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 , which has prospectively
predicted hypertension in individual subjects 20 years before
its clinical manifestation  as well as mortality .
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
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 , 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
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