ABC | Volume 111, Nº3, September 2018

Original Article Schmidt et al Anger and coronary artery disease in women Arq Bras Cardiol. 2018; 111(3):410-416 valvular heart disease; congenital heart disease; severe diseases with life expectancy <6 months; severe aortic stenosis; and ejection fraction <30%. The project was submitted to the Ethics Committee in Research of the institution and was in accordance with the Declaration of Helsinki and the Resolution 466/12 of the National Council of Health. Coronary angiography Coronary angiography was performed according to the Judkins technique, all analyses were performed in at least two views, and the severity of the coronary obstructions was assessed by use of a digital calibration system previously validated (Siemens AxiomArtis - Munich, German). Prior to the measurements, intracoronary nitroglycerin was administered routinely at the dose of 100-200 μg. Coronary artery disease was defined as ≥50% stenosis of at least one major epicardial artery. Assessment of anger Anger is an emotional state that consists of feelings that vary in intensity from mild irritation or annoyance to intense fury and rage, and changes over time spams depending on what is perceived as injustice or frustration. 17 Anger assessment was performed by use of Spielberger’s State-Trait Anger Expression Inventory (STAXI), 17 a tool translated to several languages, validated in Brazil and recommended by the Federal Council of Psychology. It comprises 40 statements about the intensity of anger, how patients usually feel and how often they experience anger. Each item is rated on a four-point Likert-type scale, scored as follows: 1 for “rarely”; 2 for “sometimes”; 3 for “often”; and 4 for “almost always”. The test is subdivided into subscales: state anger, trait anger (temperament and reaction) and anger expression (anger expression-in, anger expression-out, and anger control). Trait anger is defined as a predisposition to experiencing anger, indicating lasting personality trends. It is assessed by use of questions such as: “I get angry easily”, “I get angry when my good work is not recognized”. Anger expression provides an assessment of how anger is experienced: suppression, expression or control. (Examples: “I keep things to myself”, “I do things such as slam the door”, “I boil inside, but I do not show”). As state anger assesses the amount of anger that is experienced at a particular time, that subscale was not used in the sample of in-hospital patients. Clinical characteristics at the beginning of the study The clinical and socioeconomic characteristics, risk factors for CAD, previous medical history, clinical presentation of CAD and history of psychological diagnosis were assessed and included in a dedicated database. Hypertension was defined as previous diagnosis of the condition or use of anti‑hypertensives. Dyslipidemia was considered present in those previously diagnosed with the condition or on lipid-lowering drugs. Diabetes mellitus was defined as the previous use of insulin or oral hypoglycemic drugs, or the presence of documented fasting blood sugar > 126 mg/dL on two occasions. Previous history of depression was defined as the occurrence of at least one major depressive episode that required treatment with antidepressants. Outcomes The outcome primary cardiovascular event was a combination of cardiovascular death, acute myocardial infarction (AMI), myocardial revascularization or hospitalization due to angina. Cardiovascular death was defined as any death due to immediate cardiac causes (AMI, cardiogenic shock, arrhythmia), or death of unknown cause. Acute myocardial infarction was considered in the presence of: 1) increase and/or gradual decrease in cardiac biomarkers (preferably troponin) with at least one measure over the 99th percentile and at least one of the following criteria: 1) chest pain > 10 minutes or new ST-T changes or new left bundle-branch block; or 2) development of pathological Q waves (duration ≥ 0.03 seconds; depth ≥1 mm) in at least two contiguous precordial leads or at least two leads of adjacent limbs; or 3) evidence of viablemyocardial loss or new regional wall motion abnormality on any imaging test. Myocardial revascularization comprised primary percutaneous coronary intervention (PCIp) or coronary artery bypass grafting (CABG) occurring after entrance into the study. Hospitalization due to angina was defined as hospital length of stay longer than 24 hours to assess or treat cardiac chest pain, with neither AMI nor need for myocardial revascularization. Follow-up The participants were followed up for 48 months by use of visits and telephone contacts, to assess the occurrence of major cardiovascular events (MCVE), defined as cardiovascular death, AMI, myocardial revascularization (CABG or PCI) and hospitalization due to angina > 24 hours. Statistical analysis and justification of the sample size The sample size was calculated with power of 80, alpha of 0.05 and 95% confidence interval. At least 250 individuals were necessary to detect a relative risk of 1.60, 18 considering the 30% incidence of MCVE in the total group of women. Continuous variables were expressed as mean ± standard deviation, while categorical variables, as absolute number and percentage. The characteristics of the patients with CAD were compared to those of patients without CAD, using Student t test for independent samples for continuous variables and chi‑square test for categorical variables. The women were divided into two groups according to their scores being above or below average range (26.99). Their demographic characteristics, risk factors, previous history and STAXI scores were compared by use of Student t test or chi-square test. Cronbach’s alpha was used to assess the internal consistency of the STAXI subscales. Kolmogorov-Smirnov test was used to assess the normality of the distribution of the scores. Multiple logistic regression analysis was used to assess the variables associated with CAD on baseline angiography and control of anger. The Kaplan‑Meier curves and the log-rank test were used to compare event-free survival between patients with anger control scores above and below the sample’s average range. For all tests, a p value < 0.05 was considered statistically significant. All data were recorded in an Excel database for analysis with the SPSS program, version 24.0 for Windows. 411