Spiritual well-being and coronary artery diseases severity: Mediating effects of anger rumination and worry

Abstract

Objective:

Biological and psychological factors contribute to coronary artery disease (CAD). The purpose of this study was to investigate the relationship between spiritual well-being and CAD severity and determine the mediating effects of anger rumination and worry on this relationship.

Design:

Descriptive, cross-sectional survey.

Setting:

Afshar Hospital in Yazd, Iran.

Method:

Participants were 327 patients with CAD (138 women, 189 men). Spiritual well-being, anger rumination, worry and CAD severity were measured using demographic and medical information questionnaires, the Spiritual Well-Being Scale, the Anger Rumination Scale, the Penn State Worry Questionnaire and Gensini method. Mediation analysis was conducted using the PROCESS macro.

Results:

CAD severity was negatively correlated with spiritual well-being (r = –.62, p < .01) and positively correlated with anger rumination (r = .58, p < .01) and worry (r = .33, p < .01). The relationship between spiritual well-being and CAD severity was mediated by anger rumination. The direct effect of spiritual well-being on CAD severity was statistically significant (β = –.06, 95% confidence interval [CI] [–.09, –.04]). We find a significant indirect effect of spiritual well-being on CAD severity through anger rumination (β = –.03, 95% CI [–.05, –.02]).

Conclusion:

These results highlight the potential benefits of spiritual well-being for patients with CAD to help them reduce anger rumination and, consequently, CAD severity.

Keywords

Anger rumination cardiovascular disease severity spiritual well-being worry

Introduction

Cardiovascular disease (CVD) comprises diseases of the heart or blood vessels, of which coronary artery disease (CAD) is one of the major clinical endpoints. CAD is the leading cause of mortality and disability in most countries (Sayols-Baixeras et al., 2014). Many biological (Correll et al., 2017; Emdin et al., 2016) and psychological (Cohen et al., 2015; Gustad et al., 2013; Pedersen et al., 2017; Roest et al., 2010; Steptoe and Kivimäki, 2013; Suls, 2018; Suls and Bunde, 2005) risk factors including depression, anxiety, anger, psychological stress, obesity, decreased physical activity, diabetes and smoking contribute to the incidence and exacerbation of CVD. Moreover, studies indicate that people with chronic physical conditions are at risk of developing poor mental health (Patten, 1999). Several factors such as adverse social circumstances, for instance, unemployment or financial strain, poor physical health and the functional limitations imposed by the disease can cause worry, anxiety, depression and stress (Turner and Kelly, 2000). Studies have also shown that the symptoms of depression and anxiety are common in patients with CVD which may lead to worsening of the disease (Bonnet et al., 2005; Gustad et al., 2013; Roest et al., 2010). For instance, one study found that those who experience two periods of both conditions (depression and anxiety) simultaneously are more than 50% at risk for acute myocardial infarction (Gustad et al., 2013). Other studies have also shown that stress (Steptoe and Kivimäki, 2013) and anger (Mostofsky et al., 2014; Suls, 2018) increase the risk of cardiovascular events. Some researchers suggest anger may indicate a type of depression with an increased risk of CVD (Suls and Bunde, 2005). Anger has been shown to increase heart rate, blood pressure and vascular resistance. Sympathetic activation may cause transient myocardial ischaemia and/or disruption of a vulnerable plaque. It may also stimulate an inflammatory and pro-thrombotic response, including increased platelet aggregation, plasma viscosity and decreased fibrinolytic potential. These changes may lead to plaque disruption and thrombotic occlusion, resulting in an ischaemic event (Haukkala et al., 2010; Mittleman and Mostofsky, 2011).

There is evidence that repetitive, intrusive thoughts can affect mental and physical health; however, little attention has been devoted to determining the effects of these chronic stresses on CAD. Negative, repetitive and relatively uncontrollable intrusive thoughts are the key characteristics of depression and anxiety disorders (Newman et al., 2013; Segerstrom et al., 2000; Tully et al., 2013; Young and Nolen-Hoeksema, 2001). While worry, one of these thought patterns, often becomes more prominent in the investigations about anxiety disorders (Chalmers et al., 2016; Newman et al., 2013; Tully et al., 2013), rumination, another intrusive thought pattern, is often investigated concerning depressive disorders (Byrd-Craven et al., 2011; Cropley et al., 2012; Du Pont et al., 2018). Worry consists of uncertain thoughts about a possible future threat (Newman et al., 2013), while rumination typically involves repetitive thoughts about past negative events (Segerstrom et al., 2000). Worry indicates negative affect, related to a perceived inability to control or obtain desired results in upcoming situations (Newman et al., 2013). Anger rumination consists of memories about a past anger trigger, which may lead to consequences such as aggressive behaviour and physiological arousal (Anestis et al., 2009; Gerin et al., 2006).

Repetitive negative thoughts often reduce psychological well-being (Bushman et al., 2005). Repetitive negative thinking is associated with a notable increase in cortisol stress response (Byrd-Craven et al., 2011; Young and Nolen-Hoeksema, 2001; Zoccola et al., 2010) and severe worry is associated with a significant decrease in heart rate variability (Tully et al., 2013). Research has revealed a negative correlation between worry and anger rumination with adjustment to heart disease (Besharat and Ramesh, 2017). Repetitive negative thoughts are a form of chronic stress that results in prolonged stress-related physiological activity, increased short-term response to stress, delayed recovery or repeated activation of the stress response (Brosschot, 2010). In this regard, several studies identify stress as a risk factor for CV events (Lovallo and Gerin, 2003; Oseitutu et al., 2001; Steptoe and Kivimäki, 2013). For example, research has shown a relationship between high blood pressure response to laboratory challenges and high blood pressure in the future (Lovallo and Gerin, 2003; Oseitutu et al., 2001). Therefore, it seems likely that repetitive negative thoughts, due to their chronic nature, can contribute to the establishment and development of CAD; a disease that, due to its potential long-term limitations and uncertainties, can increase repetitive negative thoughts and consequently symptoms of depression and anxiety (Samson et al., 2007). However, so far as we know, no previous research has investigated this relationship. Accordingly, in this study, the relationship between anger, rumination and worry and CAD severity was investigated.

Depression and anxiety are common in patients with CAD (Gustad et al., 2013), which leads to functional decline, poor quality of life and greater difficulty managing physical symptoms (Katon et al., 2007). Uncontrollable physical symptoms, complications of the disease itself and decreased independence causes psychological distress (Turner and Kelly, 2000). Furthermore, the available evidence suggests that lower spiritual well-being is associated with a higher level of anxiety and depression and, in contrast, higher levels of spirituality may lead to higher mental well-being (Oman and Lukoff, 2018). It seems possible, therefore, that spirituality may help reduce worry and anger rumination. Being spiritual involves holding a set of beliefs and attitudes that give meaning to life through a sense of connectedness to the self, others, the natural environment and a higher power, contributing to the creation of inner peace and harmony (Groff and Smoker, 1996). Spirituality has been described as a higher-order emotional human characteristic (Hiebler-Ragger et al., 2018) closely connected to emotional regulation (Kirkpatrick, 2005) and health-related outcomes (Oman and Lukoff, 2018).

Several studies have emphasised the importance of spirituality in the lives of patients with heart failure (HF) in relieving suffering and distress and research shows that there is a positive correlation between spiritual well-being and better mental health in patients with symptomatic HF (Larson and Larson, 2003). For example, some studies have shown that higher spiritual well-being, particularly meaning/peace, among patients with HF is related to less depression (Bekelman et al., 2007). Also, symptomatic HF patients with higher spiritual well-being have better HF-related health status. Moreover, it has been observed that higher mental well-being is associated with reduced mortality from CVD in healthy and ill individuals (Chida and Steptoe, 2009).

Therefore, it seems that spirituality can help improve physical health by promoting mental health including reducing worry and anger rumination. Accordingly, this study aimed to (a) analyse the association between worry, anger rumination and spiritual well-being with CAD severity and (b) examine whether the association between spiritual well-being and CAD severity is mediated by worry and anger rumination.

Method

Study design and participants

This cross-sectional study included 327 patients with CAD in Afshar Hospital (a general hospital with a specialist cardiology clinic) in Yazd, Iran. In order to use their Gensini score, participants were selected among all the patients hospitalised for angiography. The inclusion criteria were suffering from CAD, aged 18 to 70 years and willingness to participate in the study. Exclusion criteria were suffering from other medical severe illnesses except for CAD such as cancer, having medical procedures or conditions that make the participants ineligible for the study and suffering from significant psychiatric disorder. All participants provided written informed consent before their inclusion in the study. The authors received permission from the hospital to conduct the study. At the time this study was performed in Iran, approval from an institutional ethics committee was necessary only for certain types of research such as experimental research. Since this study did not include an intervention, the approval from an institutional ethics committee was not sought.

Instruments

The measurement tools used in this research included (a) demographic and clinical information, (b) Gensini score, (c) the Anger Rumination Scale (ARS), (d) the Penn State Worry Questionnaire (PSWQ) and (e) and the Spiritual Well-Being Scale (SWBS).

Demographic and clinical characteristics

Basic demographic data and the presence of major cardiovascular risk factors were collected including age, sex, hypertension, dyslipidaemia, type 2 diabetes, family history of premature CVD, body mass index (BMI) and current smoking. Patients were considered to have type 2 diabetes mellitus if they had been previously diagnosed and treated for diabetes and/or if they had a fasting blood glucose level of ⩾126 mg/dL. Patients were considered to have hypertension if they had previously known hypertension, or if they were in receipt of antihypertensive therapy, or if they had a systolic blood pressure (SBP) of ⩾140 mm Hg and diastolic blood pressure (DBP) of ⩾90 mm Hg. BMI greater than or equal to 25, triglyceride level greater than 200 mg/dL (<2.8 mmol/L) and low-density lipoprotein (LDL) higher than or equal to 130 mg/dL (<3.4 mmol/L) were considered abnormal indicators.

Gensini score

The CVD severity in each patient was scored using the modified Gensini method. In this scoring system, a cumulative numeric score is determined by the degree of luminal narrowing and the anatomical location of each stenosis (Gensini, 1983; Sullivan et al., 1990). The modified Gensini score has been described and validated previously (Gensini, 1983). The most severe stenosis in each of eight coronary segments was graded from 1 to 4 (1 = 1%–49% lumen diameter reduction; 2 = 50%–74% stenosis; 3 = 75%–99% stenosis; 4 = 100% occlusion) to give a total score of between 0 and 32. This score, therefore, gives a measure that combines both the severity and extent of coronary atherosclerosis.

ARS

The 19-item ARS assesses the tendency to engage in repetitive thoughts about anger-related experiences (Sukhodolsky et al., 2001). For all items, respondents indicated their agreement on a 4-point Likert-type scale. Higher summed scores indicate greater anger rumination. The ARS has four subscales: Angry Afterthoughts, Thoughts of Revenge, Angry Memories and Understanding of Causes. The psychometric properties of the scale have been assessed in several studies. In a sample of 833, the scale showed good internal consistency (α = .95) and test–retest reliability (r = .77) for total score (Besharat and Mohammad Mehr, 2009). In addition, the convergent and discriminant validity of the ARS is supported by significant correlations with measures of psychological symptoms and dysregulated behaviour (Besharat and Mohammad Mehr, 2009). In this study, the Cronbach’s alpha coefficient for the scale was .87.

PSWQ

Worry was measured with the PSWQ, a 16-item self-report measure in which worry is rated on a 5-point Likert-type scale (Meyer et al., 1990). The PSWQ has good internal consistency (alphas of .88 or higher) and test–retest reliability (r = .74–.93) in different samples (Startup and Erickson, 2006). In this study, the Cronbach’s alpha coefficient for the PSWQ was .91.

SWBC

The SWBS consists of 20 items and assesses perceived spiritual life quality on a 6-point Likert-type scale from 1 (strongly disagree) to 6 (strongly agree) (Ellison, 1983; Paloutzian and Ellison, 1982). Higher scores indicate higher levels of well-being and spiritual satisfaction. Several studies have demonstrated the psychometric properties of the SWBS (Ellison and Smith, 1991; Paloutzian and Ellison, 1982). In this study, the Cronbach’s alpha coefficient of the SWBS was .76.

Data collection

We conducted a face-to-face questionnaire survey with patients with CAD. Respondents were informed that data would be de-identified and the results used only for scientific purposes. In total, 390 questionnaires were distributed and 366 collected. After excluding 39 invalid questionnaires (incomplete, regarded as outliers or not correctly completed), a total of 327 questionnaires were used in the final analysis.

Statistical analysis

Statistical analysis was conducted using SPSS (version 23.0). Means, standard deviations, standard error of means, frequencies, percentages, skewness and kurtosis are presented in Table 1. Pearson’s correlation and Point-Biserial correlation were used to examine associations among variables (Table 2). Regression analysis was used to control demographic and clinical variables. Mediation analyses were conducted using Hayes’ PROCESS macro (Hayes, 2013) for SPSS (PROCESS Model 4) (Table 3). Hayes Model 4 enabled us to conduct mediation tests and to assess the indirect effect of spiritual well-being on CAD severity through the mediating mechanisms of anger rumination and worry. We hypothesised that anger rumination and worry would account for unique variance in the relationship between spiritual well-being and CAD severity. It should be noted that the bootstrapping methods use a bootstrapping resampling technique to create bias-corrected 95% confidence intervals (95% CI) for the indirect effects of the mediating variable. With regard to bootstrapping, 5,000 bias-corrected bootstrap samples were requested in PROCESS.

Table 1.

Descriptive characteristics of participants.

Characteristic	M	SD	SEM	Number	%
Age	52.39	6.23	.34
Sex
Male				189	58
Female				138	42
Smoking				72	22
Family history of CAD				98	30
BMI	28.09	7.63	.42
Abnormal BMI				122	37
LDL (mg/dL)	157.05	9.11	.96
High LDL				94	29
Triglycerides (mg/dL)	278.67	5.43	1.37
High triglycerides				130	39
Glucose (mg/dL)	132.49	8.16	.89
Diabetes				93	28
Diastolic BP (mm Hg)	113.04	5.47	1.66
Systolic BP (mm Hg)	161.12	7.18	1.23
Elevated DBP				171	52
Elevated SBP				192	58
Variables	M	SD	SEM	Skewness	Kurtosis
Worry	54.44	12.31	0.67	−.38	−.32
Anger rumination	46.54	12.47	0.69	−.05	−.74
Spiritual well-being	74.05	20.12	1.11	−.08	.82
Gensini score	15.07	5.13	0.28	.15	.78

M: mean; SD: standard deviation; SEM: standard error of mean; CAD: coronary artery disease; BMI: body mass index; LDL: low-density lipoprotein; BP: blood pressure; DBP: diastolic blood pressure; SBP: systolic blood pressure.

Table 2.

Correlations between variables.

Variable	Anger rumination	Worry	Spiritual well-being	Gensini score
Age	−.13*	−.08	.08	.11*
Gender	.06	.19*	.02	.08
Smoking	.12*	.18*	−.14*	.20*
Family history of CAD	.09	.16*	.07	.14*
BMI	03.	.04	.06	.22**
High LDL	10.	.06	.07	.20*
High triglycerides	11.	.09	−.05	.24**
Diabetes	.24**	.14*	.04	.21*
Hypertension	−.21*	−.19*	−.09	.18*
Anger rumination	1	.38**	−.43**	.58**
Worry		1	.31**	.33**
Spiritual well-being			1	−.62**
Gensini score				1

CAD: coronary artery disease; BMI: body mass index; LDL: low-density lipoprotein.

p < .05. **p < .01.

Table 3.

Meditation model results.

Direct effect	Effect (β)	SE	T	p	LLCI	ULCI
Direct effect of spiritual well-being on anger rumination	−.37	.02	−13.62	<.001	−.42	−.31
Direct effect of spiritual well-being on worry	−.26	.03	−8.50	<.001	−.32	−.20
Direct effect of anger rumination on CAD severity	.09	.02	−7.63	<.001	.05	.14
Direct effect of worry on CAD severity	.03	.01	−2.98	=.103	−.00	.06
Direct effect of spiritual well-being on CAD severity	−.06	.01	4.02	<.001	−.09	−.04
Indirect effects	Effect (β)	Boot SE	Boot LLCI	Boot ULCI
Total indirect effect	−.04	.00	−.06	−.02
The specific indirect effect of spiritual well-being on CAD severity through anger rumination	−.03	.00	−.05	−.02
The specific indirect effect of spiritual well-being on CAD severity through worry	−.00	.00	−.02	.00

SE, standard error; LLCI: lower level confidence interval; ULCI: upper level confidence interval; CAD: coronary artery disease; LLCI: lower level confidence interval; ULCI: upper level confidence interval.

Results

Descriptive statistics

In all, 327 (138 women and 189 men, M = 52.39 years ± SD = 6.23) participated in this study. Smoking was reported by 22% of the participants, diabetes was identified in 28%, family history of CAD in 30%, obesity in 37%, elevated DBP in 52%, elevated SBP in 58%; 29% and 39% patients had an abnormal lipid profile due to low-density lipoprotein cholesterol (LDL-C) and triglycerides levels, respectively. The mean Gensini score was 15.07. Table 1 summarises the demographic and clinical characteristics.

Correlational analysis

Point-Biserial correlation as a special case of Pearson’s correlation was used to measure the correlation between one continuous variable and one dichotomous variable. Pearson’s correlation coefficient was used to measure the correlation between two continuous variables. The correlation coefficients are shown in Table 2. The results showed that there was a statistically significant correlation between CAD severity and worry (r = .33), anger rumination (r = .58) and spiritual well-being (r = –.62) (p = .010).

Mediation analysis

Based on results from correlational analyses, the hypothesised model was tested using the outcomes of the residual variance of CAD severity adjusted for demographic and clinical information including age, sex, hypertension, dyslipidaemia, type 2 diabetes, family history of premature CAD, BMI and current smoking. We hypothesised that anger rumination and worry would account for unique variance in the relationship between spiritual well-being and CAD severity. To assess this, the mediation model was examined for anger rumination and worry as two mediator variables (Figure 1). Within the PROCESS Macro, ‘Model 4’ was selected to examine the direct and indirect relationship among spiritual well-being, anger rumination, worry and CAD severity.

Figure 1.

Parameters and confidence intervals of the structural equation model.

Figure 1 shows the mediation model. Gensini Score and spiritual well-being were entered as the outcome and independent variables, respectively. Anger rumination and worry were entered as mediator variables. The total direct model was statistically significant, R2 = .30, F(3, 310) = 45.83, p < .0001, accounting for 30% of the overall variance of CAD severity. The mediation analysis revealed statistically significant direct effects of spiritual well-being on anger rumination (β = –.37, 95% CI [–.42, –.31]) and worry (β = –.26, 95% CI [–.32, –.20]). Likewise, we found a statistically significant and positive direct effect of anger rumination (β = .09, 95% CI [.05, .14]) and a statistically nonsignificant direct effect of worry on CAD severity (β = .03, 95% CI [–.00, .06]). Also, the direct effect of spiritual well-being on CAD severity was statistically significant and negative (β = –.06, 95% CI [–.09, –.04]). There was a statistically significant indirect effect of spiritual well-being on CAD severity through anger rumination (β = –.03, 95% CI [–.05, –.02]). Results are displayed in Table 3.

Discussion

Findings from this study revealed a statistically significant negative correlation between spiritual well-being and CAD severity. This finding is consistent with previous research (Jim et al., 2015; Koenig, 2009; Oman and Lukoff, 2018) illustrating the role of spirituality in mental and physical health. It has also been shown that spiritual well-being is negatively associated with anger rumination; anger rumination therefore appears to act as a mediator for spiritual well-being associations with CAD severity.

Religious beliefs can contribute to a greater sense of personal control, deeper meaning and intimacy (Groff and Smoker, 1996). Spirituality can play a role in reducing feelings of sadness, anger or misery by changing the appraised meaning of a stressful event (Koenig et al., 1988). Spiritual well-being has been associated with a broad range of positive outcomes, including recognising one’s strengths, an expanded view of possibilities, greater compassion for others, a better appreciation of life and a greater sense of purpose and meaning in life, which in turn facilitate personal and post-traumatic growth (Koenig, 2009).

Moreover, spirituality-inspired emotions such as hope, satisfaction, love and forgiveness can contribute to good health by affecting the neural pathways that connect to endocrine systems and immune systems (Jim et al., 2015). Some studies indicate that forgiveness is associated mentally with less mood disorders and a better quality of life and physically with lower blood pressure and heart rate (Toussaint et al., 2012). In contrast, other studies have demonstrated that anger as a negative emotion which is actively discouraged in many religions, triggers the release of the neurotransmitter norepinephrine and the endocrine hormone cortisol, which may lead to the weakened immune system, elevated blood pressure and increased risk of CVD (Larson and Larson, 2003). Social support from religious groups is also a critical factor in coping with stress (Sharma et al., 2017) and can reduce levels of anger and worry, and spiritual beliefs may allow a person to interpret uncontrollable events in a manner that results in less stress.

We found a statistically significant positive relationship between anger rumination and CAD severity – a result which is consistent with the results of prior studies (Byrd-Craven et al., 2011; Mostofsky et al., 2014; Suls, 2018; Young and Nolen-Hoeksema, 2001; Zoccola et al., 2010). We also found a statistically significant positive correlation between worry and CAD severity, a result which aligns with previous reports (Chalmers et al., 2016; Tully et al., 2013; Zoccola et al., 2010). Evidence suggests that repetitive thoughts are associated with physical consequences (Brosschot, 2010; Ottaviani et al., 2009); for instance, the cardiovascular system’s pathway, the autonomic and endocrine systems are affected in this way (Brosschot, 2010).

Repetitive thoughts (a cognitive representation of past stressful events or unpleasant future events) mediate the relationship between stress and physical illness. Stress persistence generated by repetitive thoughts has been shown to be associated with physiological activation and increasing susceptibility to disease (Verkuil et al., 2009). A sustained response to stressful events and delayed recovery of CV responses after acute stress can increase the risk of CV complications, which may be due to the continuation of stress-related thoughts (Key et al., 2008).

This study revealed no significant direct and indirect effect of worry on CAD severity within the mediation model. The findings of previous studies are inconsistent concerning the association of anxiety and worry with CVD. For example, one meta-analysis demonstrated a 52% increased risk of CVD onset for patients with anxiety symptoms such as worry (Batelaan et al., 2016), and other research shows that severe worry is associated with a significant decrease in heart rate variability (Tully et al., 2013). In contrast, other studies reported beneficial effects of anxiety on CV morbidity and mortality (Meyer et al., 2015). Research has also found no significant correlation between anxiety and CVD (Burokienė et al., 2014). Several factors can affect the impact of worry, which may also explain why we found no significant effect of worry on CAD severity. First, worry in individuals with high perceived control may mobilise a health behaviour (such as going to the doctor if one experiences chest pain) whereas worry in individuals with less perceived control may prompt feelings of helplessness (Scott et al., 2010). So, it is possible that a high level of perceived control among our participants has modified the impact of worry. It should also be noted that worry and anger rumination may indicate overlapping constructs as repetitive thoughts. So, another possible explanation is that the proportion of variance explained for CAD severity by anger rumination may overlap with the variance of worry; therefore, there might have been a direct effect of worry on CAD severity if anger rumination had not been controlled.

Limitations

This study had some limitations that need to be considered. First, the study was cross-sectional in nature, so it cannot identify causal relationships. Data were collected by means of a questionnaire, which may generate procedural reactivity and expectancy effects. The study’s focus was on CAD severity and its relationship to worry, anger rumination and spiritual well-being. Other factors unconsidered by this study may still be present. Not considering alternative hypotheses is yet another limitation, so future studies should consider other factors and hypotheses.

Conclusion

Results of this study reveal that spiritual well-being and anger rumination are significant predictors of CAD severity. These findings can strengthen theoretical models related to health and their practical application – in particular, by health professionals attentive to the role of psychological factors in preventive and therapeutic interventions related to CADs.

Footnotes

Acknowledgements

We thank the patients with CVD who participated in this study. We also thank Afshar Hospital, for access to patient data.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Somayeh Ramesh

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