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A Comparison of Cook-Medley Hostility Subscales and Mortality in Patients With Coronary Heart Disease: Data From the Heart and Soul Study

Wong, Jonathan M. MD; Sin, Nancy L. PhD; Whooley, Mary A. MD

doi: 10.1097/PSY.0000000000000059
Original Articles

Objective Hostility is associated with adverse outcomes in patients with coronary heart disease (CHD). However, assessment tools used to evaluate hostility in epidemiological studies vary widely.

Methods We administered nine subscales of the Cook-Medley Hostility Scale (CMHS) to 656 outpatients with stable CHD between 2005 and 2007. We used Cox proportional hazards models to determine the association between each hostility subscales and all-cause mortality. We also performed an item analysis using logistic regression to determine the association between each CMHS item and all-cause mortality.

Results There were 136 deaths during 1364 person-years of follow-up. Four of nine CMHS subscales were predictive of mortality in age-adjusted analyses, but only one subscale (the seven-item Williams subscale) was predictive of mortality in multivariable analyses. After adjustment for age, sex, education, smoking, history of heart failure, diabetes, and high-density lipoprotein, each standard deviation increase in the Williams subscale was associated with a 20% increased mortality rate (hazard ratio = 1.20, 95% confidence interval = 1.00–1.43, p = .046), and participants with hostility scores in the highest quartile were twice as likely to die as those in the lowest quartile (hazard ratio = 2.00, 95% confidence interval = 1.10–3.65, p = .023).

Conclusions Among nine variations of the CMHS that we evaluated, a seven-item version of the Williams subscale was the most strongly associated with mortality. Standardizing the assessment of hostility in future epidemiological studies may improve our understanding of the relationship between hostility and mortality in patients with CHD.

Supplemental digital content is available in the text.

From the School of Medicine (J.M.W.), University of California, Irvine, California; Doris Duke Clinical Research Fellowship Program (J.M.W.) and Departments of Medicine (N.L.S., M.A.W.) and Epidemiology & Biostatistics (M.A.W.), University of California, San Francisco, California; and Veterans Affairs Medical Center (M.A.W.), San Francisco, California.

All correspondence and requests for reprints should be addressed to Mary A. Whooley, MD, Department of Veteran Affairs Medical Center, 4150 Clement St (111A1), San Francisco, CA. E-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Received for publication December 30, 2012; revision received March 30, 2014.

Copyright © 2014 by American Psychosomatic Society
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