Randomized Clinical Trials in Heart Disease

To the Editor. —  Yusuf and colleagues^1,2 have done cardiac care a great service by summarizing the relative effectiveness of various therapeutic modalities using primitive meta-analytic techniques. However, their summary of various treatments fails to mention the studies done on lessening chronic negative emotion (psychosocial/emotional stress). The mechanisms that relate various subtypes of psychosocial/emotional stress to the onset and progression of coronary artery and heart disease are becoming increasingly clear. Considering physiological events that might be causal in coronary heart disease, there is evidence of increased occlusion in patients who report or display chronic anger; diminished perfusion or malignant electrocardiographic abnormalities (presumptively attributable to vasospasm) in individuals who are exposed to emotion-inducing stimuli; increases in various lipid subfractions in response to fear; and enhanced mortality in patients who display syndromes (eg, type A behavior or anxiety disorders) that are characterized by arousal of chronic negative emotion.³While several