Objective: Urbanization, which has been expanding rapidly for the past several decades, has been suggested to increase the risk of cardiovascular disease (CVD) associated with psychological factors such as anger, but the evidence is limited. We examined the hypothesis that urbanicity modifies the association of anger expression with the risk of CVD.Methods: A prospective study was conducted with 5,936 residents of urban and rural communities, aged 40 to 79, who had completed an annual health checkup including a questionnaire on anger expression between 1995 and 1998. Associations of anger expression with the risk of CVDs were examined using Cox proportional hazards models, after adjusting for classical cardiovascular risk factors.Results: During a median follow-up of 16.6 years, we identified 312 incident CVDs. The mean (standard deviation) of anger expression was 24.7 (5.8) among urban residents and 24.6 (5.7) among rural ones (p = .87). Among urban residents, anger expression was positively associated with the risk of total CVD: the multivariable hazard ratio (95% confidence interval) was 1.27 (1.05, 1.54). Meanwhile, no association was identified among rural residents: the corresponding ratio (interval) was 0.96 (0.85, 1.09), with a significant interaction between urban and rural residency with anger expression for incident CVD (p = .047). Similar associations were observed with the risk of CVD subtypes, including ischemic stroke and ischemic cardiovascular disease. 2 Conclusions:We found a positive association between anger expression and the risk of CVD among urban residents but not rural ones, suggesting that urbanicity enhances the anger-CVD association.

Background: Anger has been suggested as a risk factor for stroke. Perceived social support (PSS) may relieve anger, thus reducing the risk of stroke; however, evidence supporting this is limited. We aimed to examine whether PSS modifies the risk of stroke associated with anger expression.Methods: A cohort study was conducted among 1,806 community residents aged 40-74 years who received a cardiovascular risk survey including anger expression in 1997. A Cox proportional hazards model was applied to the participants with low and high PSS to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of the risks of total stroke and its subtypes based on total anger expression after adjusting for known stroke risk factors. Results:The median follow-up duration was 18.8 years, with 51 incident strokes. Among the participants with low PSS, anger expression had a positive association with the total stroke risk:The multivariable HR per SD increment of total anger expression was 1.43 (95% CI, 1.13-1.82).In contrast, no association was identified among those with high PSS. The corresponding HR was 0.83 (95% CI, 0.49-1.40), with a significant interaction between low and high PSS (p = 0.037).Similar associations regarding the risk of ischemic stroke were found. Conclusions:We found an increased risk of stroke associated with anger expression among the A c c e p t e d V e r s i o n 2 participants with low PSS, but not among those with high PSS. Our results suggest that PSS might mitigate the risk of stroke associated with anger.

Objective: Outdoor recreational activity (ORA) has been suggested as a practical strategy for anger management to moderate the risk of cardiovascular disease (CVD). However, there is a lack of evidence pertaining to this topic. Our aim was to examine whether ORA modified the association between anger expression and the risk of CVD. Methods: A community-based cohort study was conducted among 1877 Japanese individuals aged 40 to 79 years at baseline in 1997. The anger expression was measured using the Spielberger Anger Expression Scale. Stratified into low and high ORA (0 and ≥1 of the four behaviors), a Cox proportional hazards model was used to assess the anger expression-related risk of incident CVD (ischemic heart disease and stroke). Results: We identified 76 incident CVDs during a median follow-up of 18.8 years. Among participants with low ORA, anger expression was associated with an increased risk of CVD, whereas no association was identified among those with high ORA. The standardized hazard ratios were 1.53 (95% confidence interval, 1.23-1.91) and 0.77 (0.51-1.15) among those with low and high ORA, respectively ( p for interaction = .004). Similar associations were observed regarding the risk of total and ischemic stroke, and ischemic CVD. Conclusions: We found an elevated risk of CVD associated with anger expression among participants with low ORA but not among those with high ORA, suggesting that ORA use may mitigate the association between anger expression and CVD risk.