"Distressed"-Personality Heart-Disease Patients at Increased Risk of Future Events

September 14, 2010

September 14, 2010 (Tilburg, the Netherlands) — Heart-disease patients with a general propensity to psychological distress are at a significantly higher risk of adverse cardiovascular events, according to the results of a new analysis [1]. In identifying individuals with the type-D personality construct, physicians might be able to better identify high-risk patients at risk for future events, say researchers.

"This is the type of patient that tells you everything is okay, that there are no problems, but you can sense that something is going on, something is not quite right," explained lead investigator Dr Johan Denollet (Tilburg University, the Netherlands).

Speaking with heartwire , Denollet said that type-D personality, a relatively new construct, is a combination of two fairly normal personality traits. It is not to be confused with depression, he said, noting that while there is some overlap between type D and depression, many type-D patients do not meet the clinical criteria for depressive illness.

"On the one hand, type-D people have the tendency to experience negative emotions, such as anxiety, depression, stress, and so on," he said. "At the same time, they also score higher [on tests] measuring social inhibition. Type-D patients are more closed in social interactions and are more unlikely to disclose their personal feelings toward others and tend to feel a bit insecure. This combination makes them more liable to chronic forms of psychological distress."

The D Stands for Distressed

The new report, published in the September 14, 2010 issue of Circulation: Cardiovascular Quality and Outcomes, attempts to provide an estimate of the prognostic risk associated with type-D personality. In this meta-analysis of nine studies published from 1995 to 2009, including patients with coronary artery disease, previous myocardial infarction, congestive heart failure, recent heart transplantation, and peripheral artery disease, type-D personality was associated with a 3.7-fold increased risk of poor long-term prognosis, including an increased risk of mortality, cardiac death, and myocardial infarction.

To heartwire , Denollet said the follow-up in the individual studies examining the link between the distressed personality type and cardiac events ranged from one year to six to 10 years.

"Most of the studies went to three, four, or five years, so this is more about the mid-term risk of events," he said. "It's not about the immediate risk in patients who were just diagnosed, but more what happens in the years to come when patients have been diagnosed and treated with invasive treatments or with drugs."

Denollet said that biological mediating mechanisms, such as stress hormones like cortisol, potentially play a role in the increased risk of cardiovascular events. In an unrelated study published last week in the Journal of Clinical Endocrinology and Metabolism, researchers, led by Dr Nicole Vogelzangs (VU University Medical Center, Amsterdam, the Netherlands) provided further support for the harmful role of cortisol on the heart. In the study of 861 individuals 65 years and older, higher urinary cortisol levels were associated with an increased risk of cardiovascular death [2].

Continuing, Denollet said that there is also evidence showing an increase in proinflammatory cytokines in type-D patients with chronic heart failure, which in turn increases risk of cardiovascular events. Importantly, these distressed individuals might also possess critical behavioral characteristics, such as being less likely to quit smoking, participate in physical activity, or comply with medical therapy, that increase their risk of cardiovascular events.

"In terms of treatment, it's important to get these patients involved in cardiac rehabilitation programs, including exercise training," Denollet told heartwire . "I would also advise doctors to more closely monitor these patients, maybe by getting them into the office for a more regular checkup or even by telephone to see how they're doing and to pay particular attention to things like quitting smoking."

An analysis of 11 studies also showed that type-D personality was associated with a threefold increased risk of emotional distress, including poor mental health, anxiety, and depression.


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