Advertisement
Mayo Clinic Proceedings Home

Effects of Cardiac Rehabilitation and Exercise Training Programs on Coronary Patients With High Levels of Hostility

      Objective

      To determine the effects of cardiac rehabilitation interventions on patients with hostility, or unexpressed anger, a coronary heart disease risk factor that adversely affects morbidity and mortality after major coronary heart disease events.

      Methods

      Using validated questionnaires to evaluate behavioral characteristics and quality of life, we studied 500 consecutive patients before and after cardiac rehabilitation and compared a group of 65 patients with high levels of hostility with 435 patients with low levels of hostility.

      Results

      After rehabilitation, statistically significant improvements occurred in the total cohort in scores for anxiety, depression, and somatization, as well as total quality of life, but not in hostility score (−20%; P=.07). Patients with high levels of hostility had significant improvements in hostility scores as well as other behavioral characteristics (anxiety, depression, and somatization) and all quality-of-life components. These patients also improved exercise capacity, percent body fat, body mass index, and total cholesterol and high-density lipoprotein cholesterol levels. Compared with patients with low levels of hostility, those with high levels of hostility had greater relative improvements in hostility scores, as well as anxiety, general health, energy, mental health, and total quality-of-life scores, and had similar improvements in exercise capacity, obesity indexes, lipid levels, and other behavioral characteristics and quality-of-life measurements. After cardiac rehabilitation, the prevalence of high levels of hostility decreased by 40%, from 13% to 8% (P<.01).

      Conclusions

      These data suggest that cardiac rehabilitation reduces hostility and significantly improves quality of life and other behavioral characteristics in patients with high levels of hostility. We believe that greater attention should be directed at behavioral characteristics, including hostility, to enhance the primary and particularly the secondary prevention of coronary heart disease.

      Abbreviations:

      HDL (high-density lipoprotein), LDL (low-density lipoprotein), METs (metabolic equivalents)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Milani RV
        • Littman AB
        • Lavie CJ
        Psychological adaptation to cardiovascular disease.
        in: Messerli FH Cardiovascular Disease in the Elderly. 3rd ed. Kluwer Academic Publishers, Boston, Mass1993: 401-412
        • Milani RV
        • Lavie CJ
        • Cassidy MM
        Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events.
        Am Heart J. 1996; 132: 726-732
        • Milani RV
        • Lavie CJ
        Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events.
        Am J Med. 1996; 100: 517-523
        • Stern MJ
        • Pascale L
        • Ackcrman A
        Life adjustment postmyocardial infarction: determining predictive variables.
        Arch Intern Med. 1977; 137: 1680-1685
        • Frasure-Smith N
        • Lesperance F
        • Talajic M
        Depression following myocardial infarction: impact on 6-month survival [published correction appears in JAMA. 1994;271:1082].
        JAMA. 1993; 270: 1819-1825
        • Rosenman RH
        • Brand RJ
        • Jenkins D
        • Friedman M
        • Straus R
        • Wurm M
        Coronary heart disease in Western Collaborative Group Study: final follow-up experience of 8½ years.
        JAMA. 1975; 233: 872-877
        • Jenkins CD
        Recent evidence supporting psychologic and social risk factors for coronary disease (first of two parts).
        N Engl J Med. 1976; 294: 987-994
        • Haynes SG
        • Feinleib M
        • Kannel WB
        The relationship of psychosocial factors to coronary heart disease in the Framingham Study, III: eight-year incidence of coronary heart disease.
        Am J Epidemiol. 1980; 111: 37-58
        • Friedman M
        • Thoresen CE
        • Gill JJ
        • et al.
        Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project.
        Am Heart J. 1986; 112: 653-665
        • Shekelle RB
        • Hulley SB
        • Neaton JD
        • et al.
        The MRFIT behavior pattern study. II: type A behavior and incidence of coronary heart disease.
        Am J Epidemiol. 1985; 122: 559-570
        • Shekelle RB
        • Gale M
        • Norusis M
        Type A score (Jenkins Activity Survey) and risk of recurrent coronary heart disease in the Aspirin Myocardial Infarction Study.
        Am J Cardiol. 1985; 56: 221-225
        • Matthews KA
        • Glass DC
        • Rosenman RH
        • Bortner RW
        Competitive drive, pattern A, and coronary heart disease: a further analysis of some data from the Western Collaborative Group Study.
        J Chronic Dis. 1977; 30: 489-498
        • Dembroski TM
        • MacDougall JM
        • Williams RB
        • Haney TL
        • Blumenthal JA
        Components of type A, hostility, and anger-in: relationship to angiographic findings.
        Psychosom Med. 1985; 47: 219-233
        • Williams Jr, RB
        • Haney TL
        • Lee KL
        • Kong YH
        • Blumenthal JA
        • Whalen RE
        Type A behavior, hostility, and coronary atherosclerosis.
        Psychosom Med. 1980; 42: 539-549
        • Barefoot JC
        • Dahlstrom WG
        • Williams Jr, RB
        Hostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians.
        Psychosom Med. 1983; 45: 59-63
        • Shekelle RB
        • Gale M
        • Ostfeld AM
        • Paul O
        Hostility, risk of coronary heart disease, and mortality.
        Psychosom Med. 1983; 45: 109-114
        • Linden W
        • Stossel C
        • Maurice J
        Psychosocial interventions for palients with coronary artery disease: a meta-analysis [published correction appears in Arch Intern Med. 1996; 156:2302].
        Arch Intern Med-. 1996; 156: 745-752
        • Lavie CJ
        • Milani RV
        Effects of cardiac rehabilitation and exercise training on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in women.
        Am J Cardiol. 1995; 75: 340-343
        • Ades PA
        • Huang D
        • Weaver SO
        Cardiac rehabilitation participation predicts lower rehospitalization costs.
        Am Heart J. 1992; 123: 916-921
        • O'Connor GT
        • During JE
        • Yusuf S
        • et al.
        An overview of randomized trials of rehabilitation with exercise after myocardial infarction.
        Circulation. 1989; 80: 234-244
        • Lavic CJ
        • Milani RV
        Effects of cardiac rehabilitation programs on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in a large elderly cohort.
        Am J Cardiol. 1995; 76: 177-179
        • Lavie CJ
        • Milani RV
        Effects of cardiac rehabilitation, exercise training, and weight reduction on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in obese coronary patients.
        Am J Cardiol. 1997; 79: 397-401
        • Kellner R
        A symptom questionnaire.
        J Clin Psychiatry. 1987; 48: 268-274
        • Kellner R
        • Sheffield BF
        A self-rating scale of distress.
        Psychol Med. 1973; 3: 88-100
        • Stewart AL
        • Greenfield S
        • Hays RD
        • et al.
        Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study [published correction appears in JAMA. 1989;262:2542J.
        JAMA. 1989; 262: 907-913
        • Maines TY
        • Lavie CJ
        • Milani RV
        • Cassidy MM
        • Gilliland YE
        • Murgo JP
        Effects of cardiac rehabilitation and exercise programs on exercise capacity, coronary risk factors, behavior, and quality of life in patients with coronary artery disease.
        South Med J. 1997; 90: 43-49
        • Jackson AS
        • Pollock ML
        Practical assessment of body composition.
        Physician Sportsmed. May 1985; 13 (82–90.): 76-80
        • Lavie CJ
        • Milani RV
        Cardiac rehabilitation.
        in: Brown DL Cardiac Intensive Care. WB Saunders Co, Philadelphia, Pa1998: 329-335
        • Milani RV
        • Lavie CJ
        • Spiva H
        Limitations of estimating metabolic equivalents in exercise assessment in patients with coronary artery disease.
        Am J Cardiol. 1995; 75: 940-942
        • Friedman M
        • Rosenman RH
        Association of specific overt behavior pattern with blood and cardiovascular findings: blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease.
        JAMA. 1959; 169: 1286-1296
        • Koskenvuo M
        • Kaprio J
        • Rose RJ
        • et al.
        Hostility as a risk factor for mortality and ischemic heart disease in men [published correction appears in Psychosom Med. 1988;50:554].
        Psychosom Med. 1988; 50: 330-340
        • Dembroski TM
        • MacDougall JM
        • Costa Jr, PT
        • Grandits GA
        Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial.
        Psychosom Med. 1989; 51: 514-522
        • Mittlaman MA
        • Maclure M
        • Sherwood JB
        • et al.
        Triggering of acute myocardial infarction onset by episodes of anger: Determinants of Myocardial Infarction Onset Study Investigators.
        Circulation. 1995; 92: 1720-1725
        • Kawachi I
        • Sparrow D
        • Spiro III, A
        • Vokonas P
        • Weiss ST
        A prospective study of anger and coronary heart disease: the Normative Aging Study.
        Circulation. 1996; 94: 2090-2095
        • Jenkins CD
        • Zyzanski SJ
        • Rosenman RH
        Risk of new myocardial infarction in middle-aged men with manifest coronary heart disease.
        Circulation. 1976; 53: 342-347
        • Goodman M
        • Quigley J
        • Moran G
        • Meilman H
        • Sherman M
        Hostility predicts restenosis after percutaneous transluminal coronary angioplasty.
        Mayo Clin Proc. 1996; 71: 729-734
        • Frasure-Smith N
        • Lespérance F
        • Juneau M
        Differential long-term impact of in-hospital symptoms of psychological stress after non-Q-wave and Q-wave acute myocardial infarction [published correction appears in Am J Cardiol. 1994;74:639].
        Am J Cardiol. 1992; 69: 1128-1134
        • Allison TG
        • Williams DE
        • Miller TD
        • et al.
        Medical and economic costs of psychologic distress in patients with coronary artery disease.
        Mayo Clin Proc. 1995; 70: 734-742
        • Verrier RL
        • Hagestad EL
        • Lown B
        Delayed myocardial ischemia induced by anger.
        Circulation. 1987; 75: 249-254
        • Boltwood MD
        • Taylor CB
        • Burke MB
        • Grogin H
        • Giacomini J
        Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments.
        Am J Cardiol. 1993; 72: 1361-1365
        • Shively CA
        • Clarkson TB
        • Kaplan JR
        Social deprivation and coronary artery atherosclerosis in female cynomolgus monkeys.
        Atherosclerosis. 1989; 77: 69-76
        • Welin L
        • Tibblin G
        • Svardsudd K
        • et al.
        Prospective study of social influences on mortality: the study of men born in 1913 and 1923.
        Lancet. 1985; 1: 915-918
        • Broadhead WE
        • Kaplan BH
        • James SA
        • et al.
        The epidemiologic evidence for a relationship between social support and health.
        Am J Epidemiol. 1983; 117: 521-537
        • Ruberman W
        • Weinblatt E
        • Goldberg JD
        • Chaudhary BS
        Psycho-social influences on mortality after myocardial infarction.
        N Engl J Med. 1984; 311: 552-559
        • Nunes EV
        • Frank KA
        • Kornfeld DS
        Psychologic treatment for the type A behavior pattern and for coronary heart disease: a meta-analysis of the literature.
        Psychosom Med. 1987; 49: 159-173
        • Reich P
        • Gold PW
        Interruption of recurrent ventricular fibrillation by psychiatric intervention.
        Gen Hosp Psychiatry. 1983; 5: 255-257
        • Frasure-Smith N
        In-hospital symptoms of psychological stress as predictors of long-term outcome after acute myocardial infarction in men [published correction appears in Am J Cardiol. 1994;74: 639).
        Am J Cardiol. 1991; 67: 121-127
        • Blumenthal JA
        • Fredrikson M
        • Kuhn CM
        • Ulmer RL
        • Walsh-Riddle M
        • Appelbaum M
        Aerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia.
        Am J Cardiol. 1990; 65: 93-98
        • Blumenthal JA
        • Williams RS
        • Needels TL
        • Wallace AG
        Psychological changes accompany aerobic exercise in healthy middle-aged adults.
        Psychosom Med. 1982; 44: 529-536
        • Milani RV
        • Lavie CJ
        Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease.
        Am J Cardiol. 1998; 81: 1233-1236
        • Kranlz DS
        • Baum A
        • Wideman M
        Assessment of preferences for self-treatment and information in health care.
        J Pers Soc Psychol. 1980; 39: 977-990
        • Kulik JA
        • Mahler HI
        Social support and recovery from surgery.
        Health Psychol. 1989; 8: 221-238
        • Cohen F
        • Lazarus RS
        Active coping processes, coping dispositions, and recovery from surgery.
        Psychosom Med. 1973; 35: 375-389
        • Multiple Risk Factor Intervention Trial Research Group
        Multiple Risk Factor Intervention Trial: risk factor changes and mortality results.
        JAMA. 1982; 248: 1465-1477
        • Milani RV
        • Lavic CJ
        Reductions in coronary risk profile and total medical costs with comprehensive work-site primary prevention programs [abstract).
        Circulation. 1995; 92: 1-510
        • Milani RV
        • Lavie CJ
        Marked reductions in outpatient, inpatient, and total medical costs with comprehensive work-site primary prevention programs [abstract).
        J Am Coll Cardiol. 1997; 29: 49A-50A
        • Milani RV
        • Lavie CJ
        Prevalence and effects of nonpharmacologic treatment of “isolated” low-HDL cholesterol in patients with coronary artery disease.
        J Cardiopulm Rehabil. 1995; 15: 439-444
        • Cook WW
        • Medley DM
        Proposed hostility and pharisaic-virtue scales for the MMPI.
        J Appl Psychol. 1954; 38: 414-418
        • Allison TG
        Identification and treatment of psychosocial risk factors for coronary artery disease [editorial].
        Mayo Clin Proc. 1996; 71: 817-819