Hostility and the Risk of Ischemic Heart Disease

Abstract & Commentary

By Harold L. Karpman, MD, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman serves on the speakers bureau for Forest Laboratories.

Synopsis: The presence of any observed hostility at baseline was associated with a two-fold increased risk of incident ischemic heart disease over a 10-year period of observation.

Source: Newman JD, et al. Observed hostility and the risk of incident ischemic heart disease. J Am Coll Cardiol 2011; 58:1222-1228.

Although many studies have demonstrated a significant relationship between anger and hostility and the development of ischemic heart disease (IHD),1 other studies have not demonstrated this association.2,3 In addition, it has not been clearly demonstrated whether hostility prediction of the frequency of IHD occurs in a graded fashion since most assessments of hostility have been made using patient-reported measures, which unfortunately require self-awareness of hostility and are, therefore, more susceptible to reporting biases.4-6 By contrast, interviewer-measures of hostility allow for the assessment of interpersonal cues and manifestations of hostility that self-reporting scales do not accurately assess.

Newman and his colleagues investigated the relationship between hostility and IHD in an attempt to determine whether the observed measurement of hostility is more accurate than the patient-reported measurement.7 Previous studies had not compared methods of hostility assessment or considered important psychosocial and cardiovascular risk factors as confounders. In addition, they attempted to determine whether all expressions of hostility carried equal risk or if certain manifestations were more cardiotoxic. They assessed the independent relationship between baseline observed hostility and the 10-year incidence of IHD in 1749 adults who were part of the population-based Canadian Nova Scotia Health Survey. They concluded that observed hostility at baseline was associated with a two-fold increased risk of incident IHD over 10 years of follow-up and that observed hostility was a superior predictor of IHD compared with patient-reported measures of hostility.


It is important to recognize that the results of this study7 were obtained after adjusting for several known cardiovascular and psychosocial risk factors including depressive symptoms, patient-reported hostility, destructive anger, and positive affect. The results also suggested that although observed hostility seems to predict incident IHD in a graded fashion, this relationship was mostly due to the difference between any vs no observed hostility similar to other studies, which have suggested that the relationship was nonlinear.8,9 It must be carefully noted that hostility measures were observed only at baseline, and observations were not made continuously over the nearly 10 years of follow-up. However, results of prior studies have reported that personality characteristics such as hostility and positive affect are stable over time.10,11 Also, it is important to be aware that psychosocial factors, such as interpersonal stress and social isolation, even though associated with varying degrees of hostility could have, at least partially, contributed to the increased incidence of IHD.

The Newman study7 supports the conclusion that psychological interventions for the management of hostility will reduce the incidence of future IHD events, as has been reported in the previous studies. However, additional studies will be necessary to better characterize the relationship between hostility and IHD and to describe the subtypes of hostility which may be more likely to be associated with an increased incidence of IHD. There certainly seems to be every reason for the practicing clinician to assess all patients carefully for signs of hostility and/or anger — especially if they have any cardiovascular risk factors — to determine when it is appropriate to recommend psychological interventions, if needed, in a timely manner in order to avoid the increased risk of IHD in these patients.


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2. Surtees P, et al. Prospective cohort study of hostility and the risk of cardiovascular mortality. Int J Cardiol 2005;100:155-161.

3. Sturmer T, et al. Personality, lifestyle, and risk of cardiovascular disease and cancer: Follow-up of population-based cohort. BMJ 2006;332:1359-1366.

4. Davidson K, et al. Potential for hostility and faking-good in high-hostile men. J Behav Med 1997;20:47-54.

5. Matthews KA, et al. Hostile behaviors predict cardiovascular mortality among men enrolled in the multiple risk factor intervention trial. Circulation 2004;109:66-70.

6. Barefoot J, et al. In: Siegman AW, et al, editors. Anger, Hostility, and the Heart. Hillsdale, New Jersey: Lawrence Erlbaum, 1994:43-66.

7. Newman JD, et al. Observed hostility and the risk of incident ischemic heart disease. J Am Coll Cardiol 2011; 58:1222-1228.

8. Barefoot J, et al. Hostility, CHD incidence, and total mortality: A 25 year follow-up study of 255 physicians. Psychosom Med 1983;45:59-63.

9. Williams RB Jr, et al. Type A behavior, hostility, and coronary atherosclerosis. Psychosom Med 1980;42:539-549.

10. Davidson KW, et al. Don’t worry, be happy: Positive affect and reduced 10-year incident coronary heart disease: The Canadian Nova Scotia Health Survey. Eur Heart J 2010;31:1065-1070.

11. Conley JJ. Longitudinal stability of personality traits: A multitrait-multimethod-multioccasion analysis. J Pers Soc Psychol 1985;49:1266-1282.

12. Linden W, et al. Psychological treatment of cardiac patients: A meta-analysis. Eur Heart J 2007;28:2972-2984.