Widely Held Belief Challenged : Type A Heart Patients Die at Lower Rate, Study Says
A new study that challenges the widely held belief that aggressive behavior contributes to heart attack deaths has found that men with Type A personalities and heart disease are more likely to survive than their more easygoing Type B counterparts.
The study suggests that competitive, hard-driving behavior may inexplicably have beneficial effects and that physicians’ efforts to discourage such habits may be ill-advised.
“The strongest conclusion that we can draw from this is that among coronary heart disease patients, Type A behavior does not seem to be dangerous,” said David Ragland, a University of California, Berkeley, epidemiologist and principal author of the report, published today in the New England Journal of Medicine.
“I think the weaker implication is that we appear to find this protective effect that we’re frankly quite mystified by,” Ragland added. “Type A’s don’t die at a faster rate, they die at a lower rate. It goes against the theory of Type A behavior.”
The new research, coming on top of other studies that also have raised questions about the link between behavior and heart disease, suggests a need to re-evaluate the Type A concept and redefine the personality traits that lead to heart risk, researchers said.
As originally defined, Type A individuals tend to be competitive, achievement-oriented, impatient and have a desire to exercise control and an inability to relax. By contrast, people diagnosed as Type B are said to be relaxed, content and easy-going.
The researchers said recent work indicates that the truly pernicious traits may be hostility, self-involvement and symptoms of depression or demoralization. Those attributes may eventually prove to be the link between personality and heart disease, they said.
“I think it’s time to go beyond the original Type A’s,” said Dr. Joel Dimsdale, an associate professor of psychiatry at the University of California, San Diego, who has studied Type A’s. “. . .Today we can build upon it and go beyond Type A to a more precise delineation of risk.”
In their research, Ragland and Richard Brand, a professor of biostatistics at UC Berkeley, followed 231 men who had developed heart disease. The subjects were part of the original research project in the 1960s that produced the now-popular notion linking Type A behavior to heart disease.
Over the next 12 years, Ragland and Brand found the death rate among the 160 Type A patients to be only 58% of what it was among the Type B patients. That is, the Type B patients had a 70% higher risk of dying from heart disease.
Ragland and Brand speculate that Type A patients may respond differently to heart attacks, perhaps complying more strictly with medical treatment or changing their life styles. Or, they may heed symptoms, such as heart pain, that Type B patients might ignore.
Changing of Behavior
“Our data suggest that attempting to change Type A behavior may not have the intended effect,” Ragland said in an telephone interview. It could even be dangerous if it distracted from other changes such as controlling smoking, cholesterol levels and blood pressure, he said.
The team’s startling conclusions came under immediate fire from Dr. Meyer Friedman of San Francisco, co-author of the initial study that concluded in 1975 that Type A individuals have two to four times the risk of heart disease of Type B personalities.
Friedman, who now spends some of his time developing programs to modify Type A behavior among corporate managers and the military, called the new study “statistical nonsense” because, he said, the original definition of Type A is out of date.
He said many telltale signs of Type A behavior, such as eye-twitching and tics, were unknown when his group diagnosed the subjects used in Ragland’s study. Under his current definition, all of Ragland’s subjects would fall into the Type A category, he said.
As for the suggestion that behavior modification might be ill-advised, Friedman said, “That’s one of the most harmful statements ever made about cardiovascular disease. Because you’re allowing the behavior to go unchecked that caused the premature onset.”
But Friedman’s former collaborator, Dr. Ray Rosenman, called the new study’s conclusions “probably valid.” He attributed the discrepancy in survival rates at least in part to Type A individuals’ willingness to adapt after an initial heart attack.
One should not simply say that Type A is bad, said Rosenman, director of cardiovascular research at SRI International in Menlo Park. “It’s neither good nor bad. It’s just a fact.
“What we’re really concerned with is determining which aspects of Type A are bad and, for any given individual, where should a physician attempt to modify the response,” he said.
Not First Challengers
Ragland and Brand are not the first researchers to challenge the Type A theory, first posited by Friedman and Rosenman in the late 1950s and widely popularized in the 1970s by their book, “Type A Behavior and Your Heart.”
Support for the idea came from Friedman and Rosenman’s initial study in the 1960s in which they followed 3,154 men for 8 1/2 years. They concluded that Type A behavior was an independent risk factor for heart disease and a reliable predictor of subsequent heart attacks.
After other researchers using different methods found that Type A patients had more extensive coronary artery disease than Type B patients, an independent panel of the National Institutes of Health in 1981 classified Type A behavior as an independent risk factor.
But no researchers have been able to replicate precisely the original study’s findings.
One group found that age, sex and occupation appeared to influence the link between behavior and heart disease. Another found no relationship. Still another group has reported that special psychotherapy for Type A’s appears to reduce cardiac risk.
“My own view is, that type of personality is hard to change,” said Dimsdale, whose own work failed to substantiate the connection between Type A behavior and coronary artery disease and who wrote an editorial on the subject in this week’s New England Journal.
“Furthermore, many Type A’s are very happy as Type A’s,” he added in an interview. “Their spouses are happy with them, their co-workers are happy with them and they are happy with themselves. My own hunch would be to have those people continue with their lives.”
