Full text of DOI:10.1207/S15327558IJBM0902_01

INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE, 9(2), 77–93
Copyright © 2002, Lawrence Erlbaum Associates, Inc.
Relation Between Type A Behavior
Pattern and the Extent of Coronary
Atherosclerosis in Japanese Women
Kouichi Yoshimasu, Masakazu Washio, Shoji Tokunaga,
Keitaro Tanaka, Ying Liu, Hiroko Kodama,
Hidekazu Arai, Samon Koyanagi, Koji Hiyamuta,
Yoshitaka Doi, Tomoki Kawano, Osamu Nakagaki,
Kazuyuki Takada, Shizuka Sasazuki,
Takanobu Nii, Kazuyuki Shirai, Munehito Ideishi,
Kikuo Arakawa, Masahiro Mohri, and Akira Takeshita
This study examined the relation of Type A behavior pattern and its components to
angiographically documented coronary atherosclerosis in 198 Japanese women. A
questionnaire-based interview elicited psychosocial and other factors. Type A behav-
ior pattern was measured by 12 questions. Significant coronary stenosis was defined
when a 75% or greater luminal narrowing occurred at one or more major coronary ar-
teries or 50% or greater narrowing occurred at the left main artery. Gensini’s score
also was calculated. Logistic regression analysis was used to calculate odds ratios and
95% confidence intervals with adjustment for traditional coronary risk factors and the
presence of a job. Global Type A behavior pattern showed no material association
Kouichi Yoshimasu, Masakazu Washio, Shoji Tokunaga, Keitaro Tanaka, Ying Liu, Hiroko
Kodama, and Shizuka Sasazuki, Department of Preventive Medicine, Graduate School of Medical Sci-
ences, Kyushu University, Fukuoka, Japan; Hidekazu Arai, Department of Cardiology, Fukuoka
Tokushukai Medical Center, Fukuoka, Japan; Smon Koyanagi and Koji Hiyamuta, Cardiovascular Dis-
ease Center, National Kyushu Medical Center Hospital, Fukuoka, Japan. Yoshitaka Doi, Tomoki
Kawano, Osamu Nakagaki, and Kazuyuki Takada, Division of Internal Medicine, Saiseikai Fukuoka
General Hospital, Fukuoka, Japan; Takanobu Nii, Kazuyuki Shirai, Munehito Ideishi, and Kikuo
Arakawa, SecondDepartmentofInternalMedicine, FukuokaUniversity, SchoolofMedicine, Fukuoka,
Japan. Masahiro Mohri, Akira Takeshita, Department of Cardiovascular Medicine, Graduate School of
Medical Sciences, Kyushu University, Fukuoka, Japan.
Correspondence concerning this article should be addressed to Kouichi Yoshimasu, Department of
Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi,
Higashi-ku, Fukuoka, Japan.

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YOSHIMASU ET AL.
with the severity of coronary atherosclerosis assessed by both Gensini’s score and the
presence of significant coronary stenosis. However, its subcomponents, enthusiasm
and competitiveness, were positively related to the severity of coronary atherosclero-
sis, whereas self-confidence and perfectionism were negatively related. These find-
ings suggest overall a null association between global Type A and coronary athero-
sclerosis as well as the presence of toxic or beneficial components of Type A
behaviors in Japanese women.
Keywords:Japanesewomen, TypeAbehavior pattern, coronaryangiography, coronaryath-
erosclerosis, logistic regression analysis
Type A behavior pattern is regarded as a psychosocial risk factor for coronary heart
disease(CHD;Rosenman,Brand,Sholts,&Friedman,1976).InitialstudiesofType
AandCHDhavefocusedonmen,dueinparttotheirgreatermorbidityandmortality
rates. However, as an increasing number of women experience CHD, there is a cor-
respondingly greater interest in research into the relation between Type A and CHD
in women. Since the late 1970s, many studies have examined the relation between
TypeAandCHDorcardiovascularreactivityinwomen(Anderson&Lawler,1995;
Bass,1984;Fichera&Andreassi,1998;Haynes&Feinlieb,1980;Haynes,Feinleib,
Levine, Scotch, &Kannel, 1978;Stevens, Turner, Rhodewalt, &Talbot, 1984;Wil-
liam et al., 1980).
However, assessment of global Type A in women is confounded by the fact that
womenusuallyaresocializedtoavoidtwocomponentsofTypeAbehavior:extreme
competitiveness and the overt expression of anger (Campbell, 1999). This charac-
teristicisconsideredtrueforJapanesewomen,whostilldependgreatlyontheirhus-
bands (Shirahase, 2001). In fact, women who suppressed anger expression were
shown to experience greater cardiovascular reactivity than women who expressed
anger assertively (Anderson & Lawler, 1995). On the other hand, other studies have
reportedthathostilitywasassociatedwithcardiovascularreactivityorcoronaryath-
erosclerosis in women (Fichera & Andreassi, 1998; Low et al., 1998), and there is
presently no clear understanding of Type A and its relationship to CHD in women
(
Thoresen & Low, 1990).
Those studies, however, were performed in Western countries. There may be
someculturalvarianceswithregardtothecomponentsofthecoronary-pronebehav-
ior pattern between Western and Japanese women. In studies of Japanese men,
job-centeredlifestyleandexcessiveworkpatternsratherthanhostilityorangerhave
been emphasized as coronary-prone behaviors (Hayano et al., 1997; Hosaka &
Tagawa,1987),whereastheroleofhostilityisratherevidentasariskfactorforCHD
in Western cultures (Shekelle, Gale, Ostfeld, & Paul, 1983; Williams et al., 1980).
Of course, evidence shows that excessive work patterns (exhaustion) or time ur-
gency is a risk also in Western countries (Cole, et al., 2001; Cole, Kawachi, Sesso,

CORONARY ATHEROSCLEROSIS IN WOMEN
79
Paffenbarger, & Lee, 1999; Weidner, 2000). On the other hand, despite these find-
ings,theglobaleffectofTypeAisstillconsideredmoreimportantthananyothersin-
gle component in Western cultures (Kawachi et al., 1998).
In Japan, although a few studies have examined the relation between Type A
and CHD in male participants (Hori, Suzuki, & Hayano, 1994; Kayaba et al.,
1
990), almost nothing is known about the relation between Type A and CHD in
women, and therefore coronary-prone behavior patterns of women are still un-
clear.
A brief questionnaire developed by Maeda (1991) is thought to be useful for
Japanese people regardless of age, sex, or occupation. It was reported that this
test was correlated with Type A described by a self-imaging test in Japanese
women (Kimura, Shirasaki, & Watanabe, 2000). The purpose of this study was
to investigate the relation between (a) global Type A behavior pattern as well as
its subcomponents assessed by a questionnaire modified for Japanese character-
istics and (b) the severity of angiographically documented coronary atheroscle-
rosis in Japanese women.
METHODS
Participants
There were 838 eligible patients age 30 years or older undergoing coronary
angiography for suspected or known ischemic heart disease for the first time at
five hospitals in Fukuoka City and its suburbs from September 1996 to August
1
997. The following patients were excluded in the study: those who had cardiac
disease such as valvular disease, heart muscle disease, or myocardial infarction,
and those who had undergone aorto-coronary artery bypass or percutaneous
transluminal coronary angioplasty, because these disease conditions may have
distorted lifestyle or psychosocial factors. A total of 733 patients (87.5%) partic-
ipated in this study; 38 patients refused to participate in the study, 16 were se-
verely ill, and 51 were discharged before the interview was arranged. All of the
participants gave written informed consent. After we excluded all men (n =
4
29), 304 women remained. We further excluded women having a deformity of
the heart (n = 1). To reduce recall bias associated with long-sustained clinical
conditions, we also excluded those under treatment for angina pectoris for 6
months or more (n = 13) and those whose episode leading to coronary
angiography had lasted more than 1 year (n = 68). These excluded patients did
not differ from the remaining patients with regard to Type A characteristics and
the extent of coronary stenosis. Finally, patients for whom information on rele-
vant factors were incomplete were excluded (n = 24). Thus, 198 women re-
mained in the analysis.

8
0
YOSHIMASU ET AL.
Assessment of Cardiac Risk Factors
A questionnaire-based interview elicited details of psychosocial factors, medical
and family history, and lifestyle factors. Research physicians or nurses distributed
the questionnaires to the participants before the angiographic procedure
and collected them with interview. The interview was done before angiography
(
n = 113) or after angiography (n = 85), and interviewers were blinded with re-
gard to the outcome of the angiography in the latter case. Participants were re-
quested to answer questions regarding the previous factors before the occurrence
of a symptom or an abnormal clinical test suggestive of CHD.
Type A Behavior Pattern
Type A behavior pattern was assessed by an abbreviated set of 12 questions de-
veloped by Maeda (1991). This questionnaire was constructed based on the ini-
tial report regarding coronary-prone behaviors in Japanese people (Hasegawa,
Kimura, & Sekiguchi, 1981), with reference to the characteristics described by
Friedman and Rosenman (1959). This measure is considered to be very practical
for epidemiological investigations in busy clinics because of its convenience.
The questionnaire can be answered and evaluated very quickly, and the evalua-
tions are not affected by the characteristics of referees. Each question is listed in
the appendix. Diagnostic concordance for the global Type A behavior between
the Japanese version of the Jenkins Activity Survey (JAS) and this 12-item ques-
tionnaire was reported to be 75%, and the 1-month reproducibility also was con-
firmed in 15 healthy working participants (agreement rate = 93%; Maeda, 1993).
Each question had three prepared answers: 2, 1, and 0 points were given to
the answers of always, occasionally, and hardly for nine questions, and the
points were doubled for three questions. Cronbach’s alpha for Type A scale in
our participants was 0.74. The total score of 17 or greater was defined as Type A
according to the definition of Maeda (1991). To determine the cutoff point,
Maeda (1991) compared 100 CHD patients with 150 men in a pharmaceutical
company and 360 nursing students as control groups, and this cutoff point was
considered to best distinguish the CHD group from the healthy group. In this
study, reproducibility by test–retest method was assessed in 82 participants by
mail and telephone interview with an interval of 3 to 6 months. Intraclass corre-
lation coefficients of each item ranged from .30 to .61 (average .48), and the cor-
relation coefficient was .67 for global Type A score. The scores of the each item
were dichotomized, and the items answered with always or occasionally were
compared with those answered by hardly as referent groups.

CORONARY ATHEROSCLEROSIS IN WOMEN
81
Clinical Coronary Risk Factors
Participants were regarded as smokers if they had ever smoked even one ciga-
rette every day for 1 year or longer. Likewise, alcohol use was defined as drink-
ing alcohol at least once per week for 1 year or longer. Because of the few
number of participants with alcohol consumption of 50 ml or more per day
(
n = 2), the volume of alcohol consumption was not adjusted for in the
multivariate analysis.
Laboratory data and medical treatments for hypertension, diabetes mellitus, and
hyperlipidemia were extracted from medical records. Serum concentrations of total
cholesterol,high-densitylipoproteincholesterol,andtriglyceridesaswellasplasma
glucoseconcentrationsweremeasuredateachhospitallaboratory.Serumhigh-den-
sity lipoprotein cholesterol values were not available for some participants, and
triglyceride concentrations were not always measured at a fasting state. Thus, these
two variables were not taken into account in the analysis. History of hypertension
wasdefinedaspositiveifparticipantswereunderdrugtreatmentforhypertensionor
if they had systolic blood pressure of 160 mm Hg or higher or diastolic blood pres-
sure of 95 mm Hg or higher. Diabetes mellitus was defined as present when partici-
pants were under dietary or drug treatment for diabetes mellitus or when they had
nonfastingplasmaglucoseof200mg/dlorhighermeasuredatonehospitalorfasting
plasma glucose of 140 mg/dl or higher at the other four hospitals. Hyperlipidemia
wasdefinedaspresentwhenparticipantsusedahypolipidemicdrugorhadserumto-
tal cholesterol of 220 mg/dl or greater. Height and body weight also were recorded,
2
andabodymassindex(kg/m )of25orgreaterwasdefinedasoverweight.Variables
such as hypertension, diabetes mellitus, hyperlipidemia, and obesity were shown to
be related to coronary artery disease (CAD) in participants similar to those in this
study (Tanaka et al., 2001; Washio et al., 2001). The participants were regarded as
workers if they had a full-time or part-time job.
Coronary Angiography
Coronary artery luminal stenosis was assessed at each hospital in accordance
with the American Heart Association method (Austen, 1975). The extent of nar-
rowing of the luminal diameter was measured by calipers at one hospital and
was approximated to 0%, 25%, 50%, 75%, 90%, 99%, or 100% at the other four
hospitals. This assessment of coronary arteries was done blindly with respect to
the psychosocial and other factors. Significant coronary stenosis was defined
when a 75% or greater luminal narrowing occurred at one or more major coro-
nary arteries or when a 50% or greater narrowing occurred at left main coronary
artery. Gensini’s score also was calculated as a measure of the severity of coro-
nary atherosclerosis (Gensini, 1983). The coronary arteries were divided into 15
segments, and diseased segments were allotted 0.5 to 5 points depending on the

8
2
YOSHIMASU ET AL.
diameter of the normal vessel. Each point was multiplied by a severity score as
follows: 1% to 25% stenosis (score 1), 26% to 50% (score 2), 51% to 75%
(
score 4), 76% to 90% (score 8), 91% to 99% (score 16), and 100% (score 32).
The points for each segment were totaled to obtain a coronary atherosclerosis
score. Participantss were divided into three groups in terms of the Gensini’s
score (0, 1–9.5, and 10+).
Agreement of arteriographic diagnosis among five hospitals was assessed by
using a random sample of 10 angiograms in the series at one hospital. The pres-
ence of significant coronary stenosis was completely agreed among the five hos-
pitals, and intraclass correlation coefficient of Gensini’s score was 0.92.
Statistical Analysis
Difference in coronary risk factors according to Type A behavior pattern was
statistically tested by chi-square test or unpaired t test. Logistic regression analy-
sis was used to adjust for potential confounding variables. Covariates included
in the models were age, hospital, hypertension, diabetes mellitus,
hyperlipidemia, overweight, cigarette smoking, alcohol intake, parental CHD
(
angina pectoris and myocardial infarction), and job. Age was categorized into
three strata (<50, 50–69, and ³70). Furthermore, the presence of the angina-re-
lated symptoms such as chest pain, back pain, or irradiation pain was used as the
outcome variable, as well as the severity of coronary atherosclerosis. In this
analysis, the participants with angina-related symptoms were compared with
those having no symptoms but an abnormal clinical test result among the partici-
pants without significant coronary stenosis (n = 150). Indicator variables were
created for categories of the covariates, and adjusted odds ratios (OR) and 95%
confidence intervals (CI) were obtained from the corresponding logistic regres-
sion coefficient and their standard errors. Reported p values are always
two-sided. All computations were performed by using the SAS software Version
6
.04 (SAS Institute, Cary, NC, USA).
RESULTS
Of the 198 participants, 48 (24%) had significant coronary stenosis. Mean age
was 65.7 years (SD = 10.1). Prevalence of Type A behavior pattern was 36%.
Twenty-one percent of the participants had a full-time job, 10% had a part-time
job, and 69% had no paid occupation. Regarding traditional coronary risk fac-
tors, there was no material difference between those with Type A and without
with the exceptions that participants with Type A were younger than those with-
out Type A (p = .07) and that frequencies of alcohol use (p = .08) and working
(
p = .001) were higher among those with Type A than those without Type A.

CORONARY ATHEROSCLEROSIS IN WOMEN
83
Table 1 shows the frequencies of each item’s responses. The frequencies of
the positive responses were relatively low for the questions of busy life, time ur-
gency, rigidity, intense temper, and competition. In contrast, perfectionism,
self-confidence, and tension showed high frequencies of the positive responses.
Pearson’s correlation coefficients of each single item to whole Type A behav-
ior are shown in Table 2. Perfectionism, self-confidence, and punctuality
showed relatively high correlations with global Type A score, whereas the corre-
lation between Type A and time urgency or rigidity was poor.
Tables 3 and 4 represent the relation between the subcomponents of Type A
and the severity of coronary atherosclerosis assessed by significant stenosis and
Gensini’s score, respectively. In Table 4, the participants with 10+ score were
compared with those with 0 score as controls. Perfectionism and self-esteem
were statistically significantly or nearly significantly associated with a decreased
risk of CAD. In contrast, enthusiasm was statistically significantly associated
with an increased risk of coronary stenosis even after we adjusted for other con-
founding variables (Table 3). A similar tendency was observed when Gensini’s
score was used (Table 4). Competitiveness was nearly significantly (p = .087)
associated with an increased risk of significant stenosis.
Table 5 summarizes the relation between global Type A behavior pattern and the
riskofcoronaryatherosclerosisasdefinedbythepresenceofsignificantstenosisand
Gensini’s score. Although Type A was related to a modest, statistically
nonsignificantincreaseintheriskofcoronaryatherosclerosisasdefinedbythepres-
ence of significant stenosis, adjusted ORs associated with Type A were slightly
lower than unity regardless of adjustment for cardiac risk factors when we used
TABLE 1
Frequency (%) of Each Item’s Response on the Type A Questionnaire:
1
98 Female Participants
Abbreviated Statement
No)
(
Always
Occasionally
Hardly
Busy life (1)
23.7
18.2
29.3
12.6
49.0
47.0
48.0
20.2
42.4
34.3
20.2
11.6
24.7
23.7
29.8
14.1
28.3
35.9
35.9
39.9
33.3
28.3
28.3
20.7
51.5
58.1
40.9
73.2
22.7
17.2
16.2
39.9
24.2
37.4
51.5
67.7
Time urgency (2)
Enthusiasm (3)
Rigidity (4)
Perfectionism (5)
Self-confidence (6)
Tension (7)
Anger (8)
Punctuality (9)
Unyieldingness (10)
Intense temper (11)
Competitiveness (12)

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YOSHIMASU ET AL.
TABLE 2
Pearson’s Correlation Coefficients Between Global Type A and Each Item
Busy Life (1)
.45
.38
.51
.31
.72
.58
.43
.50
.63
.52
.48
.43
Time urgency (2)
Enthusiasm (3)
Rigidity (4)
Perfectionism (5)
Self-confidence (6)
Tension (7)
Anger (8)
Punctuality (9)
Unyieldingness (10)
Intense temper (11)
Competitiveness (12)
TABLE 3
Relation Between Items of Type A Behavior Pattern and Significant Coronary Stenosis
a
Age-Adjusted
Fully Adjustedb
Abbreviated
Statement (No)
OR
95% CI
OR
95% CI
Busy life (1)
0.5
1.0
2.1*
0.6
0.4*
0.5
1.0
0.7
1.4
1.1
0.9
1.6
0.2–1.0
0.5–2.1
1.0–4.4
0.2–1.3
0.2–0.8
0.2–1.1
0.4–2.5
0.4–1.5
0.6–3.1
0.6–2.3
0.4–1.7
0.8–3.4
0.7
1.3
2.5*
0.5
0.6
0.5
2.2
0.8
1.5
1.1
0.9
2.2
0.3–1.6
0.6–2.9
1.1–5.8
0.2–1.2
0.3–1.4
0.2–1.3
0.7–6.8
0.4–1.6
0.6–3.8
0.5–2.5
0.4–2.0
0.9–5.2
Time urgency (2)
Enthusiasm (3)
Rigidity (4)
Perfectionism (5)
Self-confidence (6
Tension (7)
Anger (8)
Punctuality (9)
Unyieldingness (10)
Intense temper (11)
Competitiveness (12)
Note. OR = odds ratio; CI = confidence interval.
a
b
N = 198. Adjusted for age, hospital, hypertension, diabetes mellitus, hyperlipidemia, overweight,
cigarette smoking, alcohol intake, parental coronary heart disease, and job.
Gensini’s score as the dependent variable, although the decreases were not statisti-
cally significant. Further analysis with Type A score as the continuous variable did
not show any material association between global Type A and significant stenosis
(
adjusted OR 1.2, 95% CI 0.6–2.3). Again, there was no substantial association be-
tween global Type A and angina-related symptoms in the participants without sig-
nificant coronary stenosis (adjusted OR 0.8, 95% CI 0.2–3.2).

CORONARY ATHEROSCLEROSIS IN WOMEN
85
TABLE 4
Relation Between Each Items of Type A Behavior Pattern and Severity
of Coronary Atherosclerosis Assessed by Gensini’s Scorea
Age-Adjusted
Fully Adjusteda
Abbreviated
Statement (No)
OR
95% CI
OR
95%
Busy life (1)
0.5
0.9
1.8
0.5
0.4*
0.4
0.8
0.7
1.0
0.9
0.8
1.7
0.2–1.2
0.4–2.1
0.8–4.1
0.2–1.4
0.2–1.0
0.2–1.0
0.3–2.5
0.3–1.6
0.4–2.5
0.4–2.0
0.4–1.7
0.7–4.0
0.5
0.9
2.0
0.3
0.5
0.2*
2.4
0.8
0.6
1.0
0.6
2.2
0.2–1.6
0.3–2.3
0.7–5.3
0.1–1.1
0.2–1.6
0.1–0.7
0.5–10.8
0.3–1.9
0.2–1.8
0.4–2.5
0.2–1.6
0.8–6.4
Time urgency (2)
Enthusiasm (3)
Rigidity (4)
Perfectionism (5)
Self-confidence (6)
Tension (7)
Anger (8)
Punctuality (9)
Unyieldingness (10)
Intense temper (11)
Competitiveness (12)
Note. OR = odds ratio; CI = confidence interval.
a
b
N = 132. Adjusted for age, hospital, hypertension, diabetes mellitus, hyperlipidemia, overweight
cigarette smoking, alcohol intake, parental coronary heart disease, and job.
p < 0.05.
*
TABLE 5
Relation Between Global Type A Behavior Pattern and Severity
of Coronary Atherosclerosis
Age-Adjusted
Fully Adjusteda
Factor
No. of Women
OR
95% CI
OR
95% CI
Type A
Stenosis
No stenosis
Absent
Present
Type A
Absent
Present
32
16
94
56
GS = 0
52
1.0
1.0
—
0.5–1.9
1.0
1.8
—
0.8–4.1
b
0 < GS < 10
44
22
1.0
0.7
—
0.3–1.3
1.0
0.8
—
0.4–1.8
39
Type A
Absent
Present
10 ≤ GS
30
11
GS = 0
52
39
1.0
0.5
—
0.2–1.2
1.0
0.6
—
0.2–1.8
Note. OR = odds ratio; CI = confidence interval; GS = Gensini’s score.
a
Adjusted for age, hospital, hypertension, diabetes mellitus, hyperlipidemia, overweight cigarette
smoking, alcohol intake, parental coronary heart disease, and job.

8
6
YOSHIMASU ET AL.
DISCUSSION
Overall Association and Negative Findings
In this study, global Type A behavior pattern was not statistically significantly
associated with the severity of coronary atherosclerosis defined by both the pres-
ence of significant stenosis and Gensini’s score. However, in the analyses re-
garding subcomponents of Type A, some items were statistically significantly
associated with an increased risk, and some were associated with a decreased
risk of CAD.
Previous studies are inconsistent with regard to the relation between Type A and
angiographically documented CAD, as is the case with studies of CHD incidence
and mortality. Although several studies reported a positive association between
Type A and CAD (Blumenthal, Williams, Kong, Schanberg, & Thompson, 1978;
Frank, Hellar, Kornfeld, Sporn, & Weiss, 1978; Krantz, Sanmarco, Selvester, &
Matthews,1979;Zyzanski,Jenkins,Ryan,Flessas,&Everist,1976),othersfailedto
find such an association (Bass & Wade, 1982; Dimsdale et al., 1978; Krantz et al.,
1
981;Scherwitz etal., 1983;Young, Barboriak, Anderson, & Hoffman, 1980). Jap-
anese studies also reported inconsistent results regarding the relation between Type
AandCAD(Horietal., 1994;Maeda, 1991;Maeda&Ito, 1990;Tagawa&Hosaka,
1
990). RecentstudiesonJapanesemaleworkers(Hayanoetal., 1997;Yoshimasuet
al., 2000) showed that Type A was associated with a decreased risk of CAD. How-
ever, these studies either used only male participants or included very few women.
William et al. (1988) studied 2,289 participants, including 679 women, and con-
cluded that the inconsistency may be due to the use of different tools for assessing
Type A, inadequate sample size, or different characteristics of study participants.
This study showed that global Type A was associated with only minimal,
nonsignificant decreases in the risk of coronary atherosclerosis assessed by
Gensini’s score. This is consistent with the results of other studies on male workers
(
Hayanoetal.,1997;Yoshimasuetal.,2000).Thesefindingsmaybeduetothechar-
acteristics of components that are fit to the cultural standards. In modern society,
where working hard or feeling time urgency is common, Type B behavior pattern
maybestressfulcomparedwithTypeA,becauseitcannotbewelladaptedtothegen-
eral culture. In this study, perfectionism and self-esteem were statistically signifi-
cantly associated with a decreased risk of CAD. These behaviors can be considered
to be an advantage in modern society and to moderate mental tension.
In Japanese male workers, a job-centered lifestyle, or a tendency to value
jobs above family or other activities, was specifically shown to be a coro-
nary-prone behavior (Hayano et al., 1997). Self-esteem, perfectionism, and ri-
gidity may be related to such a workaholic behavior pattern. On the other hand,
self-esteem can be regarded as a positive feeling. It was reported that women,
regardless of Type A, exhibited a great cardiovascular reactivity when they were

CORONARY ATHEROSCLEROSIS IN WOMEN
87
confronted with perceived threats to their self-esteem (Anderson & Lawler,
995). Perfectionism rather than sloppiness also occasionally leads to good eval-
1
uation by one’s friends and acquaintances. In fact, Type A assessed by this mea-
sure was positively associated with friendly relationships with other people for
Japanese women (Kimura et al., 2000). Thus, some components included in this
Type A measure may have preventive effects against CHD in modern society,
especially in women.
In addition, busy life and time urgency were not associated with CAD at all.
These characteristics have been considered important in Japanese culture (Oishi
et al., 1999; Yamasaki & Kikuno, 1990). In summary, these results showed that
there was no positive association between Type A and CAD in Japanese women.
Study Limitations
Our findings must be interpreted with caution because of several methodological
problems.
First, mean age of the participants was no less than 65 years. William et al.
(
1988) reported that Type A participants had more severe CAD than did Type
Bs among those age 45 or younger, and the relation was reverse among those
age 55 and older. In addition, only 31% of these participants had a full-time or
part-time job, whereas the Framingham study (Haynes & Feinleib, 1980; Haynes
et al., 1978) showed a positive association between Type A and working in
women. The observed low frequencies of busy life and time urgency in this
study may be mainly due to this effect. The social background of the participants
may have attenuated the relation between Type A and CAD in our study.
Second, selection bias is a serious concern in studies based on patients undergo-
ing coronary angiography (Pickering, 1985). Although it has been reported that the
association with traditional coronary risk factors observed in such patients is not bi-
ased seriously, psychosocial factors may be more susceptible to selection bias be-
cause patients with coronary angiography may be chosen due to the presence of
psychosocial traits. Type A participants may be, because of their punctuality, sensi-
tive to trifling physical disorders, and this may lead their physicians to refer them
more readily for angiography. Especially in the women with perfectionism, this
couldbeexpected.Inthisstudy,nolessthan76%oftheparticipantsdidnothavesig-
nificant CAD, and thus it is most likely that Type A individuals were
overrepresented among those without CAD. This type of selection bias tends to at-
tenuate the true, positive association rather than to result in a spurious positive asso-
ciation. Therefore, the observed null association between Type A and CAD may be
underestimated.
In this regard, we should note that women have higher prevalence than men
of microspastic angina and of microvascular angina (Cannon, Camici, & Ep-

8
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YOSHIMASU ET AL.
stein, 1992; Douglas, 1997; Sullivan et al., 1994), both of which are associated
with atypical chest pain patterns. Type A may be related to these diseases even
if it is not associated with CAD of major coronary arteries. Although Type A
was not associated with the angina-related symptoms in this study, the controls
used in this comparison all had known or suspected CHD suggested by abnor-
mal clinical tests. Completely healthy controls and participants with angina-re-
lated symptoms should be compared with regard to this matter.
Third,althoughahighcorrelationbetweenTypeAassessedinthisstudyandJAS
was reported (Maeda, 1991), the measure of Type A used here may not have repre-
sentedTypeAassessedbythestructuredinterview. Infact, TypeAassessedbyJAS
was not much correlated with a Japanese version of the structured interview in
women (Mono, Haney, Williams, Blumenthal, & Shirakawa, 1991).
Last, this study did not ascertain the participants’ menopausal status and use
of hormone replacement therapy. Estrogen appears to be antiatherogenic, and
more Type A women choose estrogen replacement after menopause than
non–Type A women (Matthews, Kuller, Wing, Meilahn, & Plantinga, 1996).
Therefore, the associations between Type A behavior and atherosclerosis may
be attenuated by hormone replacement therapy in postmenopausal women. This
is expected in our study, because most of the participants were considered to be
postmenopausal. Because Type A behavior was more frequent in younger
women, it is likely that any premenopausal women in this study would have
higher scores on Type A than postmenopausal women. This also may explain
the null association between Type A and CAD in our study, because
premenopausal women would be expected to have a milder degree of atheroscle-
rosis than postmenopausal women.
Positive Findings
In this study, a tendency to be enthusiastic was found to be pathogenic for CAD.
Enthusiasm sometimes helps one deal with one’s job very efficiently, and in that
sense, it can be considered beneficial. However, it is often connected with being
quick-tempered rather than composed and could be related to hard-driving com-
ponent of Type A. Enthusiasm also can be regarded as a kind of
overcommitment, defined as a personal pattern of coping with demands charac-
terized by excessive striving in combination with a strong desire to be approved
and esteemed. Joksimovic et al. (1999) showed that overcommitment predicted
restenosis after coronary angioplasty in cardiac patients.
Italsowasreportedthathighintrinsiceffort(immersion)wasrelatedtoincreased
low-densitylipoproteincholesterolinstudyof Swedishwomen(Peteretal.,1998).
Although women, especially those who don’t work outside the home, are gen-
erally considered to be less competitive than men (Thoresen & Low, 1990), com-

CORONARY ATHEROSCLEROSIS IN WOMEN
89
petitiveness was found to be pathogenic in this study. We can suppose that
competitiveness is more stressful in family or neighborhood environments rather
than in the workplace, because homemakers with competitive home environments
must be worried all the time, for instance, by conflicts with a daughter-in-law or
mother-in-law, which is a traditional problem in the Japanese family. In the West-
ern study, it also was reported that anger over autonomy issues, striving to main-
tain control of power, was associated with systolic blood pressure reactivity in
Type A women (Anderson & Lawler, 1995).
However, again, we should be careful in interpreting these positive associations
between some items of Type A and CAD, because these items had low correlation
with global Type A, and only one item was statistically significantly associated
with CAD, which means that the positive association can occur occasionally.
CONCLUSION
In this study we examined the relation between Type A behavior pattern and
angiographically documented CAD in Japanese women and showed that global
Type A was not at all associated with the severity of coronary atherosclerosis.
On the other hand, enthusiasm and competition were shown to be pathogenic for
CAD, and self-confidence and perfectionism were associated with a decreased
risk of CAD. Further studies are warranted regarding the role of psychosocial
factors in coronary atherosclerosis and thrombogenesis in Japanese women.
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APPENDIX
Questions in Maeda’s Questionnaire for Type A Behavior Pattern
1
2
3
4
5
6
7
8
9
1
1
1
. Do you have a busy daily life?
. Do you feel being pressed for time in your daily life?
. Do you easily become enthusiastic over your job or other things?
. When you are absorbed in your job, do you find it difficult to change your mind?
. Are you a perfectionist?
. Do you have confidence in yourself?
. Do you easily feel tense?
. Do you easily feel irritated or angry?
. Are you punctual with everything?
0. Are you unyielding?
1. Do you have an intense temper?
2. Do you easily become competitive about job or other things?