Coronary-Prone Behaviors in the Western Collaborative Group Study

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1 Coronary-Prone Behaviors in the Western Collaborative Group Study MICHAEL H. L. HECKER, PHD, MARGARET A. CHESNEY, PHD, GEORGE W. BLACK, MS, MPH, AND NANETTE FRAUTSCHI, PHD Two-hundred-fifty CHD cases and 5 matched controls from the Western Collaborative Group Study were studied to assess the 8.5-yr prospective relationship of specific behavioral dimensions to the incidence of coronary heart disease. Type A structured interviews administered at intake were reevaluated in terms of 12 operationally defined components, which include previously described facets of the Type A behavior pattern. Univariate risk analyses using the matched logistic model found hostility (RR = 1.92, p <.1), speaking rate (RR = 1.66, p =.3), immediateness (RR = 1.62, p =.9), competitiveness (RR = 1.5, p =.13), and Type A content (RR = 1.38, p =.45) to be significantly related to CHD incidence. Of these, only hostility remained a significant risk factor (RR = 1.93, p <.1) when all 12 components were included in the model. The original Type A global ratings and traditional CHD risk factors were also analyzed in conjunction with the components. The Type A behavior pattern comprises both benign and coronary-prone facets, with the latter most exemplified by hostility. The Type A behavior pattern is an action-emotion complex that is exhibited by predisposed men and women in response to certain stressful or challenging environmental events. This behavior pattern is composed of a number of interrelated components, including hard-driving and competitive behavior, a potential for hostility, pronounced impatience, and vigorous speech stylistics (1). Subjects exhibiting a preponderance of these Type A behaviors are classified as Type A, and those exhibiting a relative absence of these behaviors are classified as Type B. From the Department of Behavioral Medicine, SRI International, Menlo Park, California. Dr. Chesney is currently affiliated with the Department of Epidemiology & International Health, School of Medicine, University of California, San Francisco. Dr. Frautschi is currently affiliated with the Department of Psychiatry, Kaiser Permanente Medical Center, Los Angeles. Address reprint requests to: Margaret A. Chesney, Clinical Epidemiology Program, Bldg. 1, Room 21, San Francisco General Hospital, San Francisco, CA Received for publication April 27, 1987; final revision received October 22, The Western Collaborative Group Study (WCGS) was the initial prospective examination of the relationship of Type A behavior to coronary heart disease (CHD). Over the 8.5-yr follow-up period of that study, men assessed as Type A by means of the structured interview administered at intake had approximately twice the risk of developing CHD relative to their Type B counterparts (2). This risk persisted after statistical adjustment for other CHD risk factors (3). Substantial epidemiologic evidence gathered since the WCGS implicates Type A behavior in the severity of coronary atherosclerosis documented by autopsy and arteriography (4-8), in the incidence and prevalence of CHD (9, 1), and in recurrent myocardial infarction (11). Not all epidemiologic and angiographic studies have confirmed the relationship between Type A behavior and CHD. In particular, several prospective studies of persons at high riskfor CHD, including the Multiple Risk Factor Intervention Trial (12), the Multicenter Post-infarction Program (13), and Psychosomatic Medicine 5: (1988) Copyrighl 1988 by the American Psychosomatic Society, Inc. Published by Elscvier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY /88/53.5

2 M. H. L. HECKERetal. the Aspirin Myocardial Infarction Study (14), failed to support the role of Type A behavior as an independent CHD risk factor. Similarly, a number of studies of patients referred for angiographic evaluation of coronary atherosclerosis have failed to find a relationship between Type A behavior and severity of coronary artery disease (15-2). The results of these trials and angiographic studies have led some investigators to question the association between the global Type A behavior pattern and CHD. Recently, research has indicated that certain components of the Type A behavior pattern are more directly related than others to clinical CHD events and severity of coronary atherosclerosis. Matthews et al. (21) reported on a component analysis performed by Dr. Ray Bortner using a sample of the structured interviews administered at intake in the WCGS. They concluded that only a subset of Type A characteristics discriminated the 62 WCGS subjects under 5 yr of age who developed CHD over the first 4.5 yr of follow-up from 124 age-matched control subjects (22). In a recent review (23), Matthews and Haynes pointed out that the majority of items that discriminated the cases from the controls concerned anger and hostility. Similar component analyses were performed on the structured interviews administered in two samples of patients referred for coronary angiography (24, 25). One of these studies (25) involved a reanalysis of the same interviews evaluated in a previous angiographic study, in which global ratings of Type A behavior were not related to coronary artery disease (15). Results of the component analyses of the interviews in both of these studies showed that the severity of coronary artery disease was related to component ratings of the subject's potential for hostility and the subject's self-reports of avoiding overt expressions of anger when provoked. Further evidence implicating hostility in the development of CHD is provided by studies that used the Cook and Medley selfreport questionnaire scale (26), an MMPIderived scale designed to assess hostility. High scores on this scale have been found to be associated with incidence of CHD and all-cause mortality in two prospective studies (27, 28), and with severity of coronary atherosclerosis in a study of patients undergoing angiography (5). These findings were not confirmed in a recent prospective study (29) in which the MMPI was given as part of an evaluation for admission to medical school a condition that may have suppressed subjects' self-report of hostility. The relationship of the Cook and Medley scale to all-cause mortality and other questions concerning its construct validity have led some investigators to question whether it primarily assesses hostility or a broader construct (3-32). This paper reports on a component analysis of the WCGS structured interviews administered at intake to subjects who developed CHD during the 8.5-yr follow-up period. For comparison, the component analysis also includes interviews from a sample of WCGS subjects who remained free of CHD during the same period. This study differs from that of Matthews and associates (21) in three ways. First, the sample studied in the current analysis is larger and utilizes the entire age range (the sample in the Matthews study included only those subjects under 5 yr of age who developed CHD during the first 4.5 yr of follow-up). Second, the scoring system developed for the present study employed multiple raters and three playbacks of each interview for rating com- 154 Psychosomatic Medicine 5: (1988)

3 CORONARY-PRONE BEHAVIORS ponents in defined interview segments (procedures not followed in the Matthews study). Third, the present study controlled for the standard CHD risk factors in multivariate analyses. METHODS Subjects The population under study consisted of 3,154 male subjects, aged 39-59, who participated in the WCGS (1). These subjects were free of CHD at intake in and were followed prospectively for an average of 8.5 yr (2, 3). The subjects were employed by 1 California companies and were engaged primarily in white-collar occupations. A detailed description of intake procedures, examinations, and exclusion criteria for the WCGS has been published (1, 2). The structured interview was conducted at intake and audiotaped. Global Type A behavior ratings of the recorded interviews were made by Dr. Ray Rosenman and yielded approximately equal numbers of Type A and Type B subjects. Conventional risk factors for coronary heart disease, evidence of clinical CHD, and other data were assessed at intake and at annual intervals throughout the follow-up. By 1969, at the end of the 8.5-yr period, 257 subjects had developed some manifestation of CHD (i.e., coronary death, electrocardiographically confirmed nonfatal myocardial infarction, or angina pectoris). The present study focused on the 257 men who developed CHD over the course of the WCGS. Recorded interviews for seven of these subjects were either inaudible or lost, reducing the sample of CHD cases studied to 25. In the present study, each of the 25 CHD cases was matched with two controls selected from the 2,897 participants who did not develop CHD through Each of the two matched controls was required to have been employed at the same company and to have been of the same age as the CHD case at entry. In those rare occurrences where a match of the same age was impossible, a control was chosen who was 1 yr younger or older than the case. Ties were broken by selecting the two matched controls having subject identification numbers numerically closest to the subject number of the case. In summary, the 5 control subjects could be described as matched with cases on the basis of company of employment, age, and date of intake. The combined mean age at intake for CHD cases and controls was 48.5 yr. Component Scoring A component scoring procedure was developed by one of the authors (M.H.) to evaluate the selected WCGS interviews. A detailed description of this procedure is provided elsewhere (33). The procedure involves the division of the Type A structured interview into 2 segments. Each segment begins with one of 2 key questions in the interview {see Table 1) and includes the subject's response and all subsequent dialogue until the next key question is asked. The responses made by the subject during each segment are scored in terms of 12 operationally defined components, which include previously described facets of the Type A behavior pattern (1) and other variables thought to be related to CHD risk. Summary definitions of these components are presented in Table 2. A comprehensive protocol specifies and illustrates detailed scoring criteria for each component. This protocol, which consists of a code book and a library of reference tapes, was designed to minimize the need for raters to make subjective judgments. In the code book, different behaviors relating to the same component are identified and assigned numerical scores. The reference tapes are used to define and quantify several speech characteristics described below. The recorded interview is played back three times. This procedure allows the rater to concentrate on a subset of components that require a similar mode of observation and assessment. Playback 1 is used to score immediateness and Type A content. The first of these is scored on the basis of the time interval between questions and answers; the second is scored based only on the content of the subject's responses. Playback II is used to score competitiveness, hostility, self-aggrandizement, exactingness, and despondency; these components require evaluation of both the verbal content and the emotional tone of the subject's responses. Playback III is used to score loudness of voice, syllabic emphasis, speaking rate, acceleration, and hard voice; these speech characteristics are scored independently of verbal content. For each component included in playbacks I and II, each of the 2 interview segments is given a score on a 5-point scale (from to 4) that indicates the extent to which relevant be- Psychosomatic Medicine 5: (1988) 155

4 M. H. L. HECKERetal. TABLE 1. Key Questions in the WCGS Type A Structured Interview 1. Does your job carry heavy responsibility? 2. Were you on any athletic teams in high school or college? 3. Did you attend night school or take correspondence courses to advance your career? 4. Are you satisfied with your present job? 5. Do you think of yourself as hard-driving and ambitious, or as relaxed and easy-going? 6. When you play competitive games with children, do you purposely let them win? 7. In games with contemporaries, do you play to win or for the fun of it? 8. Is there any competition in your job? 9. Do you have another job or participate in civic activities? 1. When you take snapshots, do you develop your own films? 11. When you have an appointment to meet your wife or a friend, will you be there on time? 12. What are your major hobbies? 13. Do you get impatient when you are watching a slow worker? 14. Do you often do two things at the same time, like reading while eating? 15. Do you walk fast? 16. Are you irritated if you have to wait for a table in a restaurant? 17. When someone is talking to you, do you often find yourself thinking about other things? 18. Do you feel that time is passing too quickly each day to get everything done? 19. Are you irritated if you are caught behind a slow automobile and cannot pass? 2. How frequently do you get angry or upset? haviors are evident during that segment. The 2 scores are summed for each component and the total score is used in analyses. In playback III, raters integrate their assessment of speech characteristics over five consecutive segments at a time and then use a 5-point scale ( to 4) to rate these characteristics four times during each interview. The four scores are summed for each component and the total used in analyses. Two raters (authors M.H. and N.F.) evaluated the 75 selected interviews. Both had experience with this component scoring procedure in previous studies. They had no knowledge of either the identities of CHD cases and controls or the previously determined global ratings of Type A behavior. To minimize possible effects of rater differences in applying scoring criteria, the three related interviews (one CHD case and two matched controls) were assigned to the same rater for evaluation in a random order during the same month. Interviews were evaluated by only one rater, with the exception of a subset of 36 interviews that were assigned to both raters to measure interrater reliability. Statistical Analysis In the design and analysis of a case-control study, several methods are available to control the effects of extraneous variables on the relationship between risk factor and disease outcome of interest. In the design, the effects of age, company of employment, and time of entry were removed by matching controls with cases on those variables. For the analysis of a matched design, one should use a modeling technique that maintains the matching scheme. The stratified conditional-likelihood approach using a logistic model (34) is one such technique, and it was adopted here. It can incorporate both categorical and continuous covariates. For example, in estimating the relationship between a particular behavioral component and CHD incidence, one can control the effects of other behavioral components, the global Type A rating, and traditional CHD risk factors such as serum cholesterol, blood pressure, and smoking in addition to controlling the effects of matching variables. The analysis technique estimates a logistic regression coefficient for each variable included in the 156 Psychosomatic Medicine 5: (1988)

5 CORONARY-PRONE BEHAVIORS TABLE 2. Summary Definitions of Components Component Immed iateness Type A content Competitiveness Self-aggrandizement Exactingness Despondency Loudness of voice Syllabic emphasis Speaking rate Acceleration Hard voice Definition Quickness with which the subject responds to the key questions. The inverse of response latency. Content of the subject's responses indicative of Type A behavior (e.g., report of heavy job responsibility in response to the first key question). Competitive behavior exhibited during the interview (e.g., interrupting the interviewer, asking irrelevant questions, or requesting unnecessary clarification). Reports of anger or irritation involving others or unpleasant situations, and hostility expressed toward the interviewer (e.g., complaints about others, depreciation of interviewer). Claims of superiority relative to others (e.g., conceit, pompous statements, boasting). Excessive and unnecessary attention to detail, both in interpreting questions and providing answers (e.g., volunteering numerical information, requesting additional information before responding to questions). Depressed viewpoint or mood evidenced in content or tone of responses (e.g., statements of loss, pessimism, sadness, and withdrawal as a coping style). Loudness of voice during responses. Sudden increases in loudness that emphasize particular syllables, i.e., explosive speech. Speed of speaking in passages that are free of thought pauses and emotional interruptions. Temporary increases in speaking rate, usually at the end of sentences. Speech that reflects excessive muscular tension in the laryngeal structures. model. In the results presented here, standardized relative risk (RR) was estimated by computing the ratio of CHD risk at one standard deviation above the mean value of the variable to the risk at one standard deviation below the mean. This particular standardization of the RR is equivalent to that obtained for a dichotomous risk factor having roughly equal occurrence of risk levels, such as the 5% prevalence of the global Type A pattern in the WCGS. RESULTS Table 3 presents the mean, standard deviation, range, and interrater reliability coefficient for each of the component scores. The interrater reliability was determined using intraclass correlations for a randomly selected subsample of 36 interviews rated independently by the two raters. All 12 intraclass correlations were significantly greater than zero at the p =.5 level. Five of the 12 components had reliabilities greater than.8. A risk analysis using the logistic model was employed to examine the relationship between each of the components separately and CHD incidence. For this univariate analysis (see Table 4), the components significantly related to CHD incidence were hostility (RR = 1.92, p <.1); speaking rate (RR = 1.66, p =.3); immediateness (RR = 1.62, p =.9); competitiveness (RR = 1.5, p =.13); and Type A content (RR = 1.38, p =.45). The multiple logistic analysis determined whether each component is directly related to CHD incidence or is showing the univariate relationship in part because of its relationships with other components. As shown in Table 4, the hostility component remained significantly Psychosomatic Medicine 5: (1988) 157

6 M. H. L. HECKERetal. TABLE 3. Univariate Statistics and Reliability Coefficients for Behavioral Components Univariate statistic (r> = 75) Behavioral component Mean Immediateness 25.4 Type A content 46.2 Competitiveness Self-aggrandizement 7.1 Exactingness 2.3 Despondency 2.8 Loudness of voice 5. Syllabic emphasis 7.3 Speaking rate 7. Acceleration 7. Hard voice 8.3 a lntraclass correlation coefficient. Standard deviation Minimum Maximum Reliability 1 (n = 36) related to CHD incidence [RR = 1.93, p <.1) when the other components were included in the analysis. Self-aggrandizement showed a significant inverse relationship to CHD incidence (RR =.64, p =.45), indicating that the behavior assessed by this component is moderately protective for CHD when controlling for the other components. A coronary-prone composite score was calculated as the linear combination of the components that best predicted CHD using the logistic coefficients derived from the multiple logistic analysis. As shown in Table 5, this score showed a significant relative risk of 2.75 (p <.1). For comparison, the global Type A ratings assigned to these subjects at intake into the WCGS by Ray Rosenman showed a relative risk of 2.68 (p <.1) in this sample. Table 5 also presents the results of two bivariate logistic analyses: one for global Type A rating and hostility, the other for global Type A rating and the coronary-prone composite score. Although the RR decreased somewhat from the univariate analysis for each variable, these analyses show that the risks related to hostility and those related to the coronary-prone composite score remained significant after adjusting for the global Type A behavior pattern. An important strength of the global Type A behavior pattern is that its relationship to CHD incidence is independent of the standard risk factors, i.e., serum cholesterol, diastolic blood pressure, and cigarette smoking. Table 6 shows the results of the logistic analysis applied to hostility, the coronary-prone composite score, global Type A, and the three standard CHD risk factors. As expected, the univariate RR for each of the risk factors is statistically significant (p <.1), indicating that cases had significantly higher levels of these risk factors than controls. After adjustment for the effect of the risk factors, both hostility (RR = 1.84, p =.1) and the coronaryprone composite score (RR = 2.46, p <.1) remained significant as did the global Type A rating (RR = 2.82, p <.1). We also examined the interaction of hostility and age. CHD cases from 38 to 49 yr of age at intake had a RR of 1.97 compared to 158 Psychosomatic Medicine 5: (1988)

7 CORONARY-PRONE BEHAVIORS TABLE 4. Logistic Analysis of Behavioral Components and CHO Incidence Component Standardized logistic coefficient Value Standard relative risk 95% confidence interval p value Univariate findings Speaking rate Immediateness Competitiveness Type A content Loudness of voice Hard voice Exactingness Syllabic emphasis Self-aggrandizement Acceleration Despondency Multivariate findings Exactingness Competitiveness Speaking rate Immediateness Loudness of voice Type A content Hard voice Syllabic emphasis Despondency Acceleration Self-aggrandizement TABLE 5. Relative Risks for CHD Associated with, Coronary-prone Composite Score, and Global Type A in Univariate and Bivariate Analyses Standardized relative risk" 1 Bivariate 1 ' Behavior Univariate Coronary-prone composite Global Type A a AII relative risks are significant at the p <.1 level with the exception of hostility in bivariate analysis I (RR = 1.71, p =.2). ''Bivariate analysis I included hostility and global Type A. Bivariate analysis II included coronary-prone composite and global Type A. Psychosomatic Medicine 5: (1988) 159

8 M. H. L. HECKERetal. TABLE 6. Relative Risks for CHO Associated with, Coronary-prone Composite Score, and Standard Risk Factors in Univariate and Multivariate Analyses Behavior Coronary-prone composite Global Type A Standard risk factor Serum cholesterol Diastolic blood pressure Smoking (number of cigarettes) Univariate Standardized relative risk" Multivariate b a AII relative risks are significant at the p <.1 level with the exception of hostility in multivariate analysis I (RR = 1.84, p =.1). 6 Multivariate analysis I included hostility and each of the standard risk factors. Multivariate analysis II included coronary-prone composite and each of the risk factors. Multivariate analysis III included global Type A and each of the risk factors. II III their matched controls. CHD cases from 5 to 59 yr of age had a RR of 1.85 compared to their matched controls. The difference between the relative risks in the two age groups was not significant. The relationship between the components and global Type A rating was examined using Spearman rank order correlations. As shown in Table 7, all of the components except despondency were significantly related to the global rating. However, the size of the significant correlations varied from.1 to.323. Of particular interest, the hostility component correlated at only.175 with the global rating. Only three of the 12 components showed a lower correlation with the global Type A rating than did hostility. DISCUSSION The results of the present study indicate that, among the components of Type A behavior, hostility plays a leading role TABLE 7. Spearman Correlation Coefficients for Association of Behavioral Components with the Global Type A Rating Component Type A content Loudness of voice Self-aggrandizement Competitiveness Syllabic emphasis Speaking rate Hard voice Immediateness Exactingness Acceleration Despondency Coronary-prone composite Spearman r p value.6.77 in predicting incidence of CHD. Among the 12 behavioral components scored, only hostility was significantly related to CHD when all components were analyzed together in a multivariate model. Furthermore, hostility was a significant predictor of CHD when controlling for the 16 Psychosomatic Medicine 5: (1988)

9 CORONARY-PRONE BEHAVIORS global Type A rating and for standard CHD risk factors. These findings are consistent with the previous component analysis of a subset of WCGS interviews, in which ratings of potential for hostility in the intake structured interviews showed the most significant difference between CHD cases and controls (21). These findings are also in accord with recent studies reporting significant correlations between hostility ratings of Type A structured interviews and severity of angiographically documented coronary artery disease (24, 25). Support for the coronary-prone status of hostility is also suggested by the observation of significant relationships between hostility as assessed by the Cook-Medley subscale of the MMPI and incidence of CHD and allcause mortality in two prospective studies (27, 28). The correlation (r =.275) between the coronary-prone composite score and the global rating of Type A behavior was notably low. That both the Type A global rating and the coronary-prone composite score were significantly predictive of CHD in the bivariate analysis indicates that the coronary-prone composite score assessed coronary-prone behaviors that were not accounted for in the global Type A ratings and, conversely, that the global ratings included coronary-prone aspects that were not accounted for by the components assessed in this study. Although significant, the correlation in this study between hostility and the global Type A rating was not high (r =.175). These findings suggest that the global Type A ratings in the WCGS did not incorporate the same elements of hostility as does the hostility component assessed in this study. In two angiography studies (24, 25), wherein ratings of hostility in the structured interview were related to disease severity but global ratings of Type A behavior were not, the correlations between ratings of hostility and global Type A behavior were higher than that observed here. The explanation for this discrepancy is not readily apparent but probably involves either differences in the samples studied or differences in the global and hostility rating procedures employed. In the present study, the conceptualization of hostility is similar to that used by Dembroski et al. (24). Specifically, hostility is viewed as a predisposition to express, both directly and indirectly, various types and degrees of anger and related mood states, including irritation, annoyance, disgust, resentment, and frustration. Operationally, the definition of hostility used in this study differs from the definitions used by other investigators in that specific behavioral indicators of hostility were scored. These indicators include direct and indirect expressions of hostility toward the interviewer; self-reports of anger, irritation, or annoyance involving a third party or a situation; and emotional expressions of hostility conveyed by-word choice or tone of voice. The findings reported here build on the evidence accumulating in the literature that the global Type A behavior pattern comprises both benign and coronary-prone components, which need to be differentiated and evaluated separately. The present results suggest that some components (e.g., self-aggrandizement), when examined in a multivariate model, may be protective. By focusing on coronary-prone behaviors, such as hostility, the specificity of CHD prediction will be enhanced and the inconsistencies observed in some studies of the relationship between Type A behavior and CHD endpoints may be resolved. Psychosomatic Medicine 5: (1988) 161

10 M. H. L. HECKERetal. SUMMARY The Western Collaborative Group Study (WCGS) was the first to establish a prospective relationship between Type A behavior and coronary heart disease. In that original study of 3,154 middle-aged men, a multifaceted conceptualization of behaviors was nonetheless rated globally as Type A or Type B in all individuals. Until more recent research, it has remained an open question as to which of the particular facets are most responsible for the enhanced CHD risk and which, if any, are not related to disease. In the present study, the Type A structured interviews administered at intake in the WCGS were reassessed in terms of 12 operationally defined components of behavior. Two-hundred-fifty participants who developed CHD within 8.5 yr of followup, and 5 controls matched by age and company of employment who remained disease free after 8.5 yr, were evaluated. Results using the matched-logistic method of analysis demonstrated that hostility was clearly the most dominant of the 12 behavioral components with a standardized relative risk for CHD incidence of 1.93 (p <.1). A coronary-prone composite of the 12 components showed a relative risk of 2.75 (p <.1), similar in magnitude to that found in this sample for the original global Type A rating (RR = 2.68, p =.1). remained a significant predictor of CHD after controlling for global Type A ratings and for the traditional CHD risk factors: serum cholesterol, diastolic blood pressure, and cigarette smoking. However, hostility ranked only ninth among the 12 components in the magnitude of its correlation with global Type A rating. The data suggest that some facets comprising the Type A behavior pattern are benign for CHD, and that hostility, as scored in this reassessment of the WCGS interviews, is the most coronary prone of the facets and was not weighted heavily in the original rating of global Type A behavior in the WCGS. This research was supported by a research grant from the National Heart, Lung, and Blood Institute (HL-4632) and by Biomedical Research Support grant funds from the National Institutes of Health. We gratefully acknowledge Ray H. Rosenman, M.D., for providing access to the WCGS data. We also wish to thank the anonymous reviewers of this manuscript for their many helpful comments. REFERENCES 1. Rosenman RH, Friedman M, Straus R, Wurm M, Kositchek R, Werthessen NT: A predictive study of coronary heart disease: The Western Collaborative Group Study. JAMA 189:113-12, Rosenman RH, Brand RJ, Jenkins D, Friedman M, Straus R, Wurm M: Coronary heart disease in the Western Collaborative Group Study: Final follow-up experience of 85 years. JAMA 233: , Rosenman RH, Brand RJ, Sholtz RI, Friedman M: Multivariate prediction of coronary heart disease during 8.5 year follow-up in the Western Collaborative Group Study. Am J Cardiol 37:93-91, Blumenthal JA, Williams R, Kong Y, Schanberg SM, Thompson LW: Type A behavior and angiographically documented coronary disease. Circulation 58: , Psychosomatic Medicine 5: (1988)

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