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Anger Expression and Risk of Stroke and Coronary Heart Disease Among Male Health Professionals

Eng, Patricia Mona ScD; Fitzmaurice, Garrett ScD; Kubzansky, Laura D. PhD; Rimm, Eric B. ScD, and; Kawachi, Ichiro MD

Original Articles

Objective: Anger expression is a dimension of anger that may be strongly related to coronary heart disease and stroke. To date few cohort studies have evaluated the role of anger coping style in the development of cardiovascular disease. This study prospectively examined the effects of anger expression on incidence of cardiovascular disease.

Methods: Participants were male health professionals (N = 23,522), aged 50 to 85 years old and without previous cardiovascular disease, who responded to a mailed questionnaire incorporating the Spielberger Anger-Out Expression Scale in 1996. The cohort was followed for 2 years (1996–1998).

Results: Men with moderate levels of anger expression had a reduced risk of nonfatal myocardial infarction compared with those with lower levels of expression (relative risk: 0.56; 95% confidence interval: 0.32–0.97), controlling for coronary risk factors, health behaviors, use of psychotropic medication, employment status, and social integration. Anger expression was also inversely associated with risk of stroke. The multivariate relative risk of stroke was 0.42 (95% confidence interval: 0.20–0.88), comparing men with higher anger-out scores to men with lower scores. A protective dose-response relationship was observed between anger-out score and risk of stroke (p for multivariate trend test: 0.04).

Conclusions: Among this cohort of older men with high socioeconomic status and relatively low level of anger expression on average, moderate anger expression seemed to be protective against cardiovascular disease over a limited follow-up period.

From the Departments of Epidemiology (P.M.E., E.B.R.), Biostatistics (G.F.), Health and Social Behavior (L.D.K., I.K.), and Nutrition (E.B.R.), Harvard School of Public Health; and the Channing Laboratory (E.B.R., I.K.), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts.

Address reprint requests to: Ichiro Kawachi, MD, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. Email:

Received for publication August 29, 2001; revision received February 22, 2002.

Copyright © 2003 by American Psychosomatic Society
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