To the Editor: In a study published in the August 1996 issue of the Mayo Clinic Proceedings (pages 729-734), my colleagues and I were the first to report identification of type A hostile, coronary-prone, antagonistic, disagreeable behavior as a risk factor that could predict restenonsis after percutaneous transluminal coronary angioplasty (PTCA). Coronary-prone behavior has as its antecedent the sympathetic hyperreactivity phenonmenon [1], which has prospectively predicted hypertension in individual subjects 20 years before its clinical manifestation [2] as well as mortality [3].

A subset of five patients (four men) from our original study who had high scores for hostile coronary-prone behavior on the type A structured interview and persistent same-site restenosis (occurring within 6 to 26 weeks after PTCA) were enrolled in a restenosis-prone behavior modification program. When our 41 original volunteers were enrolled in our study, we offered this program at no cost (with informed consent) to any who we thought might ultimately experience persistent same-site restenosis. Because hostile, coronary-prone behavior, as assessed, measured, and scored with the use of the audiotaped type A structured interview, correlates well with systolic and diastolic blood pressure hyperreactivity and fluctuations, a prevention program using direct hemodynamic and signal-cued biofeedback was chosen. Patient education and behavioral risk factor counseling were additional important components of the program, which included five office visits after angiographic documentation of at least two same-site restenoses. Inexpensive ($15) portable biofeedback units were prescribed for the patients to use at home and at work to assist in generalization and retaining of the sympathetic nervous system hyperreactivity
response to hostility-provoking stimuli. The objective was to use biofeedback to aid in circumventing the pathophysiologic consequences of hostile responses. Although our original study failed to find that caffeine was a significant postangioplasty restenosis risk factor (perhaps because of the limited sample size), at the time of intervention, the data analysis was incomplete, and thus, we recommended abstinence from caffeine.

At this writing, four of the five patients (three men) who were included in this pilot intervention study are free of restenosis and other clinical cardiac events at 21 months after their final PTCA. Posttreatment hostility scores were not obtained because the patients were no longer blinded to our hypothesis after the debriefing and counseling procedures. These findings are encouraging for preventive cardiology and cardiac rehabilitation programs [4], inasmuch as restenosis is most likely to occur within the first 6 months after PTCA and is the major factor that limits long-term success of the procedure. My colleagues and I hope that the results of our pilot intervention study will inspire other investigators and clinicians to pursue similar and larger intervention trials examining this postangioplasty restenosis risk factor in order to improve PTCA outcomes and postpone or decrease the need for coronary artery bypass grafting.

Mark Goodman, Ph.D., M.A.
Behavioral Medicine Center
West Orange, New Jersey

REFERENCES

1. Hines EA Jr. Range of normal blood pressure and subsequent development of hypertension: a follow-up study of 1,522 patients. JAMA 1940;115:271-274
2. Menkes MS, Matthews KA, Krantz DS, Lundberg U, Mead LA, Qaqish B, et al. Cardiovascular reactivity to the cold pressor test as a predictor of hypertension. Hypetertension 1989; 14:524-530
3. Keys A, Taylor HL, Blackburn H, Brozek J, Anderson JT, Simonson E. Mortality and coronary heart disease among men studied for 23 years. Arch Intern Med 1971; 128:201-214
4. Friedman M, Thoreson CE, Gill JJ, Ulmer D, Powell LH, Price VA, et al. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the Recurrent Coronary Prevention Project. Am Heart J 1986; 112:653-665