Mind Your Heart

Clinicians as far back as the father of internal medicine, Sir William Osler, have noted characteristic behavioral patterns in patients with heart disease. In 1897, Osler observed that “the typical heart disease patient is a keen and ambitious man … whose engine is always at full speed ahead” (1). Almost a century later, cardiologists Friedman and Rosenman picked up on this theme by linking the type A behavior pattern, a combination of time urgency and hostility, with coronary heart disease (CHD) (2). In 1986, they published a randomized, controlled trial of type A behavioral therapy in 862 patients after myocardial infarction and found that, during 4.5 years of follow-up, patients who received type A behavioral therapy plus group cardiac counseling were less likely to develop CHD events (myocardial infarction or cardiac death) than those who received group cardiac counseling alone (3). Subsequent work by Barefoot and colleagues (4) and others demonstrated that hostility was the component of type A personality primarily responsible for its association with CHD events.

During the past 20 years, several other psychological factors, such as anger, anxiety, and depression, have also been associated with an increased risk for CHD events and with adverse outcomes among patients with established CHD (5, 6). A recent study of more than 25 000 patients from 52 countries found that psychological factors were stronger risk factors for incident myocardial infarction than diabetes, smoking, hypertension, and obesity (7). Despite the strong evidence supporting this relationship, however, we do not know whether or how psychological factors actually cause CHD events.

In this issue, Diez Roux and colleagues (8) report the results of an elegant cross-sectional study examining the relationship between psychological factors and coronary artery calcium in a multiethnic, community-based sample of 6814 Americans age 45 to 85 years with no …