© International Epidemiological Association 2001
Printed in Great Britain
International Journal of Epidemiology 2001;30:363–369
Time urgency and risk of non-fatal myocardial
infarction
Stephen R Cole,a,b Ichiro Kawachi,b Simin Liu,a J Michael Gaziano,a JoAnn E Manson,a,c,d
Julie E Buring a,b,c,d and Charles H Hennekense
Background Inconsistencies in the literature linking Type A behaviour pattern (TAB) to
coronary heart disease (CHD) may be due to differences in the effects of various
components of TAB, namely aggressiveness, hostility, ambitiousness, competitive
drive, and a chronic sense of time urgency.
Methods
We investigated the association between sense of time urgency/impatience and
non-fatal myocardial infarction (MI) in a study of 340 cases and an equal number
of age-, sex-, and community-matched controls.
Results
A dose-response relation was apparent among subjects who rated themselves
higher on the four-item time urgency/impatience scale (P-value for trend ,0.001),
with a matched odds ratio (OR) for non-fatal MI of 4.45 (95% CI : 2.20–8.99)
comparing those with the highest rating to those with the lowest. After further
adjustment for family history of premature MI, physical activity, body mass
index, occupation, cigarette smoking, total caloric intake, per cent calories from
saturated fat, alcohol intake, lipid levels, treated hypertension and diabetes, the
dose-response relation remained (P-value for trend = 0.015) and the adjusted OR
for MI was 3.99 (95% CI : 1.32–12.0) comparing those with the highest rating to
those with the lowest.
Conclusion
In these data, a sense of time urgency/impatience was associated with a doseresponse increase in risk of non-fatal MI, independent of other risk factors.
Prospective cohort studies of time urgency/impatience and incident CHD events
are needed to confirm or refute these observations from a case-control study.
Keywords
Coronary heart disease, non-fatal myocardial infarction, time urgency, impatience,
Type A behaviour pattern, case-control study
Accepted
24 May 2000
Data concerning Type A behaviour pattern (TAB) and coronary
heart disease (CHD) are inconsistent. Type A behaviour pattern
is an amalgamation of several elements, including aggressiveness, hostility, ambitiousness, competitive drive, and a chronic
sense of time urgency.1 Some of these, referred to as ‘toxic’
a Division of Preventive Medicine, Department of Medicine, Brigham and
Women’s Hospital and Harvard Medical School, Boston, MA, USA.
b Department of Health and Social Behavior, Harvard School of Public Health,
Boston, MA, USA.
c Department of Ambulatory Care and Prevention, Harvard Medical School,
Boston, MA, USA.
d Department of Epidemiology, Harvard School of Public Health, Boston, MA,
USA.
e Visiting Professor of Medicine, and Epidemiology and Public Health,
University of Miami School of Medicine, USA. Current address: 1415 West
Camino Real, Boca Raton, FL 33486.
Reprint requests: Dr SR Cole, Division of Preventive Medicine, Department of
Medicine, Brigham and Women’s Hospital and Harvard Medical School, 900
Commonwealth Avenue East, Boston, MA 02215, USA. E-mail: scole@rics.
bwh.harvard.edu
363
elements, may be associated with risk of CHD, while others may
not.2 Thus, simple summary scores for TAB of linear combinations of these various behavioural patterns would predict
CHD only in samples where the toxic element(s) are weighted
strongly in the summary score. Such a situation could arise using
a TAB scale that incorporates a large number of items from the
toxic relative to the non-toxic elements. This is a measurement
problem where the instrument is recording several constructs
instead of a single construct, i.e. lack of unidimensionality.3,4
Much of the literature on TAB has focused on hostility as the
toxic component of the behaviour pattern.5 However, an inadequate number of studies have examined the cardiovascular
risk associated with other components of the behaviour pattern,6,7
such as time urgency, which is characterized as a persistent
preoccupation with time and need to complete tasks in a hurry.
Indeed, the gold standard for measurement of TAB is the videotaped clinical examination (VCE),8 which devotes approximately
equal emphasis to the measurement of time urgency and freefloating hostility.
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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
We previously reported9 on the relation of both overall TAB
and suppressed anger with non-fatal myocardial infarction (MI).
It remains unclear, however, whether there is any association
between the time urgency/impatience component of TAB and
MI, and if so, whether any association is independent of traditional coronary risk factors. Noting that researchers may have
prematurely abandoned time urgency as a potentially toxic
component of TAB, we sought to determine if time urgency,
measured with a self-report questionnaire, is associated with
non-fatal MI using data from the Boston Area Health Study.
Methods
Subjects
The Boston Area Health Study was a case-control study of
340 patients with first MI and an equal number of age-, sex-,
and community-matched control subjects. Case subjects were
selected from admissions to the coronary or intensive care units
of six suburban Boston hospitals (Emerson, Framingham
Union, Leonard Morse, Mount Auburn, Newton-Wellesley and
Waltham) between 1 January 1982 and 31 December 1983.
Those eligible for inclusion were white men and women under
76 years old living in the Boston area with no previous history
of MI or angina pectoris.
Using hospital records, the diagnosis of MI was confirmed
based on clinical history accompanied by rise in creatine kinase
enzyme. Permission was sought from each admitting physician,
and informed consent was obtained from the patients in the
hospital. In short, for each case patient, a control subject of the
same sex and age (±5 years) was selected at random from
the residents’ list of the town in which the patient resided. A
detailed description of the control sampling strategy has been
previously published.10 Each subject was interviewed in his or
her home by one of two trained nurse interviewers approximately
8 weeks after discharge from the hospital.
Of the eligible subjects contacted 84% of the cases discharged
alive and 60% of controls were enrolled, yielding 340 casecontrol pairs.
Assessment of time urgency and impatience
We ascertained a sense of time urgency/impatience using four
items from the 10-item Framingham Type A scale. This 10-item
scale includes three items related to work strain, two items
on competitiveness, one item on bossiness, two items on impatience, and two items related to time pressure or urgency. The
first time urgency item was ‘Have you often felt very pressed for
time?’ The second time urgency item was ‘Usually feel pressed
for time’. We scored a positive response to each item as one
point. For the two impatience items, subjects were asked to
rate how well the traits ‘eating too quickly’ and ‘getting upset
when you have to wait for anything’ described them, using the
response options of not at all, somewhat, fairly well and very
well. For these two items, we scored a response of ‘very well’ as
one point. For each subject, we combined these four items into
a summed rating scale, with a range of 0 to 4 points.
Assessment of coronary risk factors
We obtained extensive information on coronary risk factors
related specifically to the time before the MI for cases and before
the interview for controls, including age (years), body mass
index (BMI; weight [kg]/height [m2]), cigarette smoking status
(never, former, current [,1 pack/day, 1–,2 packs/day, 2+ packs/
day]), family history of premature MI (defined as positive history
of MI before age 60 years in the individual’s mother, father, or
siblings), history of treatment for hypertension (yes/no) and
diabetes mellitus (yes/no). We recorded the ‘usual’ occupation
for each subject using Edwards’ US census grouping of occupations. White-collar occupations included (1) professionals, (2)
proprietors, managers and officials (including farm owners and
wholesale and retail dealers), and (3) clerks and kindred workers.
Blue-collar occupations included (4) skilled workers and foremen,
(5) semiskilled workers, and (6) unskilled workers (farm labourers
and other labourers). Additionally, we created a category for
homemakers. Total caloric intake, per cent of calories from saturated fat and alcohol intake were determined from a 116-item
semiquantitative food frequency questionnaire.11 We estimated
energy expenditure (kJ) from physical activity with questions
about walking, climbing stairs, and participation in sports or
recreational activities.12 We determined lipid levels from fasting
venous blood samples using the Lipid Research Clinics methods.13
Fasting blood samples were obtained from a subgroup of the
cases approximately 8 weeks after hospital discharge, as well as
from a subgroup of controls. Statistical analysis for lipids is
restricted to the 235 matched pairs with full lipid profiles.
Statistical analysis
We first examined the distribution of coronary risk factors
according to case-control status. For these comparisons, we
employed continuity-corrected χ2 tests for discrete characteristics (sex, treated hypertension and diabetes, family history of
premature MI, cigarette smoking status and occupation type),
Wilcoxon rank-sum tests for skewed continuous characteristics
(physical activity, alcohol intake, very low density lipoprotein
[VLDL] and triglycerides) and t-tests for the normally distributed
continuous characteristics (age, BMI, total calories, per cent calories from saturated fat, and the balance of the lipid values). We
adjusted lipid values for age and sex before making comparisons.
We then examined the distribution of these characteristics
according to level of the time urgency/impatience scale. For
these comparisons, we employed the Cochran-Armitage test
for trend for discrete characteristics (sex, treated hypertension
and diabetes, family history of premature MI, cigarette smoking
status and occupation type) and the Mantel-Haenszel non-zero
correlation test for continuous characteristics (age, BMI,
physical activity, alcohol intake, total calories, per cent calories
from saturated fat, and lipid values). We assessed the internal
consistency reliability of the four-item time urgency/impatience
measure using Cronbach’s coefficient alpha.14
To examine the association between our measure of time
urgency/impatience and non-fatal MI, we used conditional
logistic regression to estimate matched pair odds ratios (OR) and
95% CI.15 We took a log transformation for physical activity,
VLDL and triglycerides and categorized alcohol intake into
quintiles to adjust for the skew in each of these covariates when
controlling for them in the multivariable models. Next, we fit a
series of models adjusting for each covariate to assess potential
confounding or mediating effects, and a full model adjusting for
all covariates.
In a secondary set of analyses, we explored the association of
time urgency/impatience with non-fatal MI beyond the effects of
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TIME URGENCY AND MYOCARDIAL INFARCT
other components of TAB. To do so, we adjusted the association
between time urgency/impatience and non-fatal MI for the six
remaining items from the Framingham Type A scale.
Table 1 Characteristics of cases and controls, Boston Area Health
Study 1982–1983
Characteristica
Cases
(N = 340)b
Controls
(N = 340)c P-valued
Results
Age (years)
58 (10)
58 (10)
Sex (% male)
78
78
1.00
Of the 680 subjects, 380 (56%) indicated yes to the item ‘often
feel very pressed for time.’ Of the 679 subjects who responded
to the remaining three items, 469 (69%) indicated that they
‘usually feel pressed for time,’ 194 (29%) responded that
‘eat too quickly’ described them ‘very well’, and 201 (30%)
responded that ‘get upset when you have to wait for anything’
described them ‘very well’. The four time urgency/impatience
items combined to provide a scale with a median of 2 (mean =
1.81; quartiles 1,3; range 0–4) and an internal consistency
reliability of 0.50.
As expected, the distribution of traditional coronary risk
factors among cases differed from controls (Table 1). In Table 2,
a stronger sense of time urgency/impatience was clearly associated with younger age (P-value , 0.001), male gender (P-value
= 0.003), higher levels of smoking (P-value , 0.001), whitecollar occupation (P-value , 0.001), higher levels of physical
activity (P-value = 0.047), and higher caloric (P-value , 0.001)
and saturated fat (P-value = 0.013) intake.
In crude matched-pair analysis, the measure of time urgency/
impatience was associated with a dose-response increase in risk of
non-fatal MI (P-value for linear trend ,0.001; Table 3, Figure 1).
The OR for non-fatal MI among those with the highest rating of
time urgency/impatience was 4.45 (95% CI : 2.20–8.99) compared to those with the lowest rating of time urgency/impatience.
In multivariable models controlling for age and sex by
design and family history of premature MI, physical activity,
BMI (continuous), occupation, cigarette smoking, total caloric
intake, per cent calories from saturated fat, alcohol intake,
lipids, history of treated hypertension and diabetes, the measure
of time urgency/impatience remained significantly associated
with non-fatal MI (P-value for linear trend = 0.015; Table 3,
Figure 1). The adjusted OR for non-fatal MI among those with
the highest rating of time urgency/impatience was 3.99 (95%
CI : 1.32–12.0), while the adjusted OR among those with a
moderate rating of time urgency/impatience (scale score = 2)
was 1.99 (95% CI : 0.83–4.82), both compared to those with
the lowest rating of time urgency/impatience.
As smoking is the strongest potential confounder, we limited
our study to the 193 subjects with no history of smoking and
conducted an unmatched analysis. While results are much less
precise due to the reduction in sample size, time urgency/
impatience remained associated with risk of non-fatal MI (OR
comparing highest time urgency/impatience level to lowest =
2.03, 95% CI : 0.61–6.79).
When we looked at each time urgency/impatience item individually, the matched pair OR were 1.43 (95% CI : 1.02–2.00)
for ‘often feel very pressed for time at work,’ 1.67 (95% CI : 1.22–
2.28) for ‘usually feel pressed for time,’ 1.90 (95% CI : 1.34–
2.69) for ‘get upset when you have to wait for anything,’ and
1.36 (95% CI : 0.98–1.89) for ‘eat too quickly.’ Therefore all
four items contributed to the association between the summary
scale and increased risk of non-fatal MI.
Finally, we adjusted for the six Framingham Type A items
which measured other components of TAB (work strain,
Treated hypertension (%)
35
25
0.008
Treated diabetes (%)
14
8
0.018
Family history of MIe
,60 years of age (%)
22
15
Never
25
32
Former
32
41
6
7
20–39 (cigs/day)
17
12
40+ (cigs/day)
19
8
White collar
62
70
Blue collar
30
23
Occupation (%)
Homemaker
Body mass index (kg/m2)
Physical activity (kcal/week)
0.030
,0.001
Cigarette smoking (%)
Current:
1–19 (cigs/day)
0.952
0.108
8
7
26 (4)
26 (4)
0.483
3090 (2970) 3542 (3009)
0.007
Total calories per day
2482 (927)
2354 (773)
0.050
Per cent calories from
saturated fat
13 (3)
12 (3)
,0.001
Alcohol intake (g/day)
Total cholesterol (mg/dl)f
Total HDL g (mg/dl)f
15 (26)
20 (28)
0.001
215 (43)
212 (42)
0.325
35 (10)
43 (12)
,0.001
HDL 2 (mg/dl)f
12 (7)
18 (10)
,0.001
HDL 3 (mg/dl)f
23 (6)
26 (7)
,0.001
LDLh (mg/dl)f
137 (37)
132 (35)
0.116
VLDLi (mg/dl)f
43 (24)
37 (26)
,0.001
175 (116)
136 (96)
,0.001
Triglycerides (mg/dl)f
a All values are mean (±SD) unless otherwise indicated.
b One case was missing smoking status and 10 cases were missing occupation.
c One control was missing history of treatment for hypertension, 1 missing
smoking status and 14 controls were missing occupation.
d P-value from continuity corrected χ2, Cochran-Armitage trend test (smoking
status), t-test, or Wilcoxon rank-sum test (physical activity, alcohol intake,
VLDL, and triglycerides).
e Myocardial infarction.
f Adjusted for age and sex.
g High density lipoprotein.
h Low density lipoprotein.
i Very low density lipoprotein.
competitiveness, and bossiness). In this model, time urgency/
impatience remained independently associated with non-fatal
MI (P-value for linear trend = 0.001). Here, the TAB-adjusted
OR for non-fatal MI among those with the highest rating of
time urgency/impatience was 4.00 (95% CI : 1.83–8.75), while
the TAB-adjusted OR among those with moderate ratings of
time urgency/impatience were also elevated compared to those
with the lowest rating of time urgency/impatience (TABadjusted OR for scale score of 3 = 1.56 [95% CI : 0.85–2.87],
TAB-adjusted OR for scale score of 2 = 1.23 [95%
CI : 0.74–2.03]).
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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Table 2 Risk factors by time urgency/impatience, Boston Area Health Study 1982–1983
Score on four-item time urgency/impatience measure
Characteristica
Low–0
(N = 106)
1
(N = 156)
2
(N = 228)
3
(N = 124)
High–4
(N = 65)
P-value
for trendb
63 (9)
61 (9)
57 (9)
55 (10)
53 (10)
,0.001
Sex (% male)
69
77
80
81
88
0.003
Treated hypertension (%)
31
28
29
29
35
0.671
Treated diabetes (%)
16
11
8
8
12
0.164
Family history of MIc (%)
19
17
20
15
28
0.437
Never
38
29
26
26
23
Former
38
37
36
35
32
Age (years)
,0.001
Cigarette smoking (%)
Current:
1–19 (cigs/day)
9
6
6
6
8
20–39 (cigs/day)
8
14
18
18
14
40+ (cigs/day)
8
14
14
15
23
White collar
51
59
73
67
79
Blue collar
35
32
23
26
18
Homemaker
14
9
4
7
3
26 (4)
26 (4)
26 (4)
26 (3)
26 (3)
0.443
3382 (2984)
2837 (2273)
3285 (2976)
3578 (3113)
4005 (4102)
0.047
2169 (814)
2297 (728)
2487 (838)
2525 (933)
2678 (985)
,0.001
12(4)
12 (3)
13 (3)
13 (3)
13 (3)
0.013
15 (30)
17 (28)
20 (28)
15 (23)
17 (25)
0.857
,0.001
Occupation (%)
Body mass index (kg/m2)
Physical activity (kcal/week)
Total calories per day
Per cent calories from saturated fat
Alcohol intake (g/day)
Total cholesterol (mg/dl)d
218 (42)
215 (49)
211 (42)
215 (46)
215 (38)
0.669
Total HDLe (mg/dl)d
39 (12)
40 (13)
40 (12)
38 (11)
36 (10)
0.254
HDL 2 (mg/dl)d
16 (10)
15 (9)
15 (9)
14 (9)
13 (8)
0.153
HDL 3 (mg/dl)d
23 (7)
25 (7)
25 (7)
24 (6)
24 (6)
0.949
136 (34)
131 (39)
134 (37)
136 (38)
135 (36)
0.821
44 (29)
40 (25)
37 (24)
41 (23)
43 (27)
0.514
162 (89)
155 (97)
144 (123)
156 (92)
187 (152)
0.776
LDLf (mg/dl)d
VLDLg (mg/dl)d
Triglycerides (mg/dl)d
a All values are mean (±SD) unless otherwise indicated.
b P-value from Cochran-Armitage trend test or Mantel-Haenszel non-zero correlation test (age, body mass index, physical activity, alcohol intake, total calories,
per cent calories from fat, and lipid values).
c Myocardial infarction.
d Adjusted for age and sex.
e High density lipoprotein.
f Low density lipoprotein.
g Very low density lipoprotein.
Discussion
These data indicate that individuals reporting a greater sense of
time urgency/impatience have an increased risk of non-fatal
MI. This association was independent of age, sex, family history
of premature MI, physical activity, BMI, occupation, cigarette
smoking, total caloric intake, per cent calories from saturated
fat, alcohol intake, treated hypertension and diabetes, and lipid
levels.
The assessment of hostility includes some aspects of time
urgency (e.g. ‘It makes me angry to have people hurry me’).
However, time urgency may also be related to other psychological characteristics, such as anxiety. For example, approaches
to assess anxiety commonly contain a time urgency component,
such as ‘I work under a great deal of tension’ or ‘I am not feeling
much pressure or stress these days’. Anxiety16,17 and cognitive
responses to anxiety, such as worry,18 have been implicated as
risk factors for CHD. Our hypothesis that time urgency would
prove a particularly ‘toxic’ element of TAB was based upon the
evidence relating anxiety to CHD and the observation that time
urgency and anxiety are closely related concepts. In the present
study, the association between time urgency and non-fatal MI
appeared to be independent of the remaining components of
TAB, suggesting that time urgency is indeed an independent
predictor of increased risk of non-fatal MI.
This case-control study is subject to several limitations. First,
as with any case-control study of psychosocial exposures, time
urgency and impatience may be differentially recalled among
cases and controls. There are several reasons why recall bias
is an unlikely explanation for our findings. First, cases were
unaware of our hypothesis, and our extensive questionnaire
TIME URGENCY AND MYOCARDIAL INFARCT
367
Table 3 Odds ratios for non-fatal myocardial infarction, according to sense of time urgency/impatience, Boston Area Health Study 1982–1983
‘Usually feeling pressed for time’
No. of caseLow–0
control pairs (N = 106)
1
(N = 156)
2
(N = 228)
3
(N = 124)
High–4
P-value
(N = 65) for trend
Model controlling for:
,0.001
Age, sex
339
1.0
1.15 (0.70–1.90) 1.40 (0.86–2.26) 1.76 (1.02–3.03) 4.45 (2.20–8.99)
Age, sex, hypertension
338
1.0
1.12 (0.68–1.86) 1.42 (0.87–2.31) 1.70 (0.98–2.94) 4.28 (2.11–8.69)
,0.001
Age, sex, diabetes
339
1.0
1.20 (0.72–1.98) 1.46 (0.90–2.38) 1.85 (1.06–3.21) 4.59 (2.26–9.32)
,0.001
Age, sex, family history of MIa
339
1.0
1.12 (0.68–1.85) 1.40 (0.86–2.28) 1.81 (1.04–3.13) 4.38 (2.16–8.87)
,0.001
Age, sex, (log) physical activity
339
1.0
1.14 (0.69–1.88) 1.36 (0.84–2.22) 1.75 (1.01–3.03) 4.21 (2.07–8.57)
,0.001
Age, sex, body mass index
338
1.0
1.18 (0.72–1.95) 1.46 (0.89–2.37) 1.80 (1.04–3.12) 4.53 (2.23–9.18)
,0.001
Age, sex, occupation
316
1.0
1.07 (0.63–1.81) 1.27 (0.76–2.13) 1.64 (0.92–2.93) 4.62 (2.16–9.91)
,0.001
Age, sex, smoking statusb
337
1.0
1.04 (0.62–1.75) 1.26 (0.76–2.07) 1.68 (0.95–2.96) 4.29 (2.06–8.93)
,0.001
Age, sex, dietary informationc
339
1.0
1.10 (0.65–1.87) 1.38 (0.82–2.32) 1.79 (1.00–3.20) 3.91 (1.87–8.16)
,0.001
Age, sex, lipidsd
235
1.0
1.88 (0.92–3.86) 2.35 (1.14–4.84) 1.89 (0.85–4.19) 4.50 (1.80–11.2)
0.004
Age, sex, all coronary risk factors
221
1.0
1.39 (0.60–3.24) 1.99 (0.83–4.82) 1.71 (0.64–4.58) 3.99 (1.32–12.0)
0.015
a Myocardial infarction.
b Smoking status as: never, former, current (,1 pack/day, 1–,2 packs/day, 2+ packs/day).
c Includes: total caloric intake, per cent of calories from saturated fat and quintiles of alcohol intake.
d Includes: high density lipoprotein (HDL) , HDL , low density lipoprotein (LDL), log of very density lipoprotein (VLDL), and log of triglycerides.
2
3
Figure 1 Age- and sex- and multivariable-adjusted odds ratios for
non-fatal myocardial infarction by level of time urgency, compared to
subjects with a time urgency score of zero
on lifestyle factors was presented to them as a study of factors
involved in hospitalization. Second, the time urgency hypothesis is now, and was then (in 1982–1983), not widely known
to the lay public. Finally, the primary research question for this
case-control study, which concerned alcohol intake and MI,
was widely suspected as a factor influencing MI and no recall
bias was apparent in this association.19 A definitive test of the
hypothesis ruling out recall bias requires prospective measurement of time urgency/impatience. A further limitation of our
study is that our results only apply to non-fatal MI. While
selecting only non-fatal MI cases limits generalizability, it
allowed us to ascertain measures of time urgency and impatience
as well as extensive information on coronary risk factors directly
from the subjects, making this study possible and reducing
the possibility of confounding by unmeasured factors. Third, it
is possible that a survivorship bias is at play, whereby fatal MI
cases would have demonstrated lower time urgency than the
non-fatal MI cases that we observed. Analysis of prospective
data will be necessary to rule out this potential, but unlikely,
explanation. Fourth, there may be residual confounding by
measured factors. However, it is unlikely that there exists any
residual positive confounding of measured factors strong enough
to cancel the observed association. Fifth, random misclassification
of time urgency/impatience may have occurred. Indeed, we provide only marginal evidence of the reliability of our measurement scale, with an internal consistency reliability estimate of
0.50. However, the effect of any random misclassification would
tend to diminish the observed association towards the null.
Finally, while information on Q-wave infarction would have
been desirable, this information was not available.
We previously reported9 that the unadjusted association
between overall TAB score and non-fatal MI (matched OR =
1.57; 95% CI : 1.12–2.20) observed in the Boston Area Health
Study attenuated markedly after control for high density lipoprotein (HDL) lipid levels (adjusted OR = 1.12; 95% CI : 0.66–
1.90), suggesting either confounding or a pathway through
which TAB might affect CHD. However, our present findings
indicate that lipid levels did not mediate the association of the
time urgency/impatience component of TAB pattern on risk of
non-fatal MI. This differing result for the time urgency/impatience
component of TAB reinforces the notion that TAB is an
amalgamation of disparate elements, for which simple summary
scales are problematic.3,4
In 1966, Brozek, et al.20 demonstrated an increased risk of
CHD among those reporting the propensity to speak, walk, write,
drive, work, and eat quickly even when they did not have to do
so. De Backer et al.21 reported a nearly twofold increase in
5-year CHD incidence among those in the highest tertile of the
Jenkins Activity Survey subscale S, which measures time urgency,
speed and impatience. However, in the VA Normative Aging
Study, the Jenkins Activity Survey subscale S was not associated
with CHD risk (adjusted RR = 0.86; 95% CI : 0.69–1.09), even
though an association was found between Minnesota Multiphasic
Personality Inventory (MMPI)-Type A score and CHD.22 BoothKewley and Friedman23 reported results from a meta-analysis
of time urgency, speed and impatience and various disease endpoints. Among the nine studies of combined CHD outcomes (i.e.
including angina) they observed a significant positive association
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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
with time urgency (P-value , 0.01), however this finding was
attenuated and not significant in the four studies of time
urgency and MI (P-value = 0.31). More recently, Powell et al.24
reported an association between time urgency and mortality
among 83 non-smoking, non-diabetic women aged 30–63,
6 months after an acute MI. Six deaths occurred during an average of 8.5 years of follow-up, with time urgency associated with
a near threefold increase in risk of mortality (RR = 2.86, P-value
= 0.02).
Time urgency/impatience may affect CHD endpoints through
one or more pathways, including decreased heart rate variability
(HRV) or adverse health behaviours. Decreased HRV has been
implicated as a potential pathway through which anxiety,25
psychological stress,26 and depression27 alter the incidence of
CHD. However, no data are currently available on the association
between time urgency and HRV. Alternatively, people with a
persistent sense of time urgency/impatience may consequently
exhibit other health behaviours that place them at greater risk
for CHD. For example, people reporting an increased sense
of time urgency/impatience may subsequently exhibit reduced
physical activity, poor dietary habits, increased alcohol intake
and more smoking. However, our data do not suggest that present
smoking status, alcohol intake or physical activity substantially
mediate the association between time urgency/impatience and
non-fatal MI, as adjustment for these health behaviours did not
appreciably attenuate the observed association.
In summary, our data demonstrate a significant increased risk
of non-fatal MI associated with time urgency/impatience.
Additionally, the risk of MI among those who have an increased
sense of time urgency/impatience is independent of traditional
coronary risk factors, and appears to be independent of other
components of TAB. It is also unlikely that this association is
substantially mediated by health behaviours, such as smoking,
physical activity, caloric intake and alcohol intake, or by lipid
levels. Similar analysis in prospective cohort studies of time
urgency/impatience and incident CHD events, which are not
subject to recall bias, are needed to confirm or refute these
observations.
3 Holland PW, Wainer H. Differential Item Functioning. New York:
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4 Dean K, Salem N. Detecting measurement confounding in epidemio-
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5 Miller TQ, Smith TW, Turner CW, Guijarro ML, Hallet AJ. A meta-
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6 Wright L. The type A behavior pattern and coronary artery disease:
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Acknowledgements
This study was supported by research grants HL-24423 and
HL-21006 from the National Heart, Lung, and Blood Institute.
The authors thank the six Boston area hospitals that participated
in this study: Emerson Hospital (Dr Marvin H Kendrick),
Framingham Union Hospital (Dr Marvin Adner and Dr Gerald
Evans), Leonard Morse Hospital (Dr L Frederick Kaplan), Mount
Auburn Hospital (Dr Leonard Zir), Newton-Wellesley Hospital
(Dr James Sidd), and Waltham-Weston Hospital (Dr Solomon
Gabbay). Dr Kawachi is supported by a Career Development
Award from the National Heart, Lung, and Blood Institute.
and risk of coronary heart disease. The Normative Aging Study [see
comments]. Circulation 1994;90:2225–29.
18 Kubzansky LD, Kawachi I, Spiro A III, Weiss ST, Vokonas PS, Sparrow
D. Is worrying bad for your heart? A prospective study of worry and
coronary heart disease in the Normative Aging Study [see comments].
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19 Gaziano JM, Buring JE, Breslow JL et al. Moderate alcohol intake,
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TIME URGENCY AND MYOCARDIAL INFARCT
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International Journal of Epidemiology 2001;30:369–370
Commentary: Is there any validity to the
Type A concept?
Kenneth E Hart
In 1988, the New England Journal of Medicine published an editorial
commentary by Joel Dimsdale,1 who commented on the
‘topsy-turvy’ career of the putative psychosocial risk factor for
coronary heart disease (CHD) originally known as the Type A
behaviour pattern (TAB), an action-emotion complex observed
in people who are aggressively involved in a chronic struggle
with life to achieve more and more in less and less time. Since
its inception in the 1950s, the quest to legitimize TAB as a
genuine risk factor for CHD has indeed been turbulent, suffering numerous setbacks. Most of the controversy came from
epidemiological uncertainty generated by mixed results linking
TAB to CHD outcomes. At the beginning of the new millennium,
the vast majority of contemporary researchers would agree that
the simple model linking TAB to CHD is clearly inadequate.
Does this inadequacy necessarily mean that the Type A construct has no validity, and that the entire area of investigation
should be abandoned altogether? Some people agree, while
others beg to differ. The article by Cole and his colleagues2
in this issue of the International Journal of Epidemiology entitled
‘Time urgency and risk of non-fatal myocardial infarction’
represents the latest in a growing chain of evidence suggesting
we might be able to salvage something useful from the chequered
career of the Type A concept. The Cole et al.2 paper supports
the more general conclusion that researchers should not rush to
abandon the use of the paper-and-pencil measures for assessing
components of Type A behaviour. Briefly, Cole et al.2 culled four
items from the Framingham Type A scale to examine the relationship between subjective ratings of ‘Time Urgency & Impatience’
(TUI) and non-fatal myocardial infarction (MI) in 240 cases and
an equal number of matched controls. Their results showed time
urgency and impatience was associated with a dose-response
increase in risk of MI, independent of other risk factors. Importantly, the association remained significant after controlling for
‘global’ Type A scores.
School of Psychology, University of Leeds, Leeds, UK. E-mail: kenh@psyc.
leeds.ac.uk
This brief commentary seeks to provide a broader context
within which to interpret findings published by Cole et al. With
regard to the historical backdrop, research on TAB has evolved
to a point where most researchers now recognise that the
construct is multidimensional in nature, and that different components have differential relevance for health, illness and medical
problems resulting from a variety of causes.3 Increased recognition
that we are dealing with a family of related constructs has even
caused researchers to examine ‘cousin’ constructs. In particular,
the field has witnessed a dramatic shift away from (global)
Type A research toward research on cynical hostility (see 4 for a
meta-analysis). The ‘unravelling’ of the Type A construct has
left another legacy. As I have noted in a previous review article,5
this consists of the growth of an interesting and potentially fruitful body of literature relating the ‘Time Urgency & Irritability’
(TUI) subcomponent of the Type A construct to a variety of
measures of general ill health. In general, this emerging
literature supports the view that not all Type A behaviours are
necessarily coronary-prone or even health-relevant. Evidence
now suggests that some Type A components are irrelevant to
health and illness, but might still predict occupational performance. Moreover, this fledgling knowledge base suggests the
TUI subcomponent may be uniquely associated with a variety of
health outcomes and a negative risk profile which increases
susceptibility to general ill health. This risk ‘profile’ consists of
the presence of vulnerability factors and the absence of health
protective factors. Just to take one example, there is evidence
to suggest that individuals are vulnerable to health problems
resulting from (car) accidents by virtue of their TUI scores and
not their global Type A scores.6 When considered in the aggregate,
this growing data-base underscores the more general theme
that subcomponent measures of Type A-related constructs
are superior to global undifferentiated measures with respect
to understanding vulnerability to different types of medical
problems.
It seems appropriate at this time to take stock and evaluate
the state of theory and assessment in this area. A cluster of
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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
interrelated measurement scales can readily be identified, starting with Cole et al,2 who culled four items from the Framingham
Type A scale to develop a scale they believe measures ‘Time
Urgency & Impatience’ (TUI). Wright et al7 have developed a
42-item scale to assess a construct they labelled ‘Time Urgency
& Perpetual Activation,’ (TUPA), and have provided preliminary
evidence for construct validity in research that pitted the TUPA
against other measures that ostensibly measure the same construct. Spence et al8 factor analysed the student version of the
Jenkins Activity Survey (JAS-Form T) to develop a five-item
subscale they labelled the Impatience-Irritability (II) scale, finding
the scale was uniquely related to physical health. Landy et al.9
have also studied the construct of ‘time urgency’ in relation to
health outcomes by developing a new multidimensional scale
called the Behaviourally Anchored Rating Scale (BARS), which
ostensibly measures seven dimensions of time urgency. Menon
et al.10 have recent factor analysed the BARS, finding two
separate interpretable subscales, which they labelled ‘strategic
time urgency,’ and ‘obsessive time urgency.’ Furthermore, they
reported a differential pattern of correlations to physical/
medical symptoms implicating obsessional time urgency as the
sole health risk. By far the most widely used scale in this area is
the 21-item ‘Speed & Impatience’ (SI) subscale of the Jenkins
Activity Survey (JAS) measure of the TAB. Hart5 has reviewed
evidence to suggest the SI subscale from the JAS is uniquely
predictive (relative to global A-B scores) of generalized health
problems and health-risk processes. Clearly, work in this area
seems to be growing at a healthy pace. But, a word of caution is
in order, lest history repeat itself.
Ironically, one of the potential pitfalls in the burgeoning area
of Type A subcomponent research is the very rapid proliferation
of these different measurement scales. Because research to
adequately support the reliability or validity of the various
scales (i.e. TUI, TUPA, II, Strategic & Obsessional Time Urgency,
SI) has yet to be conducted, it cannot be assumed they are all
measuring the same theoretical construct. Also, we still do not
know if this ambiguously defined construct is sufficiently stable
over time to make it a viable CHD risk factor. Thus, generalizability of findings across different measurement scales might
be quite limited. Clearly, in order to extrapolate from the
operational level of analysis to the theoretical and conceptual
level (and thereby move the field ahead), we need to quickly
develop a programme of studies to evaluate the construct
validity and reliability of the available assessment instruments.
Without independent evidence of construct validity, empirical
associations to health indicators derived from epidemiological
research remain sterile, telling us little about the nature of the
putative causal agent. Also, in order for us to develop conceptual models of the mediating mechanisms that might explain
how this poorly understood personality construct (‘time
urgency & impatience’?) confers increased health risk, we need
to have a much richer theoretical understanding of the
attributes of the trait(s). Finally, efficient and effective
therapeutic and preventative interventions would also depend
on more precise theoretical specification of the nature of the
causal agent.
Thus, future studies that seek to extend and refine work by
Cole2 and others might wish to address the question ‘Is there any
validity to the Time Urgency & Irritability concept?’ Developmentally, the Time Urgency & Irritability concept is now beginning to metamorphose from infancy to early childhood. I sincerely
hope it can avoid following in the topsy-turvy footsteps of its
Type A predecessor, which left in its wake a rather dubious career
trajectory. Something seems to be emerging from the literature,
but what—precisely—is it?
References
1 Dimsdale JE. A perspective on Type A behavior and coronary disease.
N Engl J Med 1988;318:110–12.
2 Cole SR, Kawachi I, Liu S et al. Time urgency and risk of non-fatal
myocardial infarction. Int J Epidemiol 2001;30:363–69.
3 Booth-Kewley S, Friedman HS. Psychosocial predictors of heart
disease: a quantitative review. Psychol Bull 1987;101:342–62.
4 Miller TQ, Smith TW, Turner CW, Guijarro ML, Hallet AJ. Meta-
analytic review of research on hostility and physical health. Psychol
Bull 1996;119:322–48.
5 Hart KE. A moratorium on research using the Jenkins Activity Survey
for Type A behaviour? J Clin Psychol 1997;53:905–07.
6 Karlberg L, Unden AL, Elofsson, S, Krakau I. Is there a connection
between car accidents and Type A drivers? Behav Med 1998;24:99–106.
7 Wright L, Nielsen BA, Abbanato KR, Jackson T, Lancaster C, Son J.
The relationship of various measures of time urgency to indices of
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8 Spence JT, Helmreich RL, Pred RS. Impatience versus achievement
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9 Landy FL, Rastegary H, Thayer J, Colvin, C. Time urgency: the con-
struct and its measurement. J Appl Psychol 1991;76:644–57.
10 Menon S, Narayanan L, Spector PE. Time urgency and its relation
to occupational stressors and health outcomes for health care professionals. In: Spielberger CR, Sarason CD (eds). Stress and Emotion:
Anxiety, Anger and Curiosity. Vol. 16. San Francisco: Taylor and Francis,
1996, pp.127–42.