title: Anger expression and sleep quality in patients with coronary heart disease: findings from the Heart and Soul Study.
abstract: OBJECTIVE
  To evaluate if anger expression affects sleep quality in patients with coronary heart disease (CHD). Research has indicated that poor sleep quality independently predicts adverse outcomes in patients with CHD. Risk factors for poor sleep quality include older age, socioeconomic factors, medical comorbidities, lack of exercise, and depression.
  
  
  METHODS
  We sought to examine the association of anger expression with sleep quality in 1020 outpatients with CHD from the Heart and Soul Study. We assessed anger-in, anger-out, and anger temperament, using the Spielberger State-Trait Anger Expression Inventory 2, and measured sleep quality, using items from the Cardiovascular Health Study and Pittsburgh Sleep Quality Index. We used multivariate analysis of variance to examine the association between anger expression and sleep quality, adjusting for potential confounding variables.
  
  
  RESULTS
  Each standard deviation (SD) increase in anger-in was associated with an 80% greater odds of poor sleep quality (odds ratio (OR) = 1.8, 95% Confidence Interval (CI) = 1.6-2.1; p < .0001). This association remained strong after adjusting for demographics, comorbidities, lifestyle factors, medications, cardiac function, depressive symptoms, anger-out, and anger temperament (adjusted OR = 1.4, 95% CI = 1.5-1.7; p = .001). In the same model, each SD increase in anger-out was associated with a 21% decreased odds of poor sleep quality (OR = 0.79, 95% CI = 0.64-0.98; p = .03). Anger temperament was not independently associated with sleep quality.
  
  
  CONCLUSIONS
  Anger suppression is associated with poor sleep quality in patients with CHD. Whether modifying anger expression can improve sleep quality or reduce cardiovascular morbidity and mortality deserves further study.
authors.affiliation: Department of Psychology, University of Utah, 380 S. 1530 E., Room 502, Salt Lake City, UT 84112, USA. cmcaska@gmail.com
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Caska
authors.forename: Bethany E
authors.initials: BE
authors.lastname: Hendrickson
authors.forename: Michelle H
authors.initials: MH
authors.lastname: Wong
authors.forename: Sadia
authors.initials: S
authors.lastname: Ali
authors.forename: Thomas
authors.initials: T
authors.lastname: Neylan
authors.forename: Mary A
authors.initials: MA
authors.lastname: Whooley
mesh_terms: D000368:Aged; D000786:Anger; D015992:Body Mass Index; D003327:Coronary Disease / Q000175:diagnosis / Q000453:epidemiology*; D003863:Depression / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology; D019260:Expressed Emotion; D006304:Health Status; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000453:epidemiology; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000453:epidemiology*; D007319:Sleep Initiation and Maintenance Disorders / Q000175:diagnosis / Q000453:epidemiology*; D011795:Surveys and Questionnaires