Type A behavior and survival: a follow-up study of 1,467 patients with coronary artery disease

The Relationship between Expressive/Suppressive Hostility Behavior and Cardiac Autonomic Activations in Patients with Coronary Artery Disease

BACKGROUND

Hostility is an important psychosocial risk factor in coronary artery disease (CAD). Expressive and suppressive hostility behaviors are related to cardiovascular response in healthy adults. However, the relationships of these behavioral dimensions to cardiac autonomic activations in CAD remain unclear.

METHOD

This study involved 76 patients with CAD to whom a hostility inventory was administered, who were instructed to recall a neutral event and an anger-related event. Heart rate and blood pressure were obtained for each patient as the indices of cardiovascular response; heart rate variability was transformed from electrocardiograph and as the indices of cardiac autonomic activation.

RESULTS

The results showed that CAD patients with expressive hostility behavior experienced higher cardiovascular autonomic activations during the neutral and anger recall tasks, and lower parasympathetic activations during the recovery after an anger episode. On the other hand, CAD patients with suppressive hostility behavior experienced both sympathetic and parasympathetic activations during the baseline and recovery stages, as well as simultaneously activated higher parasympathetic response.

CONCLUSIONS

The results of this study suggested that it is appropriate to extend the cardiac autonomic activation model for expressive and suppressive hostility behaviors in patients with CAD.

KEY WORDS

Cardiac autonomic; Coronary artery disease; Expressive hostility; Suppressive hostility behaviors.

Hostility, age, and mortality in a sample of cardiac patients

This study examined hostility as a predictor of survival in a sample of 1,328 patients who had documented coronary artery disease. After controlling for disease severity, there was a significant interaction between age and hostility. Hostility was significantly associated with poorer survival but only in younger (<61.2 years) patients.

Hostility scores are associated with increased risk of cardiovascular events in women undergoing coronary angiography: a report from the NHLBI-Sponsored WISE Study

OBJECTIVE

To evaluate hostility-related personality traits assessed by the Cook Medley Hostility Inventory and to relate these to the occurrence of adverse cardiac events in women with suspected myocardial ischemia.

METHODS

The cohort included 506 women with suspected coronary artery disease from the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We examined individual components of the Cook Medley Hostility Score (CMHS) measuring cynicism, hostile affect, and aggressive responding, and a total CMHS (sum of these three) and associations with adverse events (defined as hospitalization for angina, nonfatal myocardial infarction, stroke, congestive heart failure (CHF) other vascular events and death) during 3 to 6 years follow-up using Cox proportional hazard modeling.

RESULTS

Women with adverse events had higher total CMHS (10.6 +/- 5.5) than women without any of these events (9.2 +/- 5.1) p = .02. They also had poorer survival by Kaplan-Meier analysis (log-rank p < .05). Unadjusted Cox models showed that the individual scores of cynicism and aggressive responding and the total CMHS were associated with more adverse events (all p < .05). Women with total CMHS above the median had a 35% increase risk of an adverse event in comparison to women with lower scores. In a risk-adjusted Cox model, the hazard ratio for an adverse event was 1.5 (p = .03) for women with total CMHS above the median.

CONCLUSION

In this cohort of women with suspected myocardial ischemia, higher Cook Medley scores reflecting cynicism, hostile affect, and aggressive responding were associated with poorer 3 to 6 year event-free survival and a higher risk of adverse events. After adjusting for risk factors and CAD, the association with risk for adverse events increased.

Reflections on depression as a cardiac risk factor

OBJECTIVE

Major North American cardiology organizations do not currently list depression among the officially recognized cardiac risk factors, yet many behavioral medicine specialists believe depression to be an important risk. We wondered what was missing from the available data.

METHODS

The Medline, Current Contents, and PsychInfo databases were used to perform a systematic review of the literature linking depression and depressive symptoms with cardiac disease outcomes. Because of previous reviews, we paid particular attention to publications from 2001 to 2003.

RESULTS

We identified 21 etiologic and 43 prognostic publications that had prospective designs, used recognized measures of depression, and included objective outcome measures. We also identified 79 review articles. In addition to issues of sample size, sample characteristics, and timing of measures, we noted heterogeneity in the definitions of depression, frequent repeat publications from the same data sets, heterogeneity of outcome measures, a variety of approaches for covariate selection, and a preponderance of review articles, all factors that cannot help to convince skeptics.

CONCLUSIONS

Despite these issues, the bulk of the data from prospective studies with recognized indices of depression and objective outcome measures is supportive of depression as a cardiac risk factor.

Hostility as a predictor of survival in patients with coronary artery disease

OBJECTIVE

This article presents a reanalysis of an earlier study that reported a nonsignificant relation between the 50-item Cook-Medley Hostility Scale (CMHS) and survival in a sample of coronary patients. Since publication of those results, there have been significant developments in the measurement of hostility that suggest that an abbreviated scale may be a better predictor of health outcomes. This study examined the ability of the total CMHS and an abbreviated form of the CMHS (ACM) to predict survival in a sample of patients with documented coronary artery disease (CAD) with increased statistical power.

METHODS

Nine hundred thirty-six patients (83% were male; mean age = 51.48) with CAD who were followed for an average of 14.9 years. The ACM consisted of the combination of the cynicism, hostile attribution, hostile affect, and aggressive responding subscales that were identified in an earlier study (Barefoot et al. [1989]) by a rational analysis of the item content. The relation between hostility and survival was examined with Cox proportional hazard models (hazard ratios [HRs] based on a two standard deviation difference).

RESULTS

Controlling for disease severity, the ACM was a significant predictor for both CHD mortality (HR = 1.33, p <.009) and total mortality (HR = 1.28, p <.02). The total CMHS was only a marginally significant predictor of either outcome (p values < 0.06).

CONCLUSION

The results of this study suggest that hostility is associated with poorer survival in CAD patients, and it may be possible to refine measures of hostility in order to improve prediction of health outcomes.

Bortner type A scores and basic emotions: aggression, distrustful, depression, and gregarious

We examined the correlations between scores on Bortner's scale and measures of aggression, distrustful, gregarious, and depression in 1,084 employees. Prospectively over 2 yr. we investigated the relationship of Type A behavior with cardiac mortality. Subjects classified as Type A had higher mean ratings on measures of aggression and distrustful than did persons classified as Type B. Mortality was lower in patients classified as reporting Type A behavior (12%) than in the patients classified as reporting Type B behavior (22%).

Effect of smoking and sedentary behavior on the association between depressive symptoms and mortality from coronary heart disease

It has been suggested that one of the mechanisms linking depression with elevated mortality risk is the association between depressive symptoms and other established coronary artery disease (CAD) risk factors, such as smoking and failure to exercise. The present study examined this hypothesis using repeated assessments of smoking and exercise from patients with CAD in whom depressive symptoms had been shown to predict decreased survival. Initially, associations between depressive symptoms and the risk factors of smoking and sedentary behavior were assessed. Next, patterns of smoking and sedentary behavior were examined as mediators and/or moderators of the association between depressive symptoms and mortality. Depressive symptoms were positively related to smoking (p <0.01) and sedentary behavior (p <0.01). Depressive symptoms, smoking, and sedentary behavior were independent predictors of mortality. Results indicated that smoking and/or sedentary behavior may partially mediate the relation between depressive symptoms and mortality. No evidence for moderation was found.

Components of type A behavior and two-year prognosis of patients with acute coronary syndrome

We investigated prospectively the relationship of Type A behavior and its subcomponents with cardiac mortality and recurrent nonfatal cardiac events in a 2-yr. follow-up of 90 patients [69 men and 21 women, M age=56.4 yr., SD=8.4] after acute coronary syndrome. Type A behavior was assessed via the general Bortner Type A Index. Each patient completed the Bortner's scale before hospital discharge. During the first 2-yr. follow-up, there were 14 cardiac deaths among patients with myocardial infarction. 8 patients had recurrent cardiac events and were hospitalized, and 19 patients had an effort-induced angina pectoris. Patients with acute myocardial infarction who died during follow-up had a significantly lower Bortner score than patients with a secondary cardiac event. Bortner scores of patients with acute myocardial infarction who died indicated Type B behavioral patterns. Mortality was significantly higher in the patients classified as showing Type B (21.8%) behavior than in the patients classified as showing Type A (12.0%) behavior. Patients with a secondary cardiac event had more common Type A behavior patterns and higher Bortner scores than patients without a secondary cardiac event. The items on Bortner's scale "very competitive, ever rushed, tries to do too many things at once, fast in daily activities and expresses feelings" were inversely associated with cardiac deaths. These findings suggest that patients with acute coronary syndrome classified by scores on the Bortner scale as Type B behavior have a greater probability of death, and patients classified on the Bortner scale as Type A behavior have a greater probability of secondary cardiac events during follow-up. This finding may have implications for the treatment of patients with acute coronary syndrome. The inferior survival of patients with Type B personalities argues against attempts to modify Type A behavior in postinfarction patients.

Later management of documented ischaemic heart disease: secondary prevention and rehabilitation

Patients may present with a variety of syndromes related to ischaemic heart disease. These include unstable or stable angina pectoris, acute myocardial infarction, and occasionally cardiac failure without prior anginal pain or infarction. For the purposes of this review, it will generally be assumed that the condition has been stabilised, though one important aspect of the rehabilitation process is the recognition of continuing or recurrent problems such as angina pectoris and cardiac decompensation. This should then be followed by appropriate intervention. The key components of post-hospital management of such patients are: (i) support; (ii) education; (iii) assessment; (iv) intervention (if necessary); (v) therapy; and (vi) lifestyle modification.

Depressive symptoms and survival of patients with coronary artery disease

OBJECTIVE

Multiple studies have shown that high levels of depressive symptoms increase the mortality risk of patients with established coronary disease. This investigation divided depressive symptoms into groups to assess their relative effectiveness in predicting survival.

METHODS

Questionnaires about the presence of depressive symptoms were administered to 1250 patients with significant coronary disease while they were hospitalized for diagnostic coronary angiography. Follow-up for mortality due to cardiac disease was conducted annually for up to 19.4 years. Factor analysis was used to divide items on the Zung Self-Rating Depression Scale into four groups: Well-Being, Negative Affect, Somatic, and Appetite. In addition, responses to a single item regarding feelings of hopelessness were available for 920 patients.

RESULTS

Well-Being and Somatic symptoms significantly predicted survival (p < or = .01). Negative Affect items were also related to survival (p = .0001) and interacted with age. A 2-SD difference in the Negative Affect term was associated with a relative risk of 1.29 for patients >50 years old and 1.70 for younger ones. Only Negative Affect remained significant in a model with the other symptom groups. Hopelessness also predicted survival with a relative risk of 1.5. Both the Hopelessness and Negative Affect items remained as independent predictors in the same model. All models controlled for severity of disease and treatment. With one exception (income and Hopelessness), results were essentially unchanged by additional controls for age, gender, and income.

CONCLUSIONS

Depressive symptoms differentially predicted survival, with depressive affect and hopelessness being particularly important. These effects were independent of disease severity and somatic symptoms and may be especially important in younger patients.

Social support and hostility as predictors of depressive symptoms in cardiac patients one month after hospitalization: a prospective study

OBJECTIVE

Hospitalization for cardiac disease is associated with an increased risk for depression, which itself confers a poorer prognosis. Few prospective studies have examined the determinants of depression after hospitalization in cardiac patients, and even fewer have examined depression within the weeks after hospital discharge. The present study assessed the prospective relations among perceptions of social support and trait hostility in predicting symptoms of depressive symptoms at 1 month after hospitalization for a diagnostic angiography in 506 coronary artery disease (CAD) patients.

METHOD

A series of structural equation models 1) estimated the predictive relations of social support, hostility, and depressive symptoms while in the hospital to symptoms of depression 1 month after hospitalization, and 2) compared these relations across gender, predicted risk classification, and age.

RESULTS

Social support assessed during hospitalization was independently negatively associated with depressive symptoms 1 month after hospitalization, after controlling for baseline symptoms of depression, gender, disease severity, and age. Hostility was an indirect predictor of postdischarge depressive symptomology by way of its negative relation with social support. This pattern of relations did not differ across gender, predicted risk classification, and age.

CONCLUSIONS

Our findings suggest that a patient's perceived social support during hospitalization is a determinant of depressive symptoms 1 month later. The relation of social support and hostility to subsequent depressive symptoms was similar across a variety of populations.

Psychologic and social aspects of cardiovascular disease

In summarizing the evidence, it becomes apparent that several psychologic and social variables are related to coronary heart disease (CHD). Coronary prone behavior pattern, in particular the hostility component, appears to be related to the development and perhaps expression of CHD, whereas it is not reliably related to outcomes after CHD is manifest. Depression clearly has been shown to be related to outcomes after CHD has declared itself. Lack of social ties appears to be related to mortality, whereas emotional social support has been shown to be related to recovery from coronary events. It also seems apparent that there are subsets of vulnerable individuals who might be best served by targeted interventions. Interventions are proposed as suggested by the prevailing evidence.

Evidence for the effectiveness of cardiac rehabilitation

Cardiac rehabilitation is a relatively recent development and, though it is increasingly being recognized as an important part of comprehensive cardiac care, there remains some scepticism regarding its effectiveness and some ignorance of its potential. This article reviews the literature pertaining to the effectiveness of cardiac rehabilitation for patients with coronary heart disease (CHD).

Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction

BACKGROUND

Patients with myocardial infarction (MI) with a decreased left ventricular ejection fraction (LVEF) have a poor prognosis, but the role of emotional stress in prognosis is not known. We hypothesized that emotional stress in these patients (1) is unrelated to the severity of cardiac disorder, (2) predicts cardiac events, and (3) is a function of basic personality traits.

METHODS AND RESULTS

Eighty-seven patients with MI (age, 41 to 69 years) with an LVEF of < or =50% underwent psychological assessment at baseline. Patients and their families were contacted after 6 to 10 years (mean, 7.9 years); cardiac events were defined as cardiac death or nonfatal MI. Emotional distress was unrelated to the severity of cardiac disorder. At follow-up, 21 patients had experienced a cardiac event (13 fatal events). These events were related to LVEF of < or =30%, poor exercise tolerance, previous MI, anxiety, anger, and depression (all P< or =.02). Patients with a distressed personality (type D; ie, the tendency to suppress negative emotions) were more likely to experience an event over time compared with non-type D patients (P=.00005). Cox proportional hazards analysis yielded LVEF of < or =30% (relative risk, 3.0; 95% confidence interval, 1.2 to 7.7; P=.02) and type D (relative risk, 4.7; 95% confidence interval, 1.9 to 11.8; P=.001) as independent predictors. Anxiety, anger, and depression did not add to the predictive power of type D; these negative emotions were highly correlated and reflected the personality domain of negative affectivity.

CONCLUSIONS

Personality influences the clinical course of patients with a decreased LVEF. Emotional distress in these patients is unrelated to disease severity but reflects individual differences in personality. Clinical trials should take a broad view of the target of intervention; assessment of LVEF and personality may identify patients at risk.

Hostility, aggression and the risk of nonfatal myocardial infarction in postmenopausal women

Hostility can predict coronary heart disease (CHD) and total mortality in men. However, in women this association has not been as thoroughly explored. This study examines whether hostile and aggressive attitudes are associated with myocardial infarction (MI) in postmenopausal women. Cases included 277 women who presented with an incident MI. Controls included a random sample of 988 female health maintenance organization enrollees. Women were asked the Hostile-Affect and the Aggressive-Responding factors of the Cook-Medley Hostility Scale. The Hostile-Affect score was linearly associated with increased risk for MI (odds ratio [OR] per point = 1.22; 95% confidence interval [CI95%] = 1.07-1.38), whereas the Aggressive-Responding score had a modest protective effect (OR = 0.92 per point; CI95% = 0.84-1.02); p = 0.009. Adjustment for sociodemographic and MI risk factors altered these results only slightly. These hostility measures are easily administered, and could help to identify women who are at high risk for CHD and who may benefit from preventive measures.

Heart rate and heart-rate variability in patients with acute coronary heart disease classified on Bortner's scale as type A and type B

We investigated heart rate and heart-rate variability in 82 patients, 60 men and 22 women (M = 54 yr., SD = 9) with acute coronary heart disease and scores on Bortner's scale at hospital admission and discharge. 48 patients were classified by their scores on Bortner's scale as Type A and 34 as Type B. Patients with acute coronary heart disease classified as Type A had a significantly lower mean heart rate than patients with acute coronary heart disease classified as Type B during the day at hospital admission and discharge and during the night at hospital discharge. Mean heart-rate variability was also significantly higher in the patients with acute coronary heart disease classified as Type A than in the patients with acute coronary heart disease classified as Type B during the day at hospital admission and discharge. The differences between two groups on the average heart rate and heart-rate variability were not significant during the night at hospital admission. In our study the patients with acute coronary heart disease classified by scores on Bortner's scale as Type A had higher vagal tone and more favorable sympathovagal balance than patients classified as Type B. This finding may have implications for the treatment of patients with acute coronary heart disease and may suggest some explanation about the protective effect of Type A behavior also.

Bortner type A scores and eight basic emotions for survivors of ventricular fibrillation and left ventricular failure during acute myocardial infarction

We examined Bortner scores for behavioral patterns and eight basic emotional dimensions named by Plutchik for patients with acute myocardial infarction who survived ventricular fibrillation and left ventricular failure. There were 70 patients, 48 men and 22 women ages 26 to 69 yr. (M = 54, SD = 8), admitted to the coronary care unit within 24 hours of the onset of a long-lasting chest pain. Six patients survived an episode of ventricular fibrillation that occurred within 24 to 48 hours after their admission. 15 patients developed left ventricular failure and were in Killip Classes II and III. Patients with acute myocardial infarction and left ventricular failure had mean Bortner scores significantly lower than others with acute myocardial infarction and were classed as Type B behavior. There was no difference in Bortner scores between patients with ventricular fibrillation and others with acute myocardial infarction. Patients with acute myocardial infarction and left ventricular failure scored significantly higher on Timid than others with acute myocardial infarction. Patients with acute myocardial infarction and ventricular fibrillation scored significantly lower on Depressed and higher on Distrust than other patients with acute myocardial infarction. Our findings suggest that patients with ventricular fibrillation and low scores on Depressed have good hospital prognosis. They are more critical and tend to reject people and ideas more than patients with acute myocardial infarction. This study suggests that the way in which patients with acute myocardial infarction react to their infarction, in terms of eight basic emotions and test patterns, is dependent on the complications of myocardial infarction.

Depression and long-term mortality risk in patients with coronary artery disease

Previous research has established that patients with coronary artery disease (CAD) have an increased risk of death if they are depressed at the time of hospitalization. Follow-up periods have been short in these studies; therefore, the present investigation examined this phenomenon over an extended period of time. Patients with established CAD (n = 1,250) were assessed for depression with the Zung Self-Rating Depression Scale (SDS) and followed for subsequent mortality. Follow-up ranged up to 19.4 years. SDS scores were associated with increased risk of subsequent cardiac death (p = 0.002) and total mortality (p < 0.001) after controlling for initial disease severity and treatment. Patients with moderate to severe depression had a 69% greater odds of cardiac death and a 78% greater odds of mortality from all causes than nondepressed patients. Increased risk was not confined to the initial months after hospitalization. Patients with high SDS scores at baseline still had a higher risk of cardiac death > 5 years later (p < 0.005). Compared with the nondepressed, patients with moderate to severe depression had an 84% greater risk 5 to 10 years later and a 72% greater risk after > 10 years. Patients with mild depression had intermediate levels of risk in all models. The heightened long-term risk of depressed patients suggests that depression may be persistent or frequently recurrent in CAD patients and is associated with CAD progression, triggering of acute events, or both.

Responses to Bortner's scale and the eight basic emotions by patients with acute coronary heart disease at hospital admission and discharge

We examined the prevalence of Type A behavior indicated on Bortner's scale and the Emotion Profiles of Plutchik in 190 patients, 134 men and 56 women (M age = 50 yr., SD = 9) with acute coronary heart disease at hospital admission and discharge. Type A classification was significantly more common for patients with acute coronary heart disease (75.5% versus 65%) than for the control group. Patients with acute coronary heart disease scored lower on Distrust and Dyscontrolled than the control group. Patients with unstable angina had significantly higher mean scores on Bortner's scale than patients with acute myocardial infarction and recurrent myocardial infarction at hospital discharge. Patients with recurrent myocardial infarction scored lower on Distrust and higher on Timid than patients with unstable angina at hospital admission and discharge. This research suggests that Type A behavior and some emotions are associated with acute coronary heart disease. There was a difference in scores on the Emotions Profiles and scores on Type A behavior in relation to type of acute coronary heart disease. The addition of counseling for Type A behavior to standard cardiac counseling was suggested for reduction in scores on Type A behavior.

Psychosocial factors: role in cardiac risk and treatment strategies

Recent epidemiologic research has identified several psychosocial factors that impact unfavorably on prognosis among patients with established coronary heart disease (CHD). Several biologic and behavioral characteristics have been identified in patients with these psychosocial risk factors that are biologically plausible mediators of their adverse impact on prognosis. Several small-scale clinical trials offer encouraging evidence that both behavioral and pharmacologic interventions have the potential to ameliorate the health-damaging effects of psychosocial risk factors in patients with CHD. In this article we review the evidence on these points and offer recommendations as to how incorporation of this new knowledge into clinical care of the patient with CHD can lead to reduced mortality and morbidity rates in this population.

The association between spouse-reported Type A behaviour pattern and coronary heart disease

This paper describes further validation of the Spouse-Report Type A Behaviour Pattern Questionnaire. In a case controlled study of 61 cardiac patients versus 61 community controls, the questionnaire was found to discriminate statistically between a group of patients with proven coronary heart disease and a group of matched healthy controls on the anger/hostility subscale and total Type A score. No relationship between Type A score and coronary heart disease severity was found. Possible explanations for these findings are examined.

Biobehavioral research on coronary heart disease: where is the person?

This study examined the thesis that patients with coronary heart disease (CHD) comprise discrete personality subtypes and that identification of these subtypes may benefit biobehavioral research on CHD. Measures of Negative Affectivity, Social Inhibition, and Self-Deception were used to generate a personality taxonomy through cluster analysis in a sample of 405 men with CHD. This empirical taxonomy served as a basis for the development of a conceptual model which delineates hardy, distressed, inhibited, and repressive subtypes. Coronary proneness may differ across these subtypes to the extent that potential behavioral correlates of CHD were associated with subtype membership. Distressed individuals (characterized by elevated levels of Type A behavior, anger, hostility, and life stress) and inhibited individuals (characterized by the nonexpression of anger) may be particularly coronary prone. It is concluded that research should focus on the interaction of global traits that may define subtypes of patients with CHD.

Psychiatric morbidity during the early phase of coronary care for myocardial infarction: association with cardiac diagnosis and outcome

We evaluated the association of psychiatric morbidity during the early phase of admission to a coronary care unit with cardiac diagnosis and subsequent morbidity. Ninety-two patients admitted for the first time for presumed myocardial infarction were evaluated within 48 hours of hospitalization. Anxiety and depressive symptoms and cognitive impairment were rated. Data were collected on cardiac diagnosis and morbidity. Three and 12 months after hospitalization, cardiac morbidity, psychiatric symptoms and psychosocial morbidity were assessed.

Cardiovascular rehabilitation: status, 1990

Cardiovascular rehabilitation is defined as the process of development and maintenance of a desirable level of physical, social, and psychologic functioning after the onset of a cardiovascular illness. Patient education, counseling, nutritional guidance, and exercise training play prominent roles in the process of rehabilitation. Benefits from cardiac rehabilitation include improved exercise capacity and decreased symptoms of angina pectoris, dyspnea, claudication, and fatigue. Recent pooled data regarding exercise training after myocardial infarction demonstrated a 20 to 25% reduction in mortality and major cardiac events. Exercise training may result in an improvement in systemic oxygen transport, a reduction in the myocardial oxygen requirement for a given amount of external work, and a decrease in the extent of myocardial ischemia during physical activity. The efficacy of modification of risk factors in reducing the progression of coronary artery disease and future morbidity and mortality has been established. Herein we review the history, current practice and results, and future challenges of cardiovascular rehabilitation.

Clinical correlates and prognostic significance of type A behavior and silent myocardial ischemia on the treadmill

Type A patients with coronary artery disease (CAD) tend to ignore or underreport symptoms, especially during challenging tasks such as the treadmill exercise test. To determine whether type A CAD patients might be more likely than type B patients to have silent ischemia during exercise and consequently a worse prognosis, 403 patients with stable CAD who had significant coronary disease on angiography, a positive Bruce protocol treadmill test and a structured interview to assess type A behavior were studied. Median follow-up time was 6 years. Type A patients were more likely to experience silent ischemia during exercise than were type B patients (35 vs 25%, p = 0.05). Patients with silent ischemia during exercise had a history of fewer anginal episodes/week, and type A patients with silent ischemia were less likely to have had a history of typical angina. However, using the Cox model, there were no significant differences in survival between type A patients and B patients with silent ischemia (4-year survival 86 vs 79%, p = 0.44) and no significant differences in survival between type A patients with silent ischemia and type A patients with symptomatic ischemia (6-year survival 86 vs 80%, p = 0.59). Similar results were obtained for infarction-free survival. Type A patients are more likely than type B patients to have silent ischemia during exercise, but long-term survival is not affected.