Anger Expression and Risk of Coronary Heart Disease: Evidence from the Nova Scotia Health Survey

Karina W. Davidson, PhD; Elizabeth Mostofsky, MPH


Am Heart J. 2010;159(2):199-206. 

In This Article

Abstract and Introduction


Background Whereas some studies have found that anger increases the risk of incident coronary heart disease (CHD), others found anger to be protective. Prior studies did not account for different types of anger expression, which may be associated with opposing levels of cardiovascular risk. This study examines whether distinct types of anger expression differentially predict incident CHD.
Methods We conducted a population-based, observational prospective study of 785 randomly selected Canadian men and women (50% each) aged 46 to 92 years and free of CHD in 1995. Using videotaped interviews, trained coders rated 3 types of anger expression: constructive anger (discussing anger to resolve the situation), destructive anger justification (blaming others for one's anger), and destructive anger rumination (brooding over an anger-inducing incident). The association between anger expression type per SD and incident CHD was estimated using Cox proportional hazards models adjusted for sex, age, cardiovascular risk factors, depressive symptoms, hostility, and anxiety. Interactions of anger expression type and gender were also tested.
Results There were 115 incident CHD events (14.6%) during 6,584 person-years of follow-up. The association between clinically assessed constructive anger expression and CHD varied by gender (P for interaction = .02); higher levels were associated with a lower risk of incident CHD in men only (hazard ratio 0.58, 95% CI 0.43–0.80, P < .001), whereas higher levels of destructive anger justification was associated with a 31% increased risk of CHD in both sexes (hazard ratio 1.31, 95% CI 1.03–1.67, P = .03) and predicted CHD incidence independent of covariates and depressive symptoms, hostility, and anxiety.
Conclusions Decreased constructive anger in men and increased destructive anger justification in men and women are associated with increased risk of 10-year incident CHD.


Studies on anger expression and incident coronary heart disease (CHD) have not been consistent.[1] For instance, Eng et al[2] found that moderate anger expression seemed to protect against incident myocardial infarction and stroke in men participating in the Health Professionals Study, whereas Chang et al[3] found that increased levels of angry reactions to stress (expressed or concealed anger, gripe sessions, and irritability) were strongly associated with premature CHD and premature myocardial infarction in men; and there was no significant association between self-reported measures of anger expression and incident CHD in the Framingham Offspring Study.[4] Based on these discrepant findings, some researchers have concluded that anger expression is not a clinically relevant risk factor for CHD.[1,5–7] However, we hypothesized that the conflicting findings may be due to differences in measures of anger expression.

There are at least 3 distinct types of anger expression.[8] Whereas one type of anger expression can be motivated by constructive reasons—to solve the problem—other types can be motivated by destructive reasons—to justify one's current feelings or to intensify one's anger.[9] Current self-report measures do not differentiate these types of anger expression. Furthermore, most measures rely on self-reported anger expression rather than a clinical assessment that may provide a more accurate portrayal of the motivation underlying the anger expression. For instance, one study has shown that whereas a friend, family, and observer may report that an individual expresses destructive anger justification and rumination, that individual usually reports that his or her anger is primarily constructive.[24] As a result, the findings on the association between self-reported anger expression and CHD have been inconsistent,[1,7] with relative risks ranging from insignificant to 6.40 for fatal and nonfatal myocardial infarction,[1] possibly because of combining measures of harmful and protective aspects of anger expression. Anger expression is also likely to be correlated with other negative emotions, so it is important to examine their simultaneous impact in multivariate analyses; yet such data are rarely available.[1] This analysis examines the independent role of 3 types of anger expression that were clinically assessed and examined in multivariable analyses accounting for other psychosocial factors in a randomly selected, population-based sample of adult men and women enrolled in the 1995 Nova Scotia Health Survey (NSHS95).


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