Hostility, health behaviors, and risk of recurrent events in patients with stable coronary heart disease: findings from the Heart and Soul Study

Jonathan M Wong, Beeya Na, Mathilda C Regan, Mary A Whooley, Jonathan M Wong, Beeya Na, Mathilda C Regan, Mary A Whooley

Abstract

Background: Hostility is a significant predictor of mortality and cardiovascular events in patients with coronary heart disease (CHD), but the mechanisms that explain this association are not well understood. The purpose of this study was to evaluate potential mechanisms of association between hostility and adverse cardiovascular outcomes.

Methods and results: We prospectively examined the association between self-reported hostility and secondary events (myocardial infarction, heart failure, stroke, transient ischemic attack, and death) in 1022 outpatients with stable CHD from the Heart and Soul Study. Baseline hostility was assessed using the 8-item Cynical Distrust scale. Cox proportional hazard models were used to determine the extent to which candidate biological and behavioral mediators changed the strength of association between hostility and secondary events. During an average follow-up time of 7.4 ± 2.7 years, the age-adjusted annual rate of secondary events was 9.5% among subjects in the highest quartile of hostility and 5.7% among subjects in the lowest quartile (age-adjusted hazard ratio [HR]: 1.68, 95% confidence interval [CI]: 1.30 to 2.17; P < 0.0001). After adjustment for cardiovascular risk factors, participants with hostility scores in the highest quartile had a 58% greater risk of secondary events than those in the lowest quartile (HR: 1.58, 95% CI: 1.19 to 2.09; P = 0.001). This association was mildly attenuated after adjustment for C-reactive protein (HR: 1.41, 95% CI, 1.06 to 1.87; P = 0.02) and no longer significant after further adjustment for smoking and physical inactivity (HR: 1.25, 95% CI: 0.94 to 1.67; P = 0.13).

Conclusions: Hostility was a significant predictor of secondary events in this sample of outpatients with baseline stable CHD. Much of this association was moderated by poor health behaviors, specifically physical inactivity and smoking.

Keywords: coronary artery disease; epidemiology; hostility; mortality; observational studies.

Figures

Figure 1.
Figure 1.
Distribution of cynical distrust scores. Distribution of self‐reported 8‐item cynical distrust scores administered at baseline. All items were true/false questions and true responses were worth 1 point. Cynical distrust scores ranged from 0 to 8. Approximately 99% of study participants (1011/1022) answered all 8 items.
Figure 2.
Figure 2.
Age‐adjusted annual rate of secondary events by hostility quartile. Quartile I (lightest shade of blue) represents the lowest self‐reported cynical hostility scores, with each sequential quartile increasing in hostility severity. Increasing hostility was significantly associated with “All‐cause mortality” and “Any event”, a composite of stroke/transient ischemic event, myocardial infarction, heart failure, and death. TIA indicates transient ischemic attack.
Figure 3.
Figure 3.
Change in strength of association between hostility (quartile IV vs I) and secondary events after adjustment for potential confounders and mediators. The change in effect size is expressed as the percent change of the age‐adjusted log hazard ratio (β‐coefficient). Covariates that changed the effect size for hostility by

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