Evid Based Nurs 12:121 doi:10.1136/ebn.12.4.121
  • Causation

Review: anger and hostility increase risk of coronary heart disease events in healthy people and those with existing CHD


Are personality traits of anger and hostility associated with increased risk of coronary heart disease (CHD) events in healthy people or those with existing CHD?

Review scope

Included studies evaluated the association between anger and hostility and future CHD events in healthy people and people with CHD. Studies evaluating the effect of acute anger were excluded. Outcomes were CHD events (including CHD mortality, non-fatal myocardial infarction, angina, cardiac arrest, and coronary artery restenosis).

Review methods

Medline, PsycINFO, Web of Science, and PubMed (to Nov 2008); and references were searched for prospective cohort studies published as full-length English-language articles in peer-reviewed journals. 38 articles involving 25 cohorts of healthy people (n = 71 606, duration of follow-up 2–47 y) and 19 cohorts of people with CHD (n = 8120, duration of follow-up 1–20 y) met the selection criteria (men and women were considered as separate cohorts if data were available). Mean methodological quality score (range 0–4, best) was 2.6 in studies of healthy people and 2.2 in studies of people with CHD.

Main results

Anger and hostility were associated with increased risk of CHD events in both healthy people and those with CHD (table). Greater effect sizes were seen in studies with longer duration of follow-up and those with lower quality scores, and in men compared with women (healthy people).

Anger and hostility personality traits and risk of coronary heart disease (CHD) events


Personality traits of anger and hostility are associated with increased risk of coronary heart disease events in healthy people and those with existing CHD.

Abstracted from

Chida Y, Steptoe A. The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol 2009;53:936–46.

Clinical impact ratings: Cardiology 5/7; Family/general practice 5/7; General/internal medicine 5/7; Health promotion 5/7; Psychiatry 5/7


  • Source of funding not stated.


Establishing a causal link between psychological concepts and somatic disorders with a reasonable degree of validity and reliability is difficult. To date, most studies of this type have tended to focus on the relation between stress or depression and physical illness.

The meta-analysis by Chida and Steptoe examined the association between anger and hostility and CHD, focusing on prospective cohort studies that used quantitative methods. This topic is potentially problematic because of the often arbitrary and variable sociocultural perceptions of anger and hostility. The issue is compounded further by the authors’ decision to examine anger and hostility together as one construct, bearing in mind the clear distinction between these terms. Nevertheless, the findings show that anger and hostility are associated with CHD in both healthy and CHD populations.

Interestingly, the findings of the review also suggest that the harmful effects of anger and hostility on CHD events in healthy people are greater in men than in women. The authors did not explore this phenomenon in depth; however, they proposed that the accumulation of greater stress responses in daily life may have pathophysiological consequences for CHD in men. Clearly, this finding may also be attributable to several other variables, such as social learning, alcohol consumption, and lifestyle.

Despite the obvious methodological problems associated with this type of review, Chida and Steptoe have highlighted the link between psychophysiology and CHD. The results of the review lend support to a holistic multidisciplinary approach for the prevention and treatment of heart disease and for managing anger and hostility appropriately.

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