Abstract
Background: Previous studies have reported that anger expression style is associated with cardiovascular disease and its risk factors. Epidemiologic data regarding the association between anger expression and risk of stroke have been inconsistent, and few studies have reported the association of anger expression with stroke subtypes. Hypothesis: We assessed the hypothesis that suppressed anger is associated with increased risk of stroke, and the associations vary by stroke subtype. Methods: A prospective study of Japanese subjects aged 30–74 years was undertaken using data collected from 6,276 participants (2,285 men and 3,991 women) in cardiovascular risk surveys conducted in four communities between 1995 and 1998. We used the Spielberger Anger Expression Scale to measure self-reported levels of anger expression style; anger expressed outwardly is regarded as “anger-out” and anger held in or suppressed is classified as “anger-in.” The incidence of stroke was ascertained by systematic surveillance. The hazard ratios (HRs) of incidence of stroke and its subtypes and 95% confidence intervals (CI) relative to the lowest tertile of anger expression were calculated with adjustment for age and other potential confounding factors using the Cox proportional hazards model. Results: During an average follow up of 9.1-years, 129 incident strokes (50 hemorrhagic, 77 ischemic, and 2 unclassified strokes) occurred. Men with “anger-in” scores in the highest tertile had a 1.7-fold multivariable-adjusted relative risk of stroke as compared with those in the lowest tertile, but it did not reach statistical significance (HR; 1.73, 95% CI; 0.94–3.19, p=0.08). When stratifying for stroke subtypes, the associations between “anger-in” and stroke tended to be stronger for hemorrhagic stroke than ischemic stroke; HRs (95% CI) were 3.82 (1.03–14.1) for hemorrhagic stroke and 1.32 (0.64–2.71) for ischemic stroke. Anger-in score was not associated with incidence of either hemorrhagic or ischemic stroke in women. In men and women, there were no significant associations between “anger-out” and incidence of stroke. As compared with the lowest tertile of “anger-out” scores, the multivariable-adjusted HRs of stroke for the highest tertile of “anger-out” scores were 1.39 (0.74–2.59) for men and 1.48 (0.78–2.78) for women, respectively. Conclusions: Suppressed anger may be associated with increased risk of hemorrhagic stroke among middle-aged Japanese men, but not women.
Published Version
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