Psychological factors are known to affect biological processes involved in the progression of coronary artery disease. This article focuses on psychological risk factors for progression of coronary artery disease and its clinical manifestations. Recent research on the adverse cardiovascular consequences of feelings of exhaustion and acute psychological arousal is reviewed, and a classification of psychological risk factors is presented distinguishing (1) chronic psychological risk factors, such as hostility; (2) episodic risk factors, such as exhaustion, with a duration ranging from several months to 2 years; and (3) acute psychological triggers, including mental activity and anger. The distinctive pathophysiological mechanisms by which these psychological risk factors promote coronary disease progression and cardiac ischemia are described, including hemodynamic reactivity, blood clotting, and inflammatory processes.