Freud (1895/1966) to the present (e.g. Cole et al., 1996; Pelletier, 1985) the inherent value of naturally expressing one’s thoughts and feelings has been emphasized. Emotional expression is thus viewed as a somewhat unseemly but normal part of everyday life. While emotional expression is a normative behaviour which is neither good nor bad per se, actively holding back emotion through inhibition may have negative health consequences.
Background
Having a larger social network has been shown to have beneficial effects on health and survival in adults, but few studies have evaluated the role of network diversity, in addition to network size. We explore whether social network diversity is associated with mortality, cognition and physical function among older black and white adults.
Methods
Data are obtained from the Chicago Health and Aging Project, a longitudinal, population-based study of adults aged 65 years and older at baseline. Using Cox proportional hazards regression, we estimate the hazard of mortality by network diversity (n=6497). The association between network diversity and cognition (n=6560) and physical function (n=6561) is determined using generalised estimating equations. Models were adjusted for age, gender, race, socioeconomic status, marital status and health-related variables.
Results
In fully adjusted models, elderly with more diverse social networks had a lower risk of mortality (HR=0.93, p<0.01) compared with elderly with less diverse networks. Increased diversity in social networks was also associated with higher global cognitive function (coefficient=0.11, p<0.001) and higher physical function (coefficient=0.53, p<0.001).
Conclusions
Social networks are particularly important for older adults as they face the greatest threats to health and depend on network relationships, more than younger individuals, to meet their needs. Increasing diversity, and not just increasing size, of social networks may be essential for improving health and survival among older adults.
Background and Objective: Health promotion is a growing concern field. The present study aimed to assess the effect of educational intervention via mobile on health promoting behaviors of women who referred to health centers in Bandar Abbas
Methods: This interventional study included women who referred to health centers in Bandar Abbas. The samples were randomly selected and divided in two groups including intervention (54) and control (54) groups. Data were collected by Health promoting lifestyle profile II before and 3 months after the intervention. The educational intervention via Whats App lasted 3 months. Data were analyzed by Spss-19.
Results: After the education significant increases were observed in all of domains of health promoting behaviors in intervention group (p
Overview of the general area There is a long tradition of the view that emotional stress might act as a precipitating factor in the onset or exacerbation of skin disorders. The close relationship of the skin with psychological functions is reflected in a variety of expressions such as ‘to be red with rage’ or ‘to jump out of one’s skin’. In addition, psychoimmunological and psychoendocrinological research has demonstrated that psychological factors significantly affect the course of a variety of medical conditions including dermatological disorders. However, there is no evidence that dermatological disorders are related to specific psychological traits. Rather, that the impact of skin disorders on quality of life indicates that the impairment of appearance associated with visible and sometimes disfiguring dermatological conditions creates significant psychosocial stress. The relationship between psychological factors and skin disorders is further complicated by the fact that manipulations such as self-injurious skin picking may cause artificial dermatological lesions. Finally, a high proportion of patients report symptoms that are not adequately explained by a dermatological disease or a known pathophysiological mechanism, such as body dysmorphic disorders. The focus of the present paper is on psychological factors related to skin disorders. With respect to somatoform and artificial disorders, the interested reader is referred to other sources (e.g. Stangier & Ehlers, 2000). Research evidence Vulnerability to stress There is evidence from a large number of studies that stressful life events, daily hassles and chronic stressors can significantly affect the manifestation and course of skin disorders (see also ‘Life events and health’ and ‘Stress and health’).
Introduction The substantial majority of young adults intend to become parents, but not all achieve a goal of conceiving easily when pregnancy is desired. The 1995 National Survey of Family Growth interviews conducted with 10 847 women suggested that 7.1% of married couples (2.1 million) in the United States met criteria for infertility (i.e. no contraceptive use and no pregnancy for 12 months or more; Abma et al., 1997), and 15% of women of reproductive age reported a past infertility-associated healthcare visit. In the United Kingdom, one in six couples has a fertility problem (Human Fertilisation and Embryology Authority, 2004). The American Society for Reproductive Medicine (ASRM, 1997) estimates that infertility affects females and males with almost equal frequency. Sources of female infertility commonly include ovulatory disorders and tubal or pelvic problems. Male infertility typically involves problems with sperm production (e.g. abnormal sperm density, motility or morphology) or impaired sperm delivery. Infertility remains unexplained following diagnostic work-up in approximately 20% of couples. Approximately 44% of those with impaired fecundity (i.e. difficulty conceiving or carrying a pregnancy to term) seek medical services, with higher rates among those who are white, older, married, childless and more affluent (Chandra & Stephen, 1998). Over 50% of infertile couples who pursue treatment become pregnant (ASRM, 1997).
Introduction Motor Neurone Disease (MND), is a terminal, progressive neurodegenerative disease of the central nervous system. The most common form of MND is amyotrophic lateral sclerosis (ALS) involving both upper and lower motor neurones (UMNs, LMNs). Less common are primary lateral sclerosis (involving only UMNs) progressive muscular atrophy (involving only LMNs) and progressive bulbar palsy (PBP) where there is predominant involvement of the motor systems of the brainstem (Leigh & Ray-Chaudhuri, 1994). Peak age at onset is in the sixth decade of life. Incidence is around 1–2: 100 000 per year and prevalence 5–6:100 000. Median survival in ALS is 3.5 years from diagnosis, death commonly resulting from respiratory failure. Disease progression is generally variable but prognosis is poorest in those presenting with bulbar signs (about 25% of cases). Typically the disease presents with limb muscle weakness. Overall 90–95% of cases are sporadic, but 5–10% are familial in nature. At present there is no cure for MND. However the glutamate release antagonist, riluzole, has been shown to improve survival at 18 months (Lacomblez et al., 1996). Psychological research concerning people with MND has predominantly involved investigations of the neuropsychological profile associated with ALS and of emotional and psychosocial issues (Goldstein & Leigh, 1999). Neuropsychological aspects of MND Increasing evidence that MND involves extra-motor cerebral regions is provided by findings of mild cognitive impairment occurring in up to 35–40% of non-demented patients with ALS, and by reports that a fronto-temporal dementia may also be seen in ~5% of sporadic cases (see ‘Dementias’).
Health promotion, health education and prevention Health promotion is any planned combination of educational, political, regulatory and organizational supports for actions and conditions of living conducive to the health of individuals, groups, or communities (Green & Kreuter, 2004). Involving the target individuals, groups, or communities in the development of programmes, is a prerequisite for effective health promotion. Three types of prevention are the goals of health promotion: (i) primary prevention; (ii) early detection and treatment; and (iii) patient care and support. Health education is one type of health promotion intervention. Health education is a planned activity, stimulating learning through communication, to promote health behaviour. Other health promotion instruments are resources and regulation. Health education is based on voluntary change, while regulation is based on forced compliance and will only be effective in combination with control and sanctions. In general, interventions that are directed at several levels and which use more means, will be more effective. An example of this last statement is the prevention of drunk driving. There is regulation: most countries have laws against driving under the influence of alcohol. Often there is control: drivers are stopped by the police and may be tested, although countries differ in their commitment to these control activities. There are resources: public transport is available and, especially in the weekends and during the night, cheap taxis for adolescents.
Diagnosis The term ‘enuresis’ is used when a child, beyond the age of anticipated bladder control and socially correct toileting behaviour, urinates into clothing or other inappropriate places. The defining age is usually considered to be five years. Whether the urinating is intentional or involuntary is not relevant to the general diagnosis. However, involuntary urination during the night, in a child who has never ceased to wet the bed (or has lost a previously acquired skill) is referred to as ‘nocturnal enuresis’, and colloquially as ‘bedwetting’. Nocturnal enuresis is one of the commonest reasons for families seeking help from primary care physicians. The problem was referred to as early as the sixteenth century in The boke of chyldren by Thomas Phaire, in a chapter entitled ‘Of pissing in the bedde’. ‘Diurnal enuresis’ is the term for involuntary daytime urination. It occurs in approximately 1 in 10 of the children with nocturnal enuresis. A distinction is also made between children who are ‘regular’ and those who are ‘intermittent’ bedwetters. Most enuretic children have what is called ‘primary’ nocturnal enuresis, meaning that they have wet their beds since toddlerhood. ‘Secondary’ enuresis is the term applied to children who revert to bedwetting after a sustained period of dry beds. Although urinary tract infections or diabetes may play a role in secondary enuresis, it is often impossible to identify any specific medical cause.
Introduction Hysterectomy is the most common major gynaecological operation in the UK and the USA. Prevalence rates vary in different countries and range from 8% in France, 10% in the UK and 22% in Australia to approximately one-third of women in the Netherlands and the USA. Hysterectomies are usually carried out for benign conditions, such as abnormal menstrual bleeding, fibroids and endometriosis and are therefore elective operations. In the USA, for example, approximately 90% of hysterectomies are elective operations. However, approximately 10% of hysterectomies are carried out for malignant conditions such as cancer of the cervix or uterus (see ‘Cancer: gynaecological’). There are three main types of hysterectomy: a subtotal hysterectomy, in which only the uterus is removed; a total hysterectomy, in which both the uterus and the cervix are removed; and a radical hysterectomy, in which the uterus, cervix, surrounding tissue, upper vagina and sometimes the pelvic lymph nodes are removed. Radical hysterectomies are usually only done in extreme circumstances such as cancer of the uterus or cervix. In addition, some women will have their fallopian tubes and ovaries removed at the same time, which initiates menopause. In these cases women have to decide about whether or not to use hormone replacement therapy (see ‘Hormone replacement therapy’). Currently, the most common hysterectomy carried out is the total hysterectomy, which is thought to be preferable for benign conditions because it avoids later complications with the cervix such as cervical cancer.
‘Haemophilia’ is a term referring to a group of genetically transmitted life-long blood clotting disorders which are caused by a defect in one or more of the plasma clotting factors. The most common are sex-linked recessive disorders, haemophilia A (classic haemophilia) and haemophilia B (Christmas disease), which are due to an isolated deficiency of the clotting activity of factor VIII or of factor IX, respectively. People with these disorders suffer bleeding into soft tissues, for example, joints, muscles or internal organs, which can happen after trauma or spontaneously. These bleeds can be very painful, and repeated episodes lead to weakening and crippling of joints. Bleeds into internal organs and the brain can be life-threatening. There is no cure for haemophilia. Another common blood disorder is von Willebrand’s disease or vascular haemophilia. It is an autosomal dominant genetic disorder, i.e. it is not sex-linked and affects both men and women. It is due to a combination of an abnormal factor VIII molecule with abnormal platelet function. Many problems related to treatment and its complications, as well as social and psychological problems are similar to those found in haemophilia A and B. Genetics and clinical manifestation Haemophilias A and B are genetically transmitted as follows: an affected woman carries a defective gene on one of her X chromosomes, which she can pass to any of her children.
Over the years, there have been various unusual instances of the voluntary control over physiological functions noted in the scientific literature. Luria (1958) presented a case of a mnemonist who had remarkable control of his heart rate and skin temperature to the degree that he could abruptly alter his heart rate by 50 beats per minute, and could also raise the skin temperature of one hand while simultaneously lowering the temperature of the other hand. The modification of physiological activities such as this has been the subject of anecdotal reports for a considerable period of time. Although true empirical investigation into such self-regulation through biofeedback began in the 1960s, gaining voluntary control of various physiological activities has been a goal in many different cultures for a variety of reasons. Gatchel (1999) and Gatchel et al. (2003b) have reviewed the goals that have been traditionally sought with regard to gaining control of physiological functioning: In order to achieve spiritual enlightenment, yogis and other mystics of the eastern tradition have demonstrated that through certain physical exercises, or by a sheer act of will, that individuals are capable of producing significant physiochemical changes in their bodies which, in turn, produce perceived pleasant states of consciousness (Bagchi, 1959; Bagchi & Wenger, 1957). In order to test various theories of learning, psychologists have long debated the issue of whether autonomic nervous system responses could be operantly conditioned. During the 1960s, biofeedback was viewed as a potential clinical treatment procedure for modifying psychological and medical disorders. The major focus of this present chapter is on the third category of how voluntary control of physiological activity can be used as a clinical treatment modality for medically related disorders.
The theory of planned behaviour (TPB; Ajzen, 1991, 2002b), an extension of the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), is widely used to study the cognitive determinants of health behaviours (Conner & Sparks, 2005; Sutton, 2004). It has several advantages over other ‘social cognition models’: (1) it is a general theory, and it can be argued that general theories should be preferred to health- or behaviour-specific theories for reasons of parsimony (Stroebe, 2000); (2) the constructs are clearly defined and the causal relationships between the constructs clearly specified; (3) there exist clear recommendations for how the constructs should be operationalized (Ajzen, 2002a); and (4) meta-analyses of observational studies show that the TPB accounts for a useful amount of variance in intentions and behaviour (but see the discussion of variance explained in Sutton, 2004). According to the theory, behaviour is determined by the strength of the person’s intention to perform that behaviour and the amount of actual control that the person has over performing the behaviour (Figure 1). According to Ajzen (2002b), intention is ‘the cognitive representation of a person’s readiness to perform a given behaviour, and … is considered to be the immediate antecedent of behaviour’, and actual behavioural control ‘… refers to the extent to which a person has the skills, resources and other prerequisites needed to perform a given behaviour’. Figure 1 also shows an arrow from perceived behavioural control to behaviour.
Objective:
Heart failure patients have a high hospitalization rate, and anger and hostility are associated with coronary heart disease morbidity and mortality. Using structural equation modeling, this prospective study assessed the predictive validity of anger and hostility traits for cardiovascular and all-cause rehospitalizations in patients with heart failure.
Method:
146 heart failure patients were administered the STAXI and Cook-Medley Hostility Inventory to measure anger, hostility, and their component traits. Hospitalizations were recorded for up to 3 years following baseline. Causes of hospitalizations were categorized as heart failure, total cardiac, noncardiac, and all-cause (sum of cardiac and noncardiac).
Results:
Measurement models were separately fit for Anger and Hostility, followed by a Confirmatory Factor Analysis to estimate the relationship between the Anger and Hostility constructs. An Anger model consisted of State Anger, Trait Anger, Anger Expression Out, and Anger Expression In, and a Hostility model included Cynicism, Hostile Affect, Aggressive Responding, and Hostile Attribution. The latent construct of Anger did not predict any of the hospitalization outcomes, but Hostility significantly predicted all-cause hospitalizations. Analyses of individual trait components of each of the 2 models indicated that Anger Expression Out predicted all-cause and noncardiac hospitalizations, and Trait Anger predicted noncardiac hospitalizations. None of the individual components of Hostility were related to rehospitalizations or death.
Conclusion:
The construct of Hostility and several components of Anger are predictive of hospitalizations that were not specific to cardiac causes. Mechanisms common to a variety of health problems, such as self-care and risky health behaviors, may be involved in these associations. (PsycINFO Database Record
Introduction Diabetes mellitus is a chronic disorder, characterized by raised glucose levels in blood (hyperglycaemia) and urine (glycosuria). The cause may be inherited and/or acquired deficiency of insulin production by the pancreas, or insulin resistance, where the insulin produced is ineffective. Increased blood glucose concentrations can cause structural damage, particularly to blood vessels and nerves. Microvascular complications of diabetes (diabetic retinopathy, nephropathy and neuropathy) bring problems of blindness, kidney failure, foot ulcers, gangrene and erectile impotence. However, heart disease accounts for around 50% of deaths of people with diabetes. Management involves striving to maintain blood glucose at near-normal levels through behaviour change and medication, prevention or early detection and treatment of microvascular complications and reduction of cardiovascular risk, including hypertension, lipids and weight. There are three main forms of diabetes. Type 1 diabetes usually develops in childhood or early adulthood. The pancreas stops producing insulin, so insulin by injection or infusion pump is essential for survival. Inhaled insulin is under evaluation. Type 2 diabetes typically begins in late adulthood, though maturity onset diabetes of the young (MODY) is increasing in children. Often, though not always, associated with high body mass index, insulin production and/or the body’s response to insulin declines. Management initially involves diet and exercise, perhaps with tablets to increase insulin production or uptake. In time, insulin may be required. The third form, gestational diabetes, is not considered in detail here. Diabetes prevalence is increasing rapidly worldwide, with notable ethnic differences.
Over the course of a lifespan, most people will be confronted with the loss of a close relationship: if attachments have been formed, one is likely to have to suffer the consequences of separation. The term ‘bereavement’ refers to the situation of a person who has recently experienced the loss of someone significant in their lives through that person’s death (see ‘Coping with death and dying’). The loss of a family member – such as a parent, partner, sibling or child – are typical examples, although the death of other important relationships – such as a meaningful friendship, classmate or good neighbour – may also be significant. Bereavements evoke grief, which can be defined as a primarily emotional (affective) reaction to the loss through death of a loved one. Affective reactions include yearning and pining and intense feelings of distress over the loss of the deceased person. Grief also incorporates diverse psychological and physical manifestations. The former type of manifestation includes cognitive and social-behavioural reactions such as self-blame and withdrawal from others. The latter includes physiological/somatic reactions, such as head- and stomach ache, and increased vulnerability to diseases. Sometimes mourning is used interchangeably with grief. However, there are good reasons to define mourning as the social expressions or acts expressive of grief that are shaped by the practices of a given society or cultural group. It is worth noting that researchers following the psychoanalytic tradition often use the term ‘mourning’ rather than ‘grief ’ to denote the psychological reaction to bereavement.
Hostility has long been thought to play a role in health, and recent research has now documented substantial effects on disease etiology, with much of the attention given to its role in cardiovascular disease. Several measures of this construct have been found to predict adverse cardiovascular events as well as cardiac and total mortality. It is apparent, however, that the hostility construct has multiple aspects, including cynical and suspicious attitudes, various negative emotions, and antagonistic behavior patterns. Interpersonal experiences, such as child rearing patterns and adult adversity in combination with physiological and genetic factors, influence the development of these tendencies. The links to physical health appear to involve several processes such as enhanced autonomic reactivity and altered glucose metabolism that are the product of the stress associated with antagonistic experiences. In addition, high hostility is associated with a lifestyle that produces an adverse risk factor pattern. There is promising evidence in clinical samples suggesting that interventions based on coping skills training may be able to improve health through the reduction of these hostile tendencies.
Psychosocial characteristics predict the development and course of coronary heart disease (CHD). In this review, the authors discussed human and animal research on psychophysiological mechanisms influencing coronary artery disease and its progression to CHD. They then reviewed literature on personality and characteristics of the social environment as risk factors, for CHD. Hostility confers increased risk, and a group of risk factors involving depression and anxiety may be especially important following myocardial infarction. Social isolation, interpersonal conflict, and job stress confer increased risk, Psychosocial interventions may have beneficial effects on CHD morbidity and mortality, although inconsistent results and a variety of methodological limitations preclude firm conclusions. Finally, they discussed implications for clinical care and the agenda for future research.
Coronary heart disease (CHD) is the leading cause of death in the USA and Europe [1, 2]. In roughly half the cases, the first clinical manifestations of CHD – myocardial infarction (MI) or sudden death – are catastrophic. These events are sudden, unexpected and unpredictable. The economic cost of CHD is growing. For example, in the USA over $130 billion is spent on CHD each year in direct medical costs, disability payments and lost productivity [2]. Moreover, traditional risk factors such as cigarette smoking, hyperlipidaemia and hypertension do not account fully for the timing and occurrence of these events. Depression is also a major health problem. It is associated with significant impairment of function, which may, at times, be worse than that of chronic medical disorders [3]. Depressive symptoms have been correlated with the presence of one or more chronic diseases [4, 5], as well as inability to work [6], days in bed or days away from normal activities [4], increased mortality risk [7], increased use of medical services [8], and decreased wellbeing and lowered functioning [3]. Major depressive disorder (MDD) is the most prevalent of all psychiatric disorders, affecting up to 25% of women and 12% of men during their lifetime [9]. Since 1950, the prevalence of depression has increased significantly [10]. Depression is disproportionately prevalent among cardiac patients, with estimates of MDD of about 15% in patients following acute myocardial infarction (AMI) or coronary artery bypass graft (CABG), and an additional 20% with either minor depression or elevated levels of depressive symptoms as measured by questionnaires such as the Beck Depression Inventory (BDI) [11–17].
Background and Objective: One of the ways to achieve healthy communities is training adolescents in healthy behaviors. This study was conducted to assess the impact of peer education approach to health promoting behaviors in Bastak junior high school students.
Methods: The study population was junior high school students in Bastak county, Hormozgan. In this semi-experimental study 201 students were placed in the intervention group and 157 students in the control group. The data were collected through The Adolescent Health Promotion Scale. The questionnaire measures health promoting behaviors in six areas, including nutrition, social protection, health personal responsibility, valuation of health, exercise and stress management. Intervention was performed through peer education. Data were collected before and two months after the intervention and analyzed by using SPSS19 and independent and paired t-test. Results: Health promoting behaviours scores showed a significant increase in the intervention group except health valuation area compared with pre-training (p
The interaction of Type A behavior and social support in relation to the degree of coronary artery disease (CAD) severity was investigated. One hundred thirteen patients undergoing diagnostic coronary angiography received the Type A structured interview (SI) and completed a battery of psychometric tests, including the Perceived Social Support Scale (PSSS). Statistical analyses revealed a Type by social support interaction, such that the probability of significant CAD was inversely related to the level of social support for Type As but not Type Bs. Type As with low levels of social support had more severe CAD than Type As with high levels of social support. On the other hand, this relationship was not present for Type Bs. These results are consistent with the hypothesis that social support moderates the long-term health consequences of the Type A behavior pattern.
In the absence of prior knowledge about population relations, investigators frequently employ a strategy that uses the data to help them decide whether to adjust for a variable. The authors compared the performance of several such strategies for fitting multiplicative Poisson regression models to cohort data: 1) the "change-in-estimate" strategy, in which a variable is controlled if the adjusted and unadjusted estimates differ by some important amount; 2) the "significance-test-of-the-covariate" strategy, in which a variable is controlled if its coefficient is significantly different from zero at some predetermined significance level; 3) the "significance-test-of-the-difference" strategy, which tests the difference between the adjusted and unadjusted exposure coefficients; 4) the "equivalence-test-of-the-difference" strategy, which significance-tests the equivalence of the adjusted and unadjusted exposure coefficients; and 5) a hybrid strategy that takes a weighted average of adjusted and unadjusted estimates. Data were generated from 8,100 population structures at each of several sample sizes. The performance of the different strategies was evaluated by computing bias, mean squared error, and coverage rates of confidence intervals. At least one variation of each strategy that was examined performed acceptably. The change-in-estimate and equivalence-test-of-the-difference strategies performed best when the cut-point for deciding whether crude and adjusted estimates differed by an important amount was set to a low value (10%). The significance test strategies performed best when the alpha level was set to much higher than conventional levels (0.20).
The role of psychosocial factors in the aetiology of coronary heart disease continues to be debated. Despite public perception of a major role for their effect, scientific opinion on their relevance remains divided. This paper reviews the literature on the influence of social support and life stress on coronary heart disease incidence and mortality.
Observational studies published in English, based on over 100 human subjects from the general population, investigating life stress or social support were considered. Fourteen studies derived from MEDLINE searches on MeSH headings: coronary disease; stress, psychological; social support; social isolation; life change events. An equivalent search of BIDS and studies referenced by papers identified using these sources was carried out.
The review concludes that both life stress and social support were found to have an influence on coronary heart disease, social support more so than stress. Both have a stronger influence on coronary heart disease mortality than on initial incidence of clinical disease. Measures of the quality of support, in particular emotion support, show the largest effects. The review highlights problems in drawing conclusions from the available literature; in particular, the inconsistency in measures used to define the psychosocial factors. Further studies are needed to investigate interrelationships between stress and social support, and a recommendation is made to adopt pragmatic measures in future studies, which if proven to have an effect, may be open to modification.
A new meta-analysis of research on hostility and physical health was conducted that includes 15 studies used in previous meta-analytic reviews and 30 new independent studies. Overall, the results suggest that hostility is an independent risk factor for coronary heart disease (CHD). For structured interview indicators of potential for hostility, the weighted mean r was .18. After controlling for other risk factors for CHD, the widely used Cook-Medley Hostility Scale and other cognitive-experiential measures were most predictive of all-cause mortality (weighted mean r = .16) and, to a lesser extent, CHD (weighted mean r = .08). Similar to other areas of research, the increased use of high-risk studies in recent years produced an increase in null findings.
Cynical hostility has been associated with increased cardiovascular morbidity and mortality; yet few studies have investigated this relation in population-based samples, and little is known about underlying mechanisms. This study examined the association between hostility, measured by the eight-item Cynical Distrust Scale, and risk for all-cause and cardiovascular mortality and incident myocardial infarction. Subjects were 2,125 men, ages 42-60 years, from the Kuopio Ischemic Heart Disease Risk Factor Study, a longitudinal study of unestablished and traditional risk factors for ischemic heart disease, mortality, and other outcomes. There were 177 deaths (73 cardiovascular) in 9 years of follow-up. Men with hostility scores in the top quartile were at more than twice the risk of all-cause mortality (relative hazards (RH) 2.30, 95% confidence interval (CI) 1.47-3.59) and cardiovascular mortality (RH 2.70, 95% CI 1.27-5.76), relative to men with scores in the lowest quartile. Among 1,599 men without previous myocardial infarction or angina, high scorers also had an increased risk of myocardial infarction (RH 2.18, 95% CI 1.01-4.70). Biologic and socioeconomic risk factors, social support, and prevalent diseases had minimal impact on these associations, whereas adjustments for the behavioral risk factors of smoking, alcohol consumption, physical activity, and body mass index substantially weakened the relations. Simultaneous risk factor adjustment eliminated the observed associations. Results show that high levels of hostility are associated with increased risk of all-cause and cause-specific mortality and incident myocardial infarction and that these effects are mediated primarily through behavioral risk factors.
Social relations have been repeatedly linked to coronary heart disease in men, even after careful control for standard risk factors. Women have rarely been studied and results have not been conclusive. We investigated the role of social support in the severity and extent of coronary artery disease in women.
One hundred and thirty-one women, aged 30 to 65 years, who were hospitalized for an acute coronary event and were included in the Stockholm Female Coronary Risk Study, were examined with computer assisted quantitative coronary angiography. Angiographic measures included presence of stenosis greater than 50% in at least one coronary artery (severity) and the number of stenoses greater than 20% within the coronary tree (extent). Social factors included two measures of social support, which were previously shown to predict coronary disease in prospective studies of men. After adjustment for age, lack of social support was associated with both measures of coronary artery disease. With further adjustment for smoking, education, menopausal status, hypertension, high density lipoprotein and body mass index, the risk ratio for stenosis greater than 50% in women with poor as compared to those with strong social support was 2.5 (95% confidence interval 1.2 to 5.3; P=0.003). Also, women with poor social support had more stenoses obstructing at least 20% of the coronary lumen with multivariate adjustment, but the difference from women with strong support was only of borderline significance (P=0.09).
The findings suggest that lack of social support contributes to the severity of coronary artery disease in women, independent of standard risk factors.
This study examines the effect of anger and vital exhaustion on recurrent events after percutaneous transluminal coronary angioplasty (PTCA), Data came from 149 patients (123 men and 26 women) who underwent successful PTCA, During 18 months of followup, there were 37 recurrent events (25%) for which there was objective evidence of new or progression of coronary disease, The 123 male patients with high anger were significantly more likely to have multivessel disease before PTCA (odds ratio 2.42; p = 0.04), after controlling for standard heart disease risk factors, High-anger mole patients also had a threefold increased risk for recurrent events after PTCA (RR 2.94; p = 0.01), which remained marginally significant after accounting for other heart disease risk factors and residual stenosis after PTCA (RR 2.33; p = 0.09), Among female patients, these relations were much weaker and not statistically significant, Among male patients, additional adjustment for vital exhaustion did not change the risk for recurrent events associated with high anger, A composite index of psychosocial risk based on anger and vital exhaustion was significantly related (p = 0.02) to events after PTCA after adjustment for standard heart disease risk factors, These findings add to the growing body of research on the role of psychosocial factors on clinical course in patients with coronary artery disease.
Aims
Social relations have been repeatedly linked to coronary heart disease in men, even after careful control for standard risk factors. Women have rarely been studied and results have not been conclusive. We investigated the role of social support in the severity and extent of coronary artery disease in women.
Methods and Results
One hundred and thirty-one women, aged 30 to 65 years, who were hospitalized for an acute coronary event and were included in the Stockholm Female Coronary Risk Study, were examined with com-puter assisted quantitative coronary angiography. Angio-graphic measures included presence of stenosis greater than 50% in at least one coronary artery (severity) and the number of stenoses greater than 20% within the coronary tree (extent). Social factors included two measures of social support, which were previously shown to predict coronary disease in prospective studies of men. After adjustment for age, lack of social support was associated with both measures of coronary artery disease. With further adjustment for smoking, education, meno-pausal status, hypertension, high density lipoprotein and body mass index, the risk ratio for stenosis greater than 50% in women with poor as compared to those with strong social support was 2·5 (95% confidence interval 1·2 to 5·3;P=0·003). Also, women with poor social support had more stenoses obstructing at least 20% of the coronary lumen with multivariate adjustment, but the difference from women with strong support was only of borderline significance (P=0·09).
Conclusion
The findings suggest that lack of social support contributes to the severity of coronary artery disease in women, independent of standard risk factors.The European Society of Cardiology
The Cholesterol-Lowering Atherosclerosis Study (CLAS) was a randomized, placebo-controlled, angiographic trial testing combined colestipol hydrochloride and niacin therapy in 162 nonsmoking men aged 40 to 59 years with previous coronary bypass surgery. During two years of treatment there was a 26% reduction in total plasma cholesterol, a 43% reduction in low-density lipoprotein cholesterol, plus a simultaneous 37% elevation of high-density lipoprotein cholesterol. This resulted in a significant reduction in the average number of lesions per subject that progressed (P<.03) and the percentage of subjects with new atheroma formation (P<.03) in native coronary arteries. Also, the percentage of subjects with new lesions (P<.04) or any adverse change in bypass grafts (P<.03) was significantly reduced. Deterioration in overall coronary status was significantly less in drug-treated subjects than placebo-treated subjects (P<.001). Atherosclerosis regression, as indicated by perceptible improvement in overall coronary status, occurred in 16.2% of colestipol-niacin treated vs 2.4% placebo treated (P =.002).
(JAMA 1987;257:3233-3240)
Objective.
—To determine if the presence of a disrupted marriage or living alone would be an independent prognostic risk factor for a subsequent major cardiac event following an initial myocardial infarction.
Design.
—Prospective evaluation in the placebo wing of a randomized, double-blind drug trial in patients with an enzyme-documented acute myocardial infarction who were admitted to a coronary care facility. Data for living alone and/or a marital disruption were entered into a Cox proportional hazards model constructed from important physiologic and nonphysiologic factors in the same database.
Setting.
—Multicenter trial in a mixture of community and academic hospitals in the United States and Canada.
Patients.
—All consenting patients who were 25 to 75 years of age and without other serious diseases were enrolled (placebo, N = 1234) within 3 to 15 days of the index infarction and followed for a period of 1 to 4 years (mean, 2.1 years). Nine hundred sixty-seven patients were followed for 1.1 years and 530 for 2.2 years.
Primary Outcome Measure.
—Recurrent major cardiac event (either recurrent nonfatal infarction or cardiac death).
Results.
—Living alone was an independent risk factor, with a hazard ratio of 1.54 (95% confidence interval, 1.04 to 2.29; P<.03). Using the Kaplan-Meier statistical method for calculation, the recurrent cardiac event rate at 6 months was 15.8% in the group living alone vs 8.8% in the group not living alone. Risk remained significant throughout the follow-up period (P=.001). A disrupted marriage was not an independent risk factor.
Conclusion.
—Living alone but not a disrupted marriage is an independent risk factor for prognosis after myocardial infarction when compared with all other known risk factors.(JAMA. 1992;267:515-519)
From among 250 MMPI items that discriminated significantly between teachers scoring high and teachers scoring low on the Minnesota Teacher Attitude Inventory, two sets of 50 items were selected (principally on the basis of content) to form a Hostility (Ho) Scale and a Pharisaic virtue (Pv) scale. "The Ho scale… reveals a type of individual characterized by a dislike for and distrust of others. The Pv scale… reveals a type of person who described himself as preoccupied with morality and ridden with fears and tensions." (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To assess the effect of dietary reduction of plasma cholesterol concentrations on coronary atherosclerosis, we set up a randomised, controlled, end-point-blinded trial based on quantitative image analysis of coronary angiograms in patients with angina or past myocardial infarction. Another intervention group received diet and cholestyramine, to determine the effect of a greater reduction in circulating cholesterol concentrations. 90 men with coronary heart disease (CHD), who had a mean (SD) plasma cholesterol of 7.23 (0.77) mmol/l were randomised to receive usual care (U, controls), dietary intervention (D), or diet plus cholestyramine (DC), with angiography at baseline and at 39 (SD 3.5) months. Mean plasma cholesterol during the trial period was 6.93 (U), 6.17 (D), and 5.56 (DC) mmol/l. The proportion of patients who showed overall progression of coronary narrowing was significantly reduced by both interventions (U 46%, D 15%, DC 12%), whereas the proportion who showed an increase in luminal diameter rose significantly (U 4%, D 38%, DC 33%). The mean absolute width of the coronary segments (MAWS) studied decreased by 0.201 mm in controls, increased by 0.003 mm in group D, and increased by 0.103 mm in group DC (p less than 0.05), with improvement also seen in the minimum width of segments, percentage diameter stenosis, and edge-irregularity index in intervention groups. The change in MAWS was independently and significantly correlated with LDL cholesterol concentration and LDL/HDL cholesterol ratio during the trial period. Both interventions significantly reduced the frequency of total cardiovascular events. Dietary change alone retarded overall progression and increased overall regression of coronary artery disease, and diet plus cholestyramine was additionally associated with a net increase in coronary lumen diameter. These findings support the use of a lipid-lowering diet, and if necessary of appropriate drug treatment, in men with CHD who have even mildly raised serum cholesterol concentrations.
The Cholesterol Lowering Atherosclerosis Study, a randomized angiographic clinical trial, demonstrated the beneficial effect of niacin/colestipol plus diet therapy on coronary atherosclerosis. Outcome was determined by panel-based estimates (viewed in both still and cine modes) of percent stenosis severity and change in native artery and bypass graft lesions. Computer-based quantitative coronary angiography (QCA) was also used to measure lesion and bypass graft stenosis severity and change in individual frames closely matched in orientation, opacification, and cardiac phase. Both methods jointly evaluated 350 nonoccluded lesions. The correlation between QCA and panel estimates of lesion size was 0.70 (p less than 0.0001) and for change in lesion size was 0.28 (p = 0.002). Agreement between the two methods in classifying lesion changes (i.e., regression, unchanged, or progression) occurred for 60% (210 of 350) of the lesions kappa +/- SEM = 0.20 +/- 0.05, p less than 0.001). The panel identified 442 nonoccluded lesions for which QCA stenosis measurements could not be obtained. Lesions not measurable by QCA included those with stenosis greater than 85% that could not be reliably edge tracked, segments with diffuse or ecstatic disease that had no reliable reference diameter, and segments for which matched frames could not be located. Seventy-nine lesions, the majority between 21% and 40% stenosis, were identified and measured by QCA but were not identified by the panel. This comparison study demonstrates the need to consider available angiographic measurement methods in relation to the goals of their use.
To evaluate the hypothesis that diminished social and economic resources impact adversely on cardiovascular mortality in patients with coronary artery disease.
Inception cohort study of patients undergoing cardiac catheterization from 1974 through 1980 and followed up through 1989.
Tertiary care university medical center.
Consecutive sample of 1965 medically treated patients with stenosis 75% or greater of at least one major coronary artery. Five hundred patients were not enrolled due to logistic problems; 33 refused; 64 had missing data on key medical variables. The final study population included 1368 patients, 82% male, with a median age of 52 years.
Survival time until cardiovascular death.
Independent of all known baseline invasive and noninvasive medical prognostic factors, patients with annual household incomes of $40,000 or more had an unadjusted 5-year survival of 0.91, compared with 0.76 in patients with incomes of $10,000 or less (Cox model adjusted hazard ratio, 1.9; 95% confidence interval, 1.57 to 2.32; P = .002). Similarly, unmarried patients without a confidant had an unadjusted 5-year survival rate of 0.50, compared with 0.82 in patients who were married, had a confidant, or both (adjusted hazard ratio, 3.34; 95% confidence interval, 1.84 to 6.20; P less than .0001).
Low levels of social and economic resources identify an important high-risk group among medically treated patients with coronary artery disease, independent of important medical prognostic factors. Additional study will be required to see if interventions to increase these resources improve prognosis.
To determine if the presence of a disrupted marriage or living alone would be an independent prognostic risk factor for a subsequent major cardiac event following an initial myocardial infarction.
Prospective evaluation in the placebo wing of a randomized, double-blind drug trial in patients with an enzyme-documented acute myocardial infarction who were admitted to a coronary care facility. Data for living alone and/or a marital disruption were entered into a Cox proportional hazards model constructed from important physiologic and nonphysiologic factors in the same database.
Multicenter trial in a mixture of community and academic hospitals in the United States and Canada.
All consenting patients who were 25 to 75 years of age and without other serious diseases were enrolled (placebo, N = 1234) within 3 to 15 days of the index infarction and followed for a period of 1 to 4 years (mean, 2.1 years). Nine hundred sixty-seven patients were followed for 1.1 years and 530 for 2.2 years.
Recurrent major cardiac event (either recurrent nonfatal infarction or cardiac death).
Living alone was an independent risk factor, with a hazard ratio of 1.54 (95% confidence interval, 1.04 to 2.29; P less than .03). Using the Kaplan-Meier statistical method for calculation, the recurrent cardiac event rate at 6 months was 15.8% in the group living alone vs 8.8% in the group not living alone. Risk remained significant throughout the follow-up period (P = .001). A disrupted marriage was not an independent risk factor.
Living alone but not a disrupted marriage is an independent risk factor for prognosis after myocardial infarction when compared with all other known risk factors.
The 10-year prognostic significance of psychosocial as well as medical risk factors was examined in 150 middle-aged Swedish men. Type A behavior was assessed by means of the Structured Interview; work demand, social support, and other psychosocial factors were registered through standardized questionnaires. The clinical investigation included a standard physical examination, a frontal and sagittal chest x-ray, fasting serum lipids, glucose, and urate, and a 24-hour ambulatory ECG monitoring. Thirty-seven men died during follow-up. Mortality was similar in men with Type A (24%) and Type B (22%) behavior. In multivariate analyses, lack of social support/social isolation was an independent mortality predictor in Type A, but not in Type B men. In both groups, a high frequency of ventricular ectopic beats on 24-hour ECG monitoring and a poor self-rated general health predicted mortality over the 10-year period. The 10-year mortality experience of socially isolated Type A men was 69% and that of socially integrated Type A men was 17% (p less than 0.05). The findings offer a possible explanation for the observed inconsistencies between intervention and follow-up studies of Type A behavior and coronary heart disease. It is suggested that an important effect of Type A modification programs is to increase the availability of social support. This could be the mechanism through which Type A modification exerts its main effects on cardiovascular health.
This paper provides an overview of problems in multivariate modeling of epidemiologic data, and examines some proposed solutions. Special attention is given to the task of model selection, which involves selection of the model form, selection of the variables to enter the model, and selection of the form of these variables in the model. Several conclusions are drawn, among them: a) model and variable forms should be selected based on regression diagnostic procedures, in addition to goodness-of-fit tests; b) variable-selection algorithms in current packaged programs, such as conventional stepwise regression, can easily lead to invalid estimates and tests of effect; and c) variable selection is better approached by direct estimation of the degree of confounding produced by each variable than by significance-testing algorithms. As a general rule, before using a model to estimate effects, one should evaluate the assumptions implied by the model against both the data and prior information.
Previous studies have identified the MMPI-based Cook and Medley hostility scale (Ho) as a predictor of health outcomes. To achieve a better understanding of the construct measured by this scale, Ho items were classified on an a priori basis. Six subsets were identified: Cynicism, Hostile Attributions, Hostile Affect, Aggressive Responding, Social Avoidance, and Other. Study 1 examined the correlations of these subsets with scales of the NEO Personality Inventory in two samples of undergraduates. Good convergent and discriminant validity were demonstrated, but there was some evidence that items in the Social Avoidance and Other categories reflect constructs other than hostility. Study 2 examined the ability of the Ho scale and the item subsets to predict the 1985 survival of 118 lawyers who had completed the MMPI in 1956 and 1957. As in previous studies, those with high scores had poorer survival (chi 2 = 6.37, p = 0.012). Unlike previous studies, the relation between Ho scores and survival was linear. Cynicism, Hostile Affect, and Aggressive Responding subsets were related to survival, whereas the other subsets were not. The sum of the three predictive subsets, with a chi 2 of 9.45 (p = 0.002), was a better predictor than the full Ho scale, suggesting that it may be possible to refine the scale and achieve an even more effective measure of those aspects of hostility that are deleterious to health.
Using referred samples to study predictors of disease produces statistical problems that reduce the likelihood of obtaining statistically significant results even when a substantial relationship is present between a risk factor and a disease. The present paper refers to these problems as disease based spectrum (DBS) bias. DBS bias is present when subjects are directed into or excluded from the study sample according to their disease status. For example, healthy individuals are excluded from and diseased individuals are directed into referred samples. Therefore, DBS bias is present in referred samples. Examples from the literature on Type A behavior and coronary artery disease (CAD) are presented to illustrate how DBS bias reduces statistical associations. The results of the current research indicate DBS bias has reduced the association between Type A behavior and CAD in a number of studies reported in recent years. In addition, the present article discusses techniques for assessing and controlling for DBS bias.
The Cholesterol-Lowering Atherosclerosis Study (CLAS) was a randomized, placebo-controlled, angiographic trial testing combined colestipol hydrochloride and niacin therapy in 162 nonsmoking men aged 40 to 59 years with previous coronary bypass surgery. During two years of treatment there was a 26% reduction in total plasma cholesterol, a 43% reduction in low-density lipoprotein cholesterol, plus a simultaneous 37% elevation of high-density lipoprotein cholesterol. This resulted in a significant reduction in the average number of lesions per subject that progressed (P less than .03) and the percentage of subjects with new atheroma formation (P less than .03) in native coronary arteries. Also, the percentage of subjects with new lesions (P less than .04) or any adverse change in bypass grafts (P less than .03) was significantly reduced. Deterioration in overall coronary status was significantly less in drug-treated subjects than placebo-treated subjects (P less than .001). Atherosclerosis regression, as indicated by perceptible improvement in overall coronary status, occurred in 16.2% of colestipol-niacin treated vs 2.4% placebo treated (P = .002).
This study provides the first direct comparison of the relative importance of structural versus functional aspects of social network ties as they relate to susceptibility to coronary artery disease. Data from 119 men and 40 women undergoing coronary angiography provide an opportunity to compare these associations in relation to a direct and continuous measure of atherosclerosis while controlling for age, sex, income, hypertension, serum cholesterol, smoking, angina, diabetes, family history of heart disease, Type A behavior pattern, and hostility. Regression analyses indicate that network instrumental support and feelings of being loved are more important in predicting coronary atherosclerosis than is network size, independent of all covariables (relative extent of atherosclerosis, low/high support = 1.74 and 1.5, respectively). More "problem-oriented" emotional support did not show a similarly strong association (relative extent of atherosclerosis = 1.01). These findings suggest that certain functional aspects of social network ties are more strongly associated with host resistance to coronary atherosclerosis than are structural characteristics like network size.
Socially stressed adult male cynomolgus monkeys (Macaca fascicularis) fed a low fat, low cholesterol diet developed more extensive
coronary artery atherosclerosis than unstressed controls. Groups did not differ in serum lipids, blood pressure, serum glucose,
or ponderosity. These results suggest that psychosocial factors may influence atherogenesis in the absence of elevated serum
lipids. Psychosocial factors thus may help explain the presence of coronary artery disease (occasionally severe) in people
with low or normal serum lipids and normal values for the other "traditional" risk factors.
Level of hostility (Ho) was assessed by a 50-item subscale of the Minnesota Multiphasic Personality Inventory at the initial examination of 1877 employed middle-aged men who were free of coronary heart disease (CHD). Ten-year incidence of major CHD events (myocardial infarction and CHD death) was lowest in the first quintile of the Ho scale's distribution, highest in the middle quintile, and intermediate in the other three quintiles. After adjustment for age, blood pressure, serum cholesterol level, cigarette smoking, and intake of ethanol, the relative odds of a major CHD event was 0.68 for men with Ho scores less than or equal to 10 points in comparison to men with higher scores. The Ho scale was positively associated with crude 20-year mortality from CHD, malignant neoplasms, and causes other than cardiovascular--renal diseases and malignant neoplasms. After adjustment for the risk factors listed above, the Ho scale had a statistically significant, positive, monotonic association with 20-year risk of death from all causes combined. A difference of 23 points on the Ho scale, i.e., the difference between the means of the first and the fifth quintiles, was associated with a 42% increase in the risk of death. These results support the previous findings of Williams et al. with respect to the Ho scale and coronary atherosclerosis, and also suggest that the Ho scale may be associated with factors having broad effects on survival.
Confounding is examined from first principles. In follow-up studies a confounder is a predictor of diagnosing the illness--by being either a risk indicator or a determinant of diagnostic errors; in addition, it shows different distributions between the exposed and nonexposed series. In case-referent studies confounding can arise in two ways. A priori confounders are correlates of exposure in the joint source population of cases and reference subjects; also, they are determinants of diagnosing the illness or have different selection implications between cases and referents. In addition, factors bearing on the accuracy of exposure information are confounders if distributed differently between cases and referents. Criteria based singularly on relationships in the data can be misleading. Similarly, a change in the estimate and even a change in the parameter as a result of control is not a criterion rooted in first principles of confounding and can lead to a false conclusion.
Type A behavior pattern was assessed using the structured interview and hostility level was assessed using a subscale of the Minnesota Multiphase Personality Inventory in 424 patients who underwent diagnostic coronary arteriography for suspected coronary heart disease. In contrast to non-Type A patients, a significantly greater proportion of Type A patients had at least one artery with a clinically significant occlusion of 75% or greater. In addition, only 48% of those patients with very low scores (less than or equal to 10) on the Hostility scale exhibited a significant occlusion; in contrast, patients in all groups scoring higher than 10 on the Hostility scale showed a 70% rate of significant disease. The essential difference between low and high scorers on the Hostility scale appears to consist of an unwillingness on the part of the low scorers to endorse items reflective of the attitude that others are bad, selfish, and exploitive. Multivariate analysis showed that both Type A behavior pattern and Hostility score are independently related to presence of atherosclerosis. In this analysis, however, Hostility score emerged as more related to presence of atherosclerosis than Type A behavior pattern. These findings confirm previous observations of increased coronary atherosclerosis among Type A patients. They suggest further that an attitudinal set reflective of hostility toward people in general is over and above that accounted for by Type A behavior pattern. These findings also suggest that interventions to reduce the contribution of behavioral patterns to coronary disease risk might profitably focus especially closely on reduction of anger and hostility.
This study examines the effect of coronary angioplasty on the progression and appearance of new disease in sites of the coronary tree that were not dilated by the balloon. We examined 355 pairs of coronary angiograms from 252 patients. The study consisted of consecutive patients who were referred for catheterization > 1 month after successful angioplasty. Progression/regression and the appearance of new narrowings at sites not dilated by angioplasty were determined. The life-table method was used to determine outcome, and any event (progression, regression, and new narrowing) was analyzed according to the time of occurrence. The angioplasty artery was compared with the non-angioplasty artery and the effect of restenosis was determined by comparing arteries with and without restenosis. Progression/regression rates were not significantly different in angioplasty and non-angioplasty arteries. More new narrowings were identified in the angioplasty artery (p < 0.01). With regard to narrowings located in the angioplasty artery, progression was more common, regression less common, and the appearance of new narrowings more common in arteries with restenosis than in non-angioplasty arteries or arteries without restenosis. We believe that mechanical trauma to the artery during angioplasty could accelerate disease progression and the appearance of new narrowings in angioplasty arteries, whereas normalization of flow rate and pattern, especially in arteries without restenosis, attenuates the rate of progression and the appearance of new narrowings in these arteries. The final outcome depends on the balance between these factors.
This analysis examines the pooled data from all 14 published randomized angiographic trials (with 16 treatment arms) by type of cholesterol-lowering intervention evaluated, and for all the trials combined. All interventions reduced low density lipoprotein (LDL) cholesterol levels (average reduction, 26%), whereas the effects on high density lipoprotein (HDL) cholesterol and triglycerides varied by type of intervention. Meta-analyses of the angiographic outcomes indicated that treatment reduced the odds for disease progression by 49%, increased the odds for no change by 33%, and increased the odds for regression by 219%. Cardiovascular events were reduced by 47%. Thus, lipid reduction is effective for modifying the angiographic outcome and for reducing the incidence of coronary artery disease events. All types of intervention (lifestyle, drugs, or surgery) had overall favorable effects on angiographic and clinical outcomes. There was no class effect for the statin group of drugs. Surgery (partial ileal bypass) had the most favorable angiographic outcome, possibly because of a longer duration of therapy. Trials with higher baseline LDL levels tended to have more favorable angiographic outcomes. Analyses of in-trial levels of LDL were confounded by baseline levels, and analyses of change in LDL levels in the treatment groups were confounded by not including zero change (i.e., no treatment). It is hypothesized that lowering LDL levels by 30 mg/dl (0.8 mmol/liter) is sufficient on average to modify the angiographic outcome, with modest gains from further reductions in LDL levels.
Coronary stenting in conjunction with coronary angioplasty is a valuable tool for treatment of severe coronary dissection and is effective in reducing the frequency of restenoses. Evidence is increasing that the lumen gain within the stent is negatively correlated with the rate of subacute closures and restenoses. Since the assessment of radiolucent coronary stents and complex lumen morphologies by angiography is limited, we hypothesized that the use of a balloon catheter with integrated intravascular ultrasound (IVUS) facility for stent deployment and guidance of its expansion could improve the acute lumen gain without relevant procedural prolongation.
Deployment of a single Palmaz-Schatz coronary stent with the combined imaging balloon catheter alone was successful in 18 of 20 patients eligible for this study. Corresponding measurements of minimal lumen diameter (MLD) by angiography and IVUS could be performed in 16 patients, revealing a close correlation between the two methods within the reference segments (3.10 +/- 0.38 and 3.08 +/- 0.43 mm, r = .79). Despite an adequate angiographic result in most patients after stent deployment, IVUS showed smaller MLD within the stented segment (2.15 +/- 0.23 mm) compared with angiography (2.63 +/- 0.26 mm, P < .0001) with a poor correlation (r = .27). To achieve IVUS criteria for optimal stent expansion (ratio of 0.9 between IVUS-assessed cross-sectional area of stent and reference segment), an average of three additional balloon inflations with higher pressure and/or a larger balloon diameter were performed without adverse effects in 15 of 16 patients who initially did not fulfill these criteria. This resulted in a significant increase in stent MLD to 2.63 +/- 0.27 mm (IVUS, P < .0001 versus initial MLD) and 2.89 +/- 0.32 mm (angiography, P < .0002 versus initial MLD) and a better correlation between the two methods (r = .60). The IVUS guidance led to a 40 +/- 15% increase of the minimal stent cross-sectional area with an additional time consumption of 21 minutes on average.
This study demonstrates the application of a combined imaging balloon catheter for delivery and ultrasound-guided expansion of Palmaz-Schatz coronary stents. IVUS offered a comprehensive insight into the stented coronary segments, revealing a substantial overestimation of stent dimensions by angiography. IVUS guidance led to a significant improvement of stent expansion. This additional lumen gain, which was not discernible by angiography in most patients, might result in a reduction of subacute stent thromboses as well as restenoses.
Imaging trials using arteriography have been shown to be effective alternatives to clinical end point studies of atherosclerotic vascular disease progression and the effect of therapy on it. However, lack of consensus on what end point measures constitute meaningful change presents a problem for quantitative coronary arteriographic (QCA) approaches. Furthermore, standardized approaches to QCA studies have yet to be established. To address these issues, two different arteriographic approaches were compared in a clinical trial, and the degree of concordance between disease change measured by these two approaches and clinical outcomes was assessed.
In the Familial Atherosclerosis Treatment Study (FATS) of three different lipid-lowering strategies in 120 patients, disease progression/regression was assessed by two arteriographic approaches: QCA and a semiquantitative visual approach (SQ-VIS). Lesions classified with SQ-VIS as "not," "possibly," or "definitely" changed were measured by QCA to change by 10% stenosis in 0.3%, 11%, and 81% of cases, respectively. The "best" measured value for distinguishing definite from no change was identified as 9.3% stenosis by logistic regression analysis. The primary outcome analysis of the FATS trial, using a continuous variable estimate of percent stenosis change, gave almost the same favorable result whether by QCA or SQ-VIS.
The excellent agreement between these two fundamentally different methods of disease change assessment and the concordance between disease change and clinical outcomes greatly strengthens confidence both in these measurement techniques and in the overall findings of the study. These observations have important implications for the design of clinical trials with arteriographic end points.
This study examines the effect of anger and vital exhaustion on recurrent events after percutaneous transluminal coronary angioplasty (PTCA). Data came from 149 patients (123 men and 26 women) who underwent successful PTCA. During 18 months of follow-up, there were 37 recurrent events (25%) for which there was objective evidence of new or progression of coronary disease. The 123 male patients with high anger were significantly more likely to have multivessel disease before PTCA (odds ratio 2.42; p = 0.04), after controlling for standard heart disease risk factors. High-anger male patients also had a threefold increased risk for recurrent events after PTCA (RR 2.94; p = 0.01), which remained marginally significant after accounting for other heart disease risk factors and residual stenosis after PTCA (RR 2.33; p = 0.09). Among female patients, these relations were much weaker and not statistically significant. Among male patients, additional adjustment for vital exhaustion did not change the risk for recurrent events associated with high anger. A composite index of psychosocial risk based on anger and vital exhaustion was significantly related (p = 0.02) to events after PTCA after adjustment for standard heart disease risk factors. These findings add to the growing body of research on the role of psychosocial factors on clinical course in patients with coronary artery disease.
To investigate the "toxic" total (potential for) hostility component of the type A behavior pattern (assessed by means of the structured interview) as it relates to prediction of restenosis after percutaneous transluminal coronary angioplasty (PTCA).
Patients with single vessel or multivessel coronary artery disease in whom PTCA had been scheduled or done were administered the structured interview by one trained interviewer prospectively or retrospectively (blinded to angiographic endpoints).
A total of 41 patients underwent 53 initial balloon dilations on native arteries by 1 of 5 participating cardiologists. Inclusion criteria for this study were a successful initial PTCA and post-PTCA recatheterization if a patient complained of ischemic symptoms possibly related to restenosis.
Of the 41 patients, 15 (36.6%) had restenoses at a total of 18 previous angioplasty sites. Patients with high total (potential for) hostility ratings were almost 2.5 times more likely to have restenosis than those with low total (potential for) hostility scores (95% confidence interval = 1.03 to 5.32). Logistic regression revealed that total (potential for) hostility scores predicted post-PTCA restenosis overall as well as when adjusted for gender and race. Total (potential for) hostility scores were also positively associated with the number of arteries restenosed (P = 0.01).
This is the first report of type A total (potential for) hostility behavior conferring an increased risk for restenosis after PTCA. Its modification may be effective in reducing recurrent cardiac events. A coronary-prone behavior modification program for patients with persistent, same-site restenosis after PTCA has been initiated.
Coronary restenosis has proven to be the "Achilles heel" of percutaneous coronary interventions, frequently leading to repeated procedures. The pathogenesis of restenosis can be divided into four phases: early elasic recoil (hours to days), mural thrombus formation (hours to days), neointimal proliferation and extracellular matrix formation (weeks), and chronic geometric arterial changes (months). Restenosis is device nonspecific except for intravascular stents, which can eliminate elastic recoil and prevent geometric vessel changes, leading to decreased restenosis. Of all antithrombotics tried so far, only an inhibitor of the platelet IIb/IIIa integrin, which may lead to early vessel wall passivation, has shown reduction of clinical restenosis. Trapidil (antiproliferative agent) and angiopeptin (somatostatin analog) have also resulted in improved restenosis rates. The field of local drug delivery is currently under investigation in association with radiation or molecular therapy. The current specific target of these approaches is the neointimal proliferation, especially because this is the most dominant mechanism of restenosis after stent placement. Evaluation of these novel methods is complex and interrelates the delivery system with the therapeutic agent administered. However, they provide the means for very specific and timely interruption of the pathogenic process that may lead to better understanding and, ultimately, elimination of restenosis.
Recent laboratory and epidemiological studies have suggested that high levels of anger may increase the risk of coronary heart disease (CHD).
We examined prospectively the relationship of anger to CHD incidence in the Veterans Administration Normative Aging Study, an ongoing cohort of older (mean age, 61 years) community-dwelling men. A total of 1305 men who were free of diagnosed CHD completed the revised Minnesota Multiphasic Personality Inventory (MMPI-2) in 1986. Subjects were categorized according to their responses to the MMPI-2 Anger Content Scale, which measures the degree to which individuals have problems controlling their anger. During an average of 7 years of follow-up, 110 cases of incident CHD occurred, including 30 cases of nonfatal myocardial infarction hostility. (MI), 20 cases of fatal CHD, and 60 cases of angina pectoris. Compared with men reporting the lowest levels of anger, the multivariate-adjusted relative risks among men reporting the highest levels of anger were 3.15 (95% confidence interval) [CI]: 0.94 to 10.5) for total CHD (nonfatal MI plus fatal CHD) and 2.66 (95% CI: 1.26 to 5.61) for combined incident coronary events including angina pectoris. A dose-response relation was found between level of anger and overall CHD risk (P for trend, .008).
These data suggest that high levels of expressed anger may be a risk factor for CHD among older men.
The Monitored Atherosclerosis Regression Study was a double-blind, 2-year, placebo-controlled, randomized, serial angiographic trial which tested reduction of low density lipoprotein-cholesterol with monotherapy using lovastatin on the progression of coronary atherosclerosis. Angiographic outcome was evaluated both by a panel of human readers who visually inspected matched film pairs to arrive at a global change score and by automated computerized vessel edge finding and lesion measurement (quantitative coronary angiography, QCA). In this paper, we model the association between QCA measures of coronary artery lesion change and the panel-based global change score. QCA measures included: per-patient changes in percent diameter stenosis and minimum lumen diameter averaged over all lesions; per-patient changes in average diameter and percent involvement averaged over all segments; the numbers of progressing and regressing lesions and new total occlusions; and the development of any new lesions.
Evaluating the independent effects of psychosocial and physiological factors on survival of cardiac patients is difficult because it requires obtaining extensive physiological and psychosocial data and long-term follow-up of high-risk patients.
To examine the independent contributions of psychosocial and physiological status to survival of patients who had had myocardial infarction.
The sample consisted of 348 patients in the Cardiac Arrhythmia Suppression Trial who had asymptomatic ventricular arrhythmias after myocardial infarction. Psychosocial status was assessed with the Social Support Questionnaire-6, Social Readjustment Rating Scale, State-Trait Anxiety Inventory, Self-Rating Depression Scale, Jenkins Activity Survey, and Expression of Anger Scale. Physiological data included measurement of left ventricular ejection fraction; history of previous myocardial infarction, congestive heart failure, and diabetes; and results of Holter monitoring.
At the first follow-up, after the effect of the physiological predictors was controlled for, psychosocial factors were significant independent predictors of survival. Among men in the nonactive medication group (n = 263), higher state anxiety, lower anger outward, more past life events, and lower expectations of future life events were predictors of mortality. Data suggested that the relationship of anger to mortality might differ for men and women. Increases in past life events and depression from baseline to first follow-up were greater among those who died than among those who lived.
Among patients who had asymptomatic ventricular arrhythmias after myocardial infarction, psychological status during the period after infarction contributed to mortality beyond the effect of physiological status. The results reaffirm the critical interrelationship between mind and body for cardiovascular health.
This cross-sectional study investigated the association of hostility and social support to coronary heart disease (CHD) in 2 groups of men and women: those with a familial predisposition for CHD (high-risk sample) and a randomly selected group. The hypothesis was that hostility and low social support would be associated with CHD, and would have a greater effect in the high-risk group. The random sample contained 2,447 individuals (47.1% male) from 576 families, and the high-risk sample consisted of 2,300 people (45.5% male) from 542 families. Odds ratios (OR) and their 95% confidence intervals were calculated using generalized estimating equations (GEE) for logistic regression. Family was specified as the clustering variable, and robust SEEs were obtained to account for dependence of the data within families. After controlling for age, education, body mass index, exercise, smoking history, drinking history, and drinking >5 drinks a day, hostility was associated with a history of coronary bypass surgery or coronary angioplasty in high-risk men (OR 1.21) and a history of myocardial infarction in high-risk women (OR 1.39). High-risk women with high social support had reduced odds of a previous myocardial infarction (OR 0.76), whereas women with high network adequacy in the random sample had reduced risk of myocardial infarction (OR 0.41) and angina (OR 0.49). A ratio of high hostility to low social support was associated with past myocardial infarction in high-risk women (OR 2.47) and a history of angina (OR 2.02) in the random sample men. These results suggest that high hostility and low social support are associated with some manifestations of CHD after controlling for adverse health behaviors.
Epidemiologic studies, studies of mechanisms of action, and many animal studies indicate that dietary intake of omega-3 fatty acids has antiatherosclerotic potential. Few trials in humans have examined this potential.
To determine the effect of dietary intake of omega-3 fatty acids on the course of coronary artery atherosclerosis in humans.
Randomized, double-blind, placebo-controlled, clinically controlled trial.
University preventive cardiology unit.
223 patients with angiographically proven coronary artery disease.
Fish oil concentrate (55% eicosapentaenoic and docosahexaenoic acids) or a placebo with a fatty acid composition resembling that of the average European diet, 6 g/d for 3 months and then 3 g/d for 21 months.
The results of standardized coronary angiography, done before and after 2 years of treatment, were evaluated by an expert panel (primary end point) and by quantitative coronary angiography. Patients were followed for clinical and laboratory status.
Pairs of angiograms (one taken at baseline and one taken at 2 years) were evaluated for 80 of 112 placebo recipients and 82 of 111 fish oil recipients. At the end of treatment, 48 coronary segments in the placebo group showed changes (36 showed mild progression, 5 showed moderate progression, and 7 showed mild regression) and 55 coronary segments in the fish oil group showed changes (35 showed mild progression, 4 showed moderate progression, 14 showed mild regression, and 2 showed moderate regression) (P = 0.041). Loss in minimal luminal diameter, as assessed by quantitative coronary angiography, was somewhat less in the fish oil group (P > 0.1). Fish oil recipients had fewer cardiovascular events (P = 0.10); other clinical variables did not differ between the study groups. Low-density lipoprotein cholesterol levels tended to be greater in the fish oil group.
Dietary intake of omega-3 fatty acids modestly mitigates the course of coronary atherosclerosis in humans.
Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.
Das State-Trait-A ¨ rgerausdrucks-Inventar STAXI Handbuch. First edition
- P Schwenkmezger
- V Hodapp
- Spielberger
- Cd
Schwenkmezger P, Hodapp V, Spielberger CD. Das State-Trait-A ¨ rgerausdrucks-Inventar STAXI Handbuch. First edition. Bern: Hans Huber, 1992.
Das State-Trait- A ¨ rgerausdrucks-Inventar STAXI Handbuch
- P Schwenkmezger
- V Hodapp
- Cd Spielberger
Schwenkmezger P, Hodapp V, Spielberger CD. Das State-Trait-
A ¨ rgerausdrucks-Inventar STAXI Handbuch. First edition. Bern:
Hans Huber, 1992.
Social networks and coronary artery disease
- Seeman
The Cook-Medley hostility scale
- Barefoot
Coronary heart disease
- Greenwood
Type A behavior, social support, and coronary risk
- Orth-Gomer
The effect of dietary ω-3 fatty acids on coronary atherosclerosis
- von Schacky