Tying Personality to Heart Attacks : Researchers Rate ‘Type A’ Persons as Prime Candidates

Hostility may be a cardiac villain, along with cholesterol, smoking and high blood pressure, according to some scientists studying heart disease risk factors.

“There’s increasing agreement that what an individual feels and thinks may be as important as what he eats or inhales,” said Dr. Meyer Friedman, a San Francisco physician who pioneered work on psychosocial links to cardiovascular disease. Two decades ago Friedman, with Dr. Ray Rosenman, described Type A behavior and proposed that it could help bring on a heart attack. The pair showed that coronary heart disease, affecting the heart’s own blood vessels, was seven times more prevalent in Type A men than in their calmer Type B peers.

Type A people are “the ones who are always in a hurry, even if it is just to go the store for milk. They fume in a traffic jam and seem to have a short temper all the time. They are impatient and always seem to be battling time or somebody else,” said Friedman, who describes himself as Type A.

Relative Importance

The American Heart Assn. says the Type A behavior pattern is one psychosocial factor related to heart and blood vessel diseases but is not as important a risk factor as smoking, high blood pressure or high blood cholesterol. Type A is a description of behavior that scientists are trying to refine through precise research.

Depending on the population group sampled, between 15% and 80% of the adults studied have been found to be Type A.

Each year about 12 heart attacks occur in every 1,000 Type A men in contrast to only four or five per 1,000 in Type B men, says Dr. Redford Williams Jr., a psychiatrist at Duke University Medical Center. In work funded by the National Heart, Lung and Blood Institute, he is learning how personality and stress can interact to produce extreme physical reactions.

It appears that some components of Type A behavior may set off a surge of stress hormones. Those hormones--including cortisol, epinephrine and testosterone--help regulate the heart and blood vessels as well as lipid metabolism. Williams explained that the hormones help trigger the “fight or flight” response that prepares the body for sudden action.

“The work we have done so far suggests that Type A men have an exaggerated response of those hormones to everyday stresses,” said Williams. “It is possible that a person who responds too much to stress over a period of years could develop heart disease as a result. But today that is only a theory.”

Heart Attacks Unexplained

Friedman’s theory about Type A behavior and heart disease first gained respect as studies demonstrated that other coronary risk factors couldn’t explain why aggressive, impatient people were getting more heart attacks.

“Something about Type A behavior seems to make it a separate risk for heart disease,” said Dr. J. Alan Herd, director of the Institute for Preventive Medicine at Methodist Hospital in Houston. Studies showed that the Type A heart attacks couldn’t be blamed on leisure hours spent sitting around smoking and gorging on cholesterol-laced food. Type A’s were special heart disease candidates.

That idea hit home with Americans after publication of a best seller by Friedman and Rosenman, “Type A Behavior and Your Heart.” By the late 1970s, it wasn’t unusual for wives to wonder whether their middle-aged white husbands, the typical heart attack victims, were too aggressive in the business world. But scientists doubted Type A as a cause of heart disease, Williams said, because it wasn’t “precise enough.”

“There had to be something to Type A behavior, simply because both men and women who acted that way had more heart disease. But not everybody who was Type A got heart attacks. We wanted to know which parts of Type A behavior were toxic,” said Williams.

Scientists were also concerned because some major studies, notably the Multiple Risk Factor Intervention Trial, failed to show a strong connection between general Type A behavior and heart disease. However, Friedman criticizes this study because of what he calls “faulty clinical means of diagnosing Type A behavior.”

“That MRFIT study was important because it suggested that a finer focus was needed to link behavior to heart disease,” said Dr. Ted Dembroski, a psychologist at the University of Maryland, Baltimore County. “Since then, researchers have broken Type A down into specific elements, such as anger and hostility, and found significant relationships with heart disease.”

For seven years the Duke researchers studied patients undergoing coronary angiography, a diagnostic procedure that detects blocked coronary arteries. Such blockages often contribute to a heart attack.

Researchers used an experimental scoring of the Minnesota Multiphasic Personality Inventory, a standard psychological test used for several decades.

“We studied hostility. But by hostility, we don’t mean an open display of aggression. Instead, the items we measure are designed to test a person’s attitudes. The participants who scored high on the hostility scale demonstrated a lack of trust in other people,” Williams said. “They suspected that other people around them couldn’t be trusted to be nice. In essence, they seemed to think others were out to get them.”

Seventy percent of the patients who scored high on the MMPI hostility scale had significant blockages in their coronary arteries. An even stronger link between hostility and heart attacks emerged when Williams and psychologists looked at a group of physicians, a profession generally regarded as brimming with Type A behavior. They examined the records of 225 physicians who had taken the MMPI test while medical students. Physicians with high hostility scores had a heart attack rate that was five times higher than doctors with lower scores.

But now in addition to test scores, Williams and other scientists can measure how Type A behavior affects the body.

“The original idea that stress always produced heart disease in Type A people was too simple, and life just isn’t that way.” Herd said. Scientists are realizing “that psychological factors can be graded and measured, much as the body’s responses to cholesterol can be monitored.

“One of the most important things we’ve learned so far is that day in and day out, Type A people seem to work closer to their limits--doing their best all the time. Everybody has a performance limit, “ the Houston scientist adds.

As people come closer to their performance limits, the effects of the stress hormones and resulting cardiovascular response become more pronounced. “That combination of hormones and overresponses may lead to heart disease,” Williams said.

Two years ago, his Duke research team found that Type A men’s bodies pumped out excessive levels of the stress hormones, compared to Type B men.

Tests that measured reaction time and mental arithmetic work of both Type A and Type B men showed that the Type A’s had bodies that responded excessively. The Type A men consistently produced high levels of the stress hormones and an extreme physiological response.

Mental Arithmetic

While doing mental arithmetic problems, the Type A men showed elevated levels of norepinephrine, epinephrine and cortisol--and increased blood flow to the muscles. Williams said excessive hormonal levels have been linked to the formation of cholesterol plaques in the arteries of animals.

During the reaction-time experiment, the Type A men produced excess testosterone, a male sex hormone. Type A men with a history of hypertension also had high levels of cortisol.

Williams thinks stress hormones might figure into the development of heart disease because:

--Cortisol and testosterone could play a role in atherosclerosis (a type of hardening of the arteries). Doctors already know that Type A people often have more severe atherosclerosis than Type B people do.

--Epinephrine and norepinephrine increase blood clotting. The formation of blood clots in arteries that are already clogged and narrowed by cholesterol deposits is now thought to be a final, critical event in many heart attacks.

An estimated 1.5 million Americans will have a heart attack this year, according to the American Heart Assn.’s publication, “Heart Facts 1985.” And the association says stress is one contributing factor to heart disease.

Before research linking heart disease and hormones can be applied to preventing a first heart attack, more proof is needed, Williams said. “We need to demonstrate, both in animals and in other groups of people, that hormones can be linked to heart disease. For example, we need more work to demonstrate the same effects in Type A women.”

Friedman’s recent work suggests that behavior modification can reduce risk for a second heart attack in Type A persons. “Their habits don’t have to stay the same. We’ve shown that heart attack patients who get both medical attention and help in changing their behavior are less likely to have a second heart attack. The new ways of behaving had an impact on their health, and many said it improved their relationships with their families and at work,” Friedman said.

Patients were taught to express themselves without exploding at other people. They learned to make “thought use” of time spent standing in line. Instead of fuming about the waste of time, they now accept the fact that they have no control in the situation and they think about other things, such as how to organize their day.

Friedman studied 592 patients and found that the 44% who underwent behavior modification training and stuck to their new behavior had lower heart attack rates. At the end of three years, they had a 7.2% rate of non-fatal heart attacks, in contrast to 13% of a group of patients (270) who got only medical attention.

Other heart specialists say Friedman’s work is important because it shows that something can be done to stop Type A people from hurrying and worrying themselves into fatal heart attacks.

Herd thinks the cardiologists and psychiatrists studying behavioral links to heart attacks are following a path similar to that taken by those who ultimately gave cholesterol a bad name. “There was a time when people thought cholesterol was the risk factor. Things weren’t that simple with cholesterol, and I think the same is true of Type A.”