In a sample of relatively healthy postmenopausal women, we observed a prospective association between negative psychosocial factors and CAC progression over approximately three years. Although an aggregated index of negative psychosocial factors predicted greater CAC, this effect appears to be driven by significantly greater CAC progression among women who are both highly cynical and prone to anger suppression. The finding that the combination of cynicism and anger suppression may be cardiotoxic is consistent with results from an older cross-sectional study, which documented that hostility and anger-in interacted to determine extent of angiographically-determined atherosclerosis among (mostly male) patients (31; although note that this methodological approach has since been criticized; 34). Our findings are somewhat inconsistent with previous studies of carotid intima-media thickness (IMT), another noninvasive marker of subclinical atherosclerosis that is moderately correlated with CAC (35
). Although both cynical hostility and anger suppression have been associated with carotid IMT in cross-sectional analyses (36
), neither predicts progression of IMT longitudinally (38
), with one exception. A study of 119 middle-aged men found that the interaction between cynical hostility and anger-in was nonsignificant but that cynicism and anger control (i.e., efforts to control angry feelings by avoiding open expression of irritation or aggression) additively predicted 2-year progression of carotid atherosclerosis (32
). To our knowledge, the current study is the first to suggest the combination of hostility and anger suppression predicts progression of CAC in an initially healthy women. Results highlight the importance of examining the combination of negative attitudes relevant to emotional experience (in this case, frequent hostile cognitions) and differences in emotion regulation or expression to identify individuals at risk for CVD.
Consistent with results from another sample (14
), psychosocial risk factors were significantly predictive of CAC progression only for women who had initial CAC at baseline. This suggests that the trajectory to CAC progression in late-life may begin before women are in their mid-50s and that those who have developed a significant atherosclerotic burden evidenced by CAC by midlife may be more vulnerable to the effects of psychosocial and other risk factors. CAC by EBCT measures calcified plaque as an estimate of total plaque burden (both calcified and noncalcified). It is possible that psychosocial risk factors accelerate the natural history from soft, potentially unstable to more stable plaque. More likely, however, our findings indicate that psychosocial factors predict increasing atherosclerotic burden over time in midlife women.
Contrary to hypotheses, results revealed no significant association between positive psychosocial resources, including optimism, purpose in life, self-esteem, mastery, and perceived social support, and CAC progression. Relative to psychological risk factors such as negative emotions and stress, protective factors have received limited empirical attention as potential predictors of CVD (1
). Optimism has been prospectively linked to incident CVD in women (40
) as well as progression of carotid IMT (41
), but an earlier analysis of the HWS cohort reported that positive factors were cross-sectionally associated with aortic but not coronary calcification (9
). Perhaps positive psychosocial factors are more important once CVD has developed, helping individuals to cope with medical procedures and symptoms and to sustain adherence to medication and lifestyle changes.
A recent paper by Rozanski and colleagues (11
) highlighted an intriguing difference in findings of cross-sectional versus longitudinal studies linking psychological risk factors and CAC. They argued that studies examining concurrent measures of psychological risk tend to report null results, whereas those that measured psychological factors several years prior to CAC scanning reported positive results. This discrepancy parallels the observed associations between CAC and traditional CVD risk factors such as low-density lipoprotein cholesterol assessed prospectively but not concurrently (42
). The current study contributes to this literature by demonstrating that psychosocial factors assessed prior to CAC predicted change
in CAC over several years, whereas previous analyses of this same cohort reported no significant cross-sectional association between positive or negative psychosocial attributes and CAC (9
). As this is only the second sample in which psychosocial factors have been examined as predictors of CAC progression (14
), more research is needed to determine whether emotional and social factors predict not only presence or extent of calcification at a single timepoint, but also the extent of change in calcification over time.
This study has several limitations. First, participants in our sample were predominantly well-educated white women, and findings may not generalize to other racial or socioeconomic groups. Second, the sample was relatively small, which may have limited statistical power to detect effects. Third, psychological attributes and states were assessed at a single timepoint, when women were in their mid-60s. Given that atherosclerosis develops over the life course, the association between psychosocial factors and atherosclerosis may be strongest when chronic, cumulative emotional or social factors (e.g., recurrent major depression; consistently low social support) are assessed (11
). Repeated assessment of psychosocial factors may be particularly important to understanding the role of positive attributes and coping resources in the development of CVD, as these factors may be particularly likely to exhibit variability over time as participants age (43
). Assessment of psychosocial risk and protective factors was also limited to self-report in this study; given that some cross-sectional reports find associations between spousal reports of psychological traits and CAC but not self-reported traits (12
), our reliance on self-reports could have resulted in an underestimate of some associations. A final limitation of the study was the use of abbreviated measures (e.g., cynicism scale reduced to 6 items from 13 items), which may limit comparability to previous work. Strengths of the study include the examination of a wide range of psychosocial measures, prospective design, and focus on older women without history of frank cardiovascular disease.
In summary, our results suggest that psychosocial risk factors, particularly the combination of cynical attitudes and a tendency to suppress anger, predict greater increases in CAC among relatively healthy older women. These findings highlight psychosocial risk factors that may accelerate the progression of subclinical coronary atherosclerosis and that may therefore represent potential targets for psychological intervention. Interventions aimed at reducing cynical attitudes and/or encouraging constructive expression of anger may not only benefit psychological well-being, but could also alter the trajectory of cardiovascular risk among older women.