Cardiac Outcome Worse in Distressed Patients

  • by Staff Writer, MedPage Today

Action Points

  • Explain to interested patients that a type D (or distressed) personality profile is linked to poor cardiovascular outcomes -- independent of depression.
  • Note that this paper from the Netherlands is a review of studies largely from the same group that conducted the retrospective analyses -- and that causality could not be inferred from the study design.

Cardiac patients with a type D (distressed) personality appear to be at increased risk for poor cardiovascular outcomes -- including myocardial infarction and death, retrospective analyses showed.

In the analyses of studies done between 1995 and 2009 among more than 6,000 cardiac patients with type D personality, nine studies revealed a more than threefold increased risk of poor cardiovascular outcomes, with a mean odds ratio of 3.7 (95% CI 2.7 to 5.1), according to Johan Denollet, PhD, of Tilburg University in the Netherlands.

And in some studies conducted by Denollet's group, the odds ratios for cardiac death, myocardial infarction, and allograft rejection were as high as 6.8 and 8.9, they reported online in Circulation: Cardiovascular Quality and Outcomes.

The type D personality profile is characterized by a tendency to experience negative emotions and to be socially inhibited, according to background supplied by the authors. The researchers noted that the type D personality represented a chronic and more subtle form of distress distinct from that seen in depression.

Depression, anxiety, and anger all are characteristics that reflect distress and have been linked with adverse cardiac outcomes, Denollet and co-authors observed. "Specific negative emotions have been related to adverse cardiac events, but a general propensity to psychological distress may also affect cardiovascular outcomes," they wrote.

To estimate the prognostic cardiovascular risk associated with generalized distress as represented by type D personality, Denollet and colleagues performed a quantitative analysis of data from six of their own studies and three studies from other groups, for a total of 6,121 type D patients.

In two of these studies they found odds ratios of 2.5 and higher for coronary heart disease in patients with type D personality and odds ratios of 3.8 and higher for that outcome in four studies.

Type D personality also was associated with odds ratios of 2.3 and higher for heart failure, transplantation, and peripheral artery disease.

In addition, type D cardiac patients were at risk for long-term emotional distress, with odds ratios for symptoms such as anxiety, depression, and poor mental health in 11 studies ranging from 1.9 to 8.6.

To further explore a possible connection between type D personality and clinical depression, the researchers also conducted a narrative review of 29 studies that assessed both these factors and their effects on health outcomes.

They found that type D personality and depression were distinct entities, reflecting different manifestations of psychological distress and being associated with different cardiovascular effects.

In some studies, for example, depression was associated with future events such as atrial fibrillation, while in others type D personality was associated with outcomes such as poor health status after myocardial infarction.

While there was some overlap between depression and type D personality, the distinction between the two conditions was clear when the risk of cardiac events remained after adjusting for depression.

The difference also related to chronicity. "Depression is an episodic risk marker and type D a chronic risk marker for clinical manifestations of coronary disease," they explained.

There are plausible biological and behavioral pathways linking type D to cardiac risk. Experiments have shown that this personality type is associated with elevations in blood pressure, heart rate, and cardiac output, as well as with increases in the activity of proinflammatory cytokines, Denollet and co-authors noted.

Type D personality also was associated with increased cortisol and oxidative stress, they found.

In addition, patients with the distressed personality type D also are less likely to seek timely medical care or to adhere to medication, according to the researchers.

But "cardiac patients are not 'doomed' because they have a type D personality," they wrote. "In fact, type D patients may learn new strategies to reduce their level of distress and to improve their social skills."

Denollet and colleagues plan more studies to examine the effects of intervention in these patients.

Acknowledging the limitations of their analyses, the team cautioned that their findings did not imply causality.

"One should also keep in mind that type D research does not assert any causal claim regarding the incidence of cardiovascular disease but is merely focused on the association between general distress and prognosis in cardiovascular population," Denollet and co-authors wrote.

The study also was limited in that it was primarily a summary of the group's own work, so independent prospective studies are needed.

The study was supported by a grant from the Netherlands Organization for Scientific Research.

The authors declared no financial disclosures.
