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Anger predicts long-term mortality in patients with myocardial infarction Franco Bonaguidi Institute of Clinical Physiology, CNR Pisa, Italy DECLARATION OF CONFLICT OF INTEREST No conflict of interest Background 1 – IFC, Personality traits and prognosis Religiosity is associated with prolonged survival in patients undergoing liver transplantion Bonaguidi F, Rovai D, et al .Liver Transpl. 2010;16:1158-63. Anxiety and low emotional sensitivity are significant predictors of 8-year cardiac mortality after AMI Carpeggiani C, Bonaguidi F, et al. Eur Heart J. 2005;26:1612-7 Background 2 – Anger and CAD • A meta-analysis of 25 studies showed that anger and hostility are associated with coronary heart disease outcomes both in healthy and coronary heart disease population. Chida Y, Steptoe A. J Am Coll Cardiol. 2009;53:936-46 • Patients with CAD who suppress their anger were at increased risk of adverse cardiac events, and this was accounted for by individual differences in type D personality (tendency to live negative emotions and strong inhibition to express them) Denollet J, et.al. Am J Cardiol 2010; 105:1555-1560. Aim To evaluate the predictive value of the personality traits and behavioural responses in patients who survived acute myocardial infarction (AMI). Methods 228 patients (200 males, mean age=55±8 years) with AMI were recruited from 13 Italian Coronary Care Units. At pre-discharge patients were evaluated for psychological aspects using both the 16PF questionnaire of Cattel (Extraversion; Anxiety; Sensitivity;Self-control) and the Psy-Inventory scales (Responsibility; Energy;Obsessiveness;Anger; stress-related disturbances and time urgency). Clinical data, including traditional risk factors, peak cardiac necrosis enzymes (CPK), left ventricular WMSI (by 2D-echocardiography) and HRV were also considered in the study. Patients were followed-up for ten years (median 97 months). A Cox regression analysis was used to select the significant predictors of future cardiac events. Results During the follow-up period, 51 events were recorded 28 cardiac deaths 51 events 23 non fatal re-infarction) FACTORS RESULTS OF UNIVARIATE COX ANALYSIS HR (95% CI) p value Age (yrs) 1.04 (1.00-1.08) 0.034 Gender (male) 2.66 (0.82-8.56) 0.100 Traditional risk factors (diabetes ) 2.30 (1.12- 4.73) 0.023 Peak cardiac necrosis infarction 0.74 (0.42-1.29) 0.293 Left ventricular WMSI (2D Echo) 1.29 (0.75-2.25) 0.353 HR variability 1.04 (0.60-1.79) 0.889 Extraversion 1.14 (0.65-1.98) 0.654 Anxiety 1.83 (1.06-3.16) 0.029 Sensitivity 0.89 (0.52-1.54) 0.068 Self-control 0.83 (0.48-1.44) 0.505 Responsibility 0.59 (0.31-1.13) 0.114 Energy 0.69 (0.39-1.19) 0.181 Obsessiveness 1.08 (0.63-1.87) 0.767 Anger 2.35 (1.33-4.16) 0.003 Stress-related disturbances 1.96 (1.14-3.37) 0.154 Time-urgency 1.14 (0.66-1.97) 0.631 Psychological aspects (16 PF Cattel ) Psy-Inventory Scales RESULTS OF MULTIVARIATE COX ANALYSIS Hazard Ratio for patients (n=228) Variable(95% Confidence Interval) P __________________________________________________ Anger 2.30 (1.29 to 4.08 0.004 Stress- related Disturbances 1.90 (1.09 to 3.28) 0.022 1 Infaction-free survival 0.9 Anger - 0.8 78.5 % 0.7 p = 0.0025 Log Rank Anger + 0.6 57.4 % 0.5 0 12 24 36 48 60 72 84 96 108 120 Months Months 0 24 48 72 96 120 A- 123 91 81 76 69 16 A+ 105 79 69 59 46 12 Conclusions Anger and symptoms related to stress increased the risk of new events, outperforming all other clinical, imaging, laboratory and electrocardiographic biomarkers. These data provide epidemiological support to targeted psychotherapy and/or behavioural interventions in anger over-reactions and suggest the inclusion of psychological aspects in risk stratification models. Consuma dentro te con la tua rabbia. Consumed by your anger inside you (Divina Commedia, Inferno, Canto VII, vv.7-9) “Figlio, or tu vedi l’anime di color cui vinse l’ira” “ Now seest thou son! The souls of those, whom anger overcame” Divina commedia, Inferno, Canto VII, 118-119. ì Illustration by Paul Gustave Doré ì Inferno, gli iracondi, illustrazione di ì Paul Gustave Doré, Physiological and behavioural characteristics linking anger with increased CHD risk Physiological characteristics Increased sympathetic nervous system function. Reduced parasympathetic nervous system function. Increased or dysregulated hypothalamic-pituitary-adrenal axis activation. Behavioural characteristics. Cigarette smoking Alchol consumption Increased energy intake