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(Circulation. 2000;102:630.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Inadequate Response to Treatment in Coronary Heart Disease
Adverse Effects of Type D Personality and Younger Age on 5-Year Prognosis and Quality of Life
From the University Hospital of Antwerp (J.D., J.V., D.L.B.), Antwerp, Belgium, and the Department of Psychology, Tilburg University, the Netherlands (J.D.).
Correspondence to Johan Denollet, PhD, Clinical Health Psychology, Room P508, Tilburg University, PO Box 90153, Warandelaan 2, 5000 LE Tilburg, Netherlands. E-mail J.Denollet{at}kub.nl
Background—Improvement in treatment of patients with coronary heart disease (CHD) has caused longer survival but also an increase in the number of patients at risk for subsequent cardiac events and impaired quality of life (QOL). We hypothesized that chronic emotional distress confers an increased risk of poor outcome despite appropriate treatment.
Methods and Results—This prospective study examined the
5-year prognosis of 319 patients with CHD. Baseline assessment included
symptoms of depression/anxiety and distressed personality type (type
D—ie, high negative affectivity and social inhibition). The main end
points were cardiac death or nonfatal myocardial infarction and
impaired QOL. There were 22 cardiac events (16 nonfatal); they were
related to left ventricular ejection fraction (LVEF)
50%, poor exercise tolerance, age 55 years, symptoms of
depression, and type D personality. Multivariate
analysis yielded LVEF 50% (OR, 3.9; P=0.009),
type D personality (OR, 8.9; P=0.0001), and age 55
years (OR, 2.6; P=0.05) as independent predictors of
cardiac events. Convergence of these risk factors predicted the absence
of the expected therapeutic response that was observed in 10% of the
patients. When 2 or 3 risk factors occurred together, the rate of poor
outcome was 4-fold higher (P=0.0001). Estimates of
medical costs increased progressively with an increasing number of risk
factors. Smoking, symptoms of depression, and type D personality were
independent predictors of impaired QOL.
Conclusions—Decreased LVEF, type D personality, and younger age increase the risk of cardiac events; convergence of these factors predicts nonresponse to treatment. Emotionally stressed and younger patients with CHD represent high-risk groups deserving of special study.
Key Words: coronary disease • infarction • prognosis • quality of life • depression • psychosocial stress
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