(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
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Abstract |
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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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Introduction |
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Indexes of disease severity, such as decreased left ventricular function or exercise tolerance, are associated with poor prognosis in patients with coronary heart disease (CHD).1 Emotional distress has, in addition to standard risk factors, been widely associated with CHD.2 3 4 Whereas acute emotional stress may precipitate cardiac events in high-risk individuals,3 chronic emotional stress increases susceptibility to the underlying pathophysiological processes.4 Emotional stress may thus elicit coronary spasm, platelet activation, and decreased heart rate variability,5 6 7 thereby leading to myocardial ischemia, thrombotic occlusion, cardiac arrhythmias, myocardial infarction, and sudden cardiac death.2 3 4 8
Chronic emotional stress is largely dependent on broad personality
traits that refer to individual differences in emotions and behavior
that are relatively stable across time.9 Type A behavior
has often been mistaken for a personality type, but type A was in fact
designed to avoid association with broad personality
traits.10 Therefore, multivariate
analyses were used in previous research to delineate the
"distressed" personality (type D).11 Type D patients
simultaneously tend to experience negative emotions and
inhibit the expression of emotion/behavior (Table 1
). Type D personality is
associated with vulnerability to chronic emotional
distress9 and an increased risk for cardiac
events11 12 in CHD patients.
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Several issues need to be solved, however. First, because improvement in treatment and secondary prevention has caused a decline in mortality resulting from CHD,13 it is unclear whether emotional distress has any prognostic value in CHD patients on appropriate treatment. Second, psychological risk factors often tend to converge within individuals. Because such convergence may, in turn, elevate the risk for adverse cardiac events,2 CHD patients who are at risk for the convergence of psychological risk factors should therefore be identified. Third, although quality of life (QOL) is increasingly being acknowledged as an important outcome measure in cardiac patients,14 15 little is known about its long-term determinants.16
We report here on a prospective 5-year follow-up study designed to address these issues. Patients received thrombolysis (29%), ß-blockers (54%), aspirin (72%), revascularization procedures (76%), and rehabilitation (100%), ie, interventions known to improve prognosis.17 A new instrument9 was used for a standardized diagnosis of patients at risk for the convergence of psychological stresses. End points included cardiac events and poor QOL. We hypothesized that both cardiac disorder and emotional distress confer an increased risk of cardiac events and impaired QOL despite appropriate cardiac treatment.
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Methods |
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Subjects
Between January 1989 and December 1992, 322 patients with CHD (297 men, 25 women; age, 35 to 70 years; mean age, 56.7 years) were selected from a consecutive series of patients attending the Antwerp cardiac rehabilitation program. Patients were eligible for this study if they had experienced a myocardial infarction (n=162) or coronary bypass/angioplasty (n=160) within 2 months before entering the program. Patients with impaired left ventricular function were included; patients with major comorbidity (eg, cancer) were excluded. They all underwent a standardized treatment regimen, ie, an outpatient program comprising 36 sessions (3 sessions for 1 h/wk) of ECG-monitored, aerobic, and pulse-targeted exercise training, along with 6 psychosocial group sessions for patients and spouses. Individual medical, nutritional, and psychological counseling tailored the program to the needs of each patient. Medical care in the follow-up interval consisted of a cardiological check-up every 6 months. Three patients died of noncardiac causes during follow-up; the final sample consisted of 319 patients.
Prognostic Factors
Left ventricular function and exercise tolerance
were included as indexes of disease severity. As suggested by
others,1 a decrease in left ventricular
function was defined as a left ventricular ejection
fraction (LVEF) 50% as calculated from ventricular
angiography. Poor exercise tolerance was assessed with a
symptom-limited exercise test 6 weeks after the coronary event
(ie, peak workload 140 W for younger patients and 120 W for older
patients). Other biomedical factors included
thrombolysis after myocardial infarction; treatment
with aspirin, ß-blockers, or ACE inhibitors at
discharge from the rehabilitation program; failure to quit smoking; and
history of hyperlipidemia or hypertension. Demographic
factors included sex and age (ie, 55 versus 
56 years).
Emotional Distress
This study included measures of both episodic distress,
lasting several months, and chronic distress, lasting several
years.4 Symptoms of depression/anxiety are markers of
episodic distress most prominently linked to CHD.2
Patients scoring in the upper tertile on the despondency scale
(r=0.63 with the Zung Depression Scale)18
and/or the state anxiety scale19 were considered to report
many symptoms of depression (19 symptoms) and/or anxiety (44
symptoms), respectively. Chronic emotional distress was assessed with
the Type D Scale 16 (DS16)9 ; its validity and reliability
are summarized in the Appendix. A median split on the DS16
negative affectivity and social inhibition scales was used to classify
99 patients as type D (9 and 15, respectively) and 220 patients as
non–type D.
End Points
The main end points in this study were cardiac events (cardiac
death or nonfatal myocardial infarction) and impaired QOL.
Revascularization (coronary bypass or
angioplasty) during follow-up was a secondary end point. The Health
Complaints Scale (HCS) and the Global Mood Scale (GMS) are
psychometrically sound and sensitive measures of QOL.20
The HCS comprises 12 somatic items (eg, tightness of chest, shortness
of breath, fatigue) and 12 items of perceived disability that are
frequently reported by CHD patients21 ; these items are
rated on a 5-point scale of distress. The GMS comprises 10 negative and
10 positive mood terms that are rated on a 5-point scale of
intensity.22 Depressive affect is characterized by the
interaction of high negative and low positive mood22 ; a
median split on the negative and positive mood scales was used to
assess depressive affect at follow-up.
A multicategorical index23 ranging from event-free survival with good QOL (rating=1) to cardiac death (rating=10) was used to summarize outcome data. Events were rated as 10 (cardiac death), 7 (myocardial infarction), 4 (revascularization), and 1 (event-free survival); poor perceived health was rated as 1 and depressive affect also as 1. For example, revascularization with poor perceived health and depressive affect was rated as 4+1+1=6. The economic impact of outcome was estimated with the use of data on the direct medical care costs of fatal ($17 532) and nonfatal ($15 540) cardiac events,24 coronary bypass ($32 347), and angioplasty ($21 113)14 and mild ($1820) to severe ($2100) depressive symptoms.25
Procedure and Analyses
At entry into the rehabilitation program, all patients
filled out the emotional distress and type D scales. After 5 years,
patients and their families were contacted by telephone and mail to
determine the study end points. Mortality and infarction data were
derived from hospital records and discussed with the patient’s
attending physician. The follow-up questionnaire contained the QOL
scales; if patients failed to return the questionnaire, they were
contacted again 4 and 8 weeks later to maximize outcome data on QOL.
The 
2 statistic was used to examine any
changes in 5-year cardiac mortality between the 1985 to 1988
rehabilitation cohort11 and the 1989 to 1992 cohort of the
present study. Baseline measures were dichotomized, and the OR for
cardiac events for each pair of groups was assessed through logistic
regression analysis and the 2
statistic. MANOVA and an unpaired t test were used to
examine continuous scores of QOL. These scores were dichotomized to
identify patients with impaired QOL, and ORs were calculated. Multiple
logistic regression analyses were used to determine the best
independent predictors of cardiac events and impaired QOL. Criteria for
entry and removal were based on the likelihood ratio test with limits
set at P0.05 and P>0.05. Finally, patients
were stratified by number of prognostic factors to examine the effect
of convergence of risk factors on prognosis and direct medical care
costs.
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Results |
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No patients were lost to follow-up. Patients in the present study had a low rate of 5-year cardiac death (ie, 6/319=2%) compared with patients from the 1985 to 1988 rehabilitation cohort11 (ie, 15/303=5%; P=0.032). This finding is consistent with the notion that the patients in the present study received appropriate treatment.13 After 5 years, 22 patients had experienced a cardiac event; there were 16 nonfatal myocardial infarctions.
Cardiac Events
Cardiac events were significantly associated with LVEF
50%, poor exercise tolerance, symptoms of depression, type D
personality, and age 55 years (Table 2). No drug treatment variables were
related to outcome, suggesting an accurate pharmacological approach to
the individual medical situation of patients in this study. Type D
patients had a greater risk for both death and nonfatal myocardial
infarction compared with non–type D patients—ie, 5/75=6% versus
1/200=0.5% cardiac deaths (P=0.006) and 11/81=13% versus
5/205=2% nonfatal infarctions (P=0.007), respectively.
Including revascularization as an end point in
secondary analyses also yielded significant associations with
LVEF 50%, symptoms of depression, type D personality, and age 55
years. Poor exercise tolerance did no longer reach statistical
significance, whereas symptoms of anxiety were significant
(P=0.036).
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To determine whether disease severity and emotional distress were
independent predictors of adverse cardiac events, we entered these
factors in a stepwise logistic regression model. This model included
LVEF 50% (OR, 3.9), type D personality (OR, 8.9), and age 55 years
(OR, 2.6) but not poor exercise tolerance or symptoms of
depression/anxiety (Table 3).
Accordingly, secondary analyses indicated that LVEF 50% and
type D personality were retained as independent predictors of total
events, including revascularization procedures.
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Quality of Life
Of the 313 surviving patients, 299 (95%) completed and returned
the follow-up questionnaire, 11 (4%) failed to return the
questionnaire, and 3 (1%) provided incomplete data. Nonresponders did
not differ significantly from responders on any of the baseline
measures. With continuous scores of somatic complaints, perceived
disability, and negative and positive mood as an outcome measure,
MANOVA indicated that poor QOL after 5 years of follow-up was
associated with female sex (P=0.004), age 55 years at
baseline (P=0.05), poor exercise tolerance at baseline
(P=0.003), failure to quit smoking (P=0.02),
symptoms of depression (P=0.0001) and anxiety
(P=0.0001) at baseline, type D personality
(P=0.0001), and nonfatal myocardial infarction
(P=0.003) or revascularization
(P=0.0001) during follow-up.
Using median splits at follow-up, 104 patients were classified as
reporting poor perceived health (ie, HCS somatic complaints >6 and HCS
feelings of disability >8) and 82 patients as reporting depressive
affect (ie, GMS negative mood >6 and GMS positive mood <24). A
stepwise logistic regression model yielded failure to quit smoking (OR,
2.3 and 2.6), symptoms of depression (OR, 3.3 and 2.7), and type D
personality (OR, 2.2 and 2.6) as independent prognostic factors for
both poor perceived health and depressive affect (Table 4). Poor health was also predicted by
LVEF 50% and hyperlipidemia, and depressive affect
was predicted by female sex and symptoms of anxiety. Accordingly,
psychosocial factors had a prognostic power above and beyond that of
standard biomedical factors in the prediction of poor QOL.
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On a Scale From 1 to 10
Next, all patients were rated in terms of their outcome ranging
from event-free survival with good QOL (rating=1) to cardiac death
(rating=10). Most patients were rated 1 or 2; 10% of patients were
rated 6 (Table 5). There were 4
independent prognostic factors for poor outcome (categories 6 through
10) as opposed to good outcome (categories 1 to 2); ie, LVEF 50%
(OR, 4.7; 95% CI, 1.8 to 12.4; P=0.002), type D personality
(OR, 8.3; 95% CI, 3.4 to 20.4; P=0.0001), age 55 years
(OR, 2.6; 95% CI, 1.1 to 6.1; P=0.024), and symptoms of
depression at baseline (OR, 2.4; 95% CI, 1.0 to 5.6;
P=0.042). Hence, cardiac disorder, emotional distress, and
younger age provided additional prognostic information.
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Convergence of Risk Factors
To examine the effect of convergence of risk factors,
patients were stratified according to LVEF 50%, type D personality,
and age 55 years. Only 3 of 107 patients without any of these
prognostic factors had a poor outcome; in contrast, prognostic factors
occurring in combination significantly magnified the risk for poor
outcome (the Figure, top). Of 10 patients
combining 3 risk factors (LVEF50% plus type D plus 55 years), 5
had a poor outcome. Convergence of risk factors was paralleled by
an increase in estimated medical costs (the Figure, bottom).
Overall, patients with 2 or 3 prognostic factors had 4 times the risk
for poor outcome compared with patients with either 0 or 1 prognostic
factor; ie, the rate for poor outcome was 18/64=28% versus 15/255=6%
(P<0.0001). Accordingly, mean estimated medical costs were
$10 400 and $3600 for both groups, respectively
(P<0.0001).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Cardiac disorder (decreased LVEF), emotional distress (type D personality), and premature onset of CHD (younger age at index event) were independent predictors of poor prognosis. Convergence of these distinctly different factors heightened the risk for poor outcome; when 2 or 3 factors occurred together, the rate of adverse health outcome was 4-fold higher. Estimates of direct medical costs increased progressively with increasing number of factors. Examination of the QOL end points revealed that behavioral/psychological indexes (smoking, depressive symptomatology, type D personality) outweighed biomedical indexes in the long-term prediction of physical and emotional well-being. Overall, these findings provide clinical evidence that CHD patients constitute a heterogeneous group and that failure to account for emotional distress and age at disease onset may lead to inaccurate risk estimates.
In line with epidemiological data in the United States,13 we observed a significant decrease in 5-year cardiac mortality. Aspirin and ß-blockers improve survival in CHD patients17 ; in the present study, 72% and 54% of patients were treated with these drugs, respectively. Cardiac rehabilitation also improves survival17 and decreases the incidence of ventricular arrhythmias26 and cardiac death27 in patients with left ventricular dysfunction. However, despite appropriate medical treatment and a low mortality rate, younger age and emotional distress still emerged as independent predictors of cardiac events.
In the present sample of middle-aged and predominantly male
subjects, patients 55 years of age had a greater risk of cardiac
events than patients 56 years of age. This finding may indicate that
younger men with CHD represent a distinct group in terms of
risk factors and prognosis. Consistent with previous
findings,2 episodic distress (symptoms of depression and
anxiety) was associated with an increased risk for cardiac events. This
risk, however, was accounted for by individual differences in chronic
emotional distress (ie, type D personality). Hence, the present
study confirms and expands previous findings11 12 by
showing that type D personality was still a predictor of cardiac events
despite appropriate treatment. The adverse effect of type D personality
may, in fact, extend beyond cardiac events to include impaired QOL.
Little is known about the long-term determinants of QOL in cardiac patients. The present findings suggest that QOL is a complex phenomenon explained by multiple factors. Failure to quit smoking emerged as a major predictor of poor QOL. In addition, symptoms of depression and type D personality were independent predictors of QOL. The fact that baseline levels of depressive symptomatology predicted depressive affect 5 years later supports the notion that the relation between depressive symptoms and CHD implies an element of chronicity.28 Poor perceived health was also predicted by a decreased LVEF, and depressive affect was predicted by female sex and anxiety. Hence, apart from disease severity, research needs to focus on smoking, chronic negative emotions, and personality as determinants of poor QOL in CHD.
Using a composite end point, we found that 10% of patients experienced a deterioration in health status within the first 5 years of the index event. Biomedical and psychosocial factors predicted this absence of the expected therapeutic response to medical/surgical intervention and rehabilitation. Although the generalizability of these findings is limited by the small number of women29 and the exclusion of elderly patients,30 they do suggest that we need to identify ways to optimize treatment for certain subgroups of high-risk patients. Conversely, non–type D patients who were >55 years of age and had an LVEF >50% had an excellent prognosis, suggesting that the present treatment regimen did meet the needs of this subgroup.
These findings have implications for clinical research and practice. First, outcome research in CHD has focused largely on the role of disease severity1 and sex- and age-based differences29 30 ; it is time now to also account for psychological factors.2 Second, the identification of CHD patients who experience emotional distress may lead to more accurate risk estimates in clinical practice. The DS169 is a brief, sound measure that allows rapid screening of chronic emotional distress among patients with CHD. Third, emotional distress as a risk factor is subject to clinical modification.31 Patient-specific interventions2 targeting specific risk factors may include stress management.32
In conclusion, we found that 10% of patients with CHD did not display the expected therapeutic response to cardiac treatment and secondary prevention. A decreased LVEF, chronic emotional distress, and younger age at disease onset accounted for their susceptibility to cardiac events and impaired QOL 5 years after the index event. When 2 or 3 risk factors occurred together, the rate of adverse health outcomes was 4-fold higher. The longer survival of patients with CHD will lead to a growing group of patients at risk of subsequent cardiac events and chronic conditions.15 In addition to cardiac disorder, patients’ ages and levels of emotional distress must be considered to optimize this risk stratification.
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Received November 18, 1999; revision received February 11, 2000; accepted March 2, 2000.
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References |
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1. Emond M, Mock MB, Davis KB, et al, for the Participants in the Coronary Artery Surgery Study (CASS). Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) registry. Circulation. 1994;90:2645–2657.
2.
Rozanski A, Blumenthal JA, Kaplan J. Impact of
psychological factors on the pathogenesis of
cardiovascular disease and implications for therapy.
Circulation. 1999;99:2192–2217.
3.
Mittleman MA, Maclure M, Sherwood JB, et al.
Triggering of acute myocardial infarction onset by episodes of anger.
Circulation. 1995;92:1720–1725.
4.
Kop WJ. Chronic and acute psychological
risk factors for clinical manifestations of coronary artery
disease. Psychosom Med. 1999;61:476–487.
5. Yeung AC, Vekshtein VI, Krantz DS, et al. The effect of atherosclerosis on the vasomotor response of coronary arteries to mental stress. N Engl J Med. 1991;325:1551–1556.[Abstract]
6. Grignani G, Soffiantino F, Zucchella M, et al. Platelet activation by emotional stress in patients with coronary artery disease. Circulation. 1991;83(suppl II):II-128–II-136.
7. Carney RM, Saunders RD, Freedland KE, et al. Association of depression with reduced heart rate variability in coronary artery disease. Am J Cardiol. 1995;76:562–564.[Medline] [Order article via Infotrieve]
8.
Blumenthal JA, Jiang W, Waugh RA, et al. Mental
stress-induced ischemia in the laboratory and ambulatory
ischemia during daily life: association and
hemodynamic features. Circulation. 1995;92:2102–2108.
9. Denollet J. Personality and coronary heart disease: the Type D Scale-16 (DS16). Ann Behav Med. 1998;20:209–215.[Medline] [Order article via Infotrieve]
10. Dimsdale JE. A perspective on type A behavior and coronary disease. N Engl J Med. 1988;318:110–112.[Medline] [Order article via Infotrieve]
11. Denollet J, Sys SU, Stroobant N, et al. Personality as independent predictor of long-term mortality in patients with coronary heart disease. Lancet. 1996;347:417–421.[Medline] [Order article via Infotrieve]
12.
Denollet J, Brutsaert DL. Personality, disease
severity, and the risk of long-term cardiac events in patients with a
decreased ejection fraction after myocardial infarction.
Circulation. 1998;97:167–173.
13.
Rosamond WD, Chambless LE, Folsom AR, et al.
Trends in the incidence of myocardial infarction and in mortality due
to coronary heart disease, 1987 to 1994. N Engl
J Med. 1998;339:861–867.
14.
Hlatky MA, Rogers WJ, Johnstone I, et al. Medical
care costs and quality of life after randomization to coronary
angioplasty or coronary bypass surgery. N Engl
J Med. 1997;336:92–99.
15.
Cohn JA, Goldstein SO, Greenberg BH, et al,
for the Vesnarinone Trial Investigators. A dose-dependent increase in
mortality with vesnarinone among patients with severe heart failure.
N Engl J Med. 1998;339:1810–1816.
16.
Pignalberi C, Patti G, Chimenti C, et al. Role of
different determinants of psychological distress in acute
coronary syndromes. J Am Coll Cardiol. 1998;32:613–619.
17. Lau J, Antman EM, Jimenez-Silva J, et al. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med. 1992;327:248–254.[Abstract]
18. Erdman RA, Duivenvoorden HJ, Verhage F, et al. Predictability of beneficial effects in cardiac rehabilitation: a randomized clinical trial of psychosocial variables. J Cardiopulm Rehabil. 1986;6:206–213.
19. Van Der Ploeg HM, Defares PB, Spielberger CD. ZBV: A Dutch-language adaptation of the Spielberger State-Trait Anxiety Inventory. Lisse, Netherlands: Swets & Zeitlinger; 1980.
20. McGee HM, Hevey D, Horgan JH. Psychosocial outcome assessment for use in cardiac rehabilitation service evaluation: a 10-year systematic review. Soc Sci Med. 1999;48:1373–1393.
21.
Denollet J. Health complaints and outcome
assessment in coronary heart disease. Psychosom Med. 1994;56:463–474.
22. Denollet J. Emotional distress and fatigue in coronary heart disease: the Global Mood Scale (GMS). Psychol Med. 1993;23:111–121.[Medline] [Order article via Infotrieve]
23.
Ormel J, Oldehinkel T, Brilman E, et al. Outcome
of depression and anxiety in primary care: a three-wave
31/2-year study of psychopathology and disability. Arch
Gen Psychiatry. 1993;50:759–766.
24. Russell MW, Huse DM, Drowns S, et al. Direct medical costs of coronary artery disease in the United States. Am J Cardiol. 1998;81:1110–1115.[Medline] [Order article via Infotrieve]
25.
Unützer J, Patrick DL, Simon G, et al.
Depressive symptoms and the cost of health services in HMO patients
aged 65 years and older: a 4-year prospective study. JAMA. 1997;277:1618–1623.
26. Hertzeanu HL, Shemesh J, Aron LA, et al. Ventricular arrhythmias in rehabilitated and nonrehabilitated post-myocardial infarction patients with left ventricular dysfunction. Am J Cardiol. 1993;71:24–27.[Medline] [Order article via Infotrieve]
27.
Specchia G, De Servi S, Scirè A, et al.
Interaction between exercise training and ejection fraction in
predicting prognosis after a first myocardial infarction.
Circulation. 1996;94:978–982.
28.
Barefoot JC, Schroll M. Symptoms of depression,
acute myocardial infarction, and total mortality in a community sample.
Circulation. 1996;93:1976–1980.
29.
Vaccarino V, Parsons L, Every NR, et al, for the
National Registry of Myocardial Infarction 2 Participants. Sex-based
differences in early mortality after myocardial infarction.
N Engl J Med. 1999;341:217–225.
30. Ahnve S, Gilpin E, Dittrich H, et al. First myocardial infarction: age and ejection fraction identify a low-risk group. Am Heart J. 1988;116:925–932.[Medline] [Order article via Infotrieve]
31.
Linden W, Stossel C, Maurice J. Psychosocial
interventions for patients with coronary artery disease: a
meta-analysis. Arch Intern Med. 1996;156:745–752.
32.
Blumenthal JA, Jiang W, Babyak M, et al. Stress
management and exercise training in cardiac patients with myocardial
ischemia: effects on prognosis and evaluation of mechanisms.
Arch Intern Med. 1997;157:2213–2223.
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N. Kupper, J. Denollet, E. J. C. de Geus, D. I. Boomsma, and G. Willemsen Heritability of Type-D Personality Psychosom Med, September 1, 2007; 69(7): 675 - 681. [Abstract] [Full Text] [PDF]
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 S. S Pedersen, D. A. Theuns, A. Muskens-Heemskerk, R. A. Erdman, and L. Jordaens Type-D personality but not implantable cardioverter-defibrillator indication is associated with impaired health-related quality of life 3 months post-implantation Europace, August 1, 2007; 9(8): 675 - 680. [Abstract] [Full Text] [PDF]
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A. E. Aquarius, J. Denollet, J. F. Hamming, D. P. Van Berge Henegouwen, and J. De Vries Type-D Personality and Ankle Brachial Index as Predictors of Impaired Quality of Life and Depressive Symptoms in Peripheral Arterial Disease Arch Surg, July 1, 2007; 142(7): 662 - 667. [Abstract] [Full Text] [PDF]
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 A. A Schiffer, J. Denollet, J. W Widdershoven, E. H Hendriks, and O. R F Smith Failure to consult for symptoms of heart failure in patients with a type-D personality Heart, July 1, 2007; 93(7): 814 - 818. [Abstract] [Full Text] [PDF]
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W. A. Shibeshi, Y. Young-Xu, and C. M. Blatt Anxiety Worsens Prognosis in Patients With Coronary Artery Disease J. Am. Coll. Cardiol., May 22, 2007; 49(20): 2021 - 2027. [Abstract] [Full Text] [PDF]
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P. de Jonge, R. H.S. van den Brink, T. A. Spijkerman, and J. Ormel Only Incident Depressive Episodes After Myocardial Infarction Are Associated With New Cardiovascular Events J. Am. Coll. Cardiol., November 8, 2006; (2006) j.jacc.2006.06.077v1. [Abstract] [Full Text] [PDF]
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 J. Denollet, S. S. Pedersen, A. T.L. Ong, R. A.M. Erdman, P. W. Serruys, and R. T. van Domburg Social inhibition modulates the effect of negative emotions on cardiac prognosis following percutaneous coronary intervention in the drug-eluting stent era Eur. Heart J., January 2, 2006; 27(2): 171 - 177. [Abstract] [Full Text] [PDF]
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S Al-Ruzzeh, T Athanasiou, O Mangoush, J Wray, T Modine, S George, and M Amrani Predictors of poor mid-term health related quality of life after primary isolated coronary artery bypass grafting surgery Heart, December 1, 2005; 91(12): 1557 - 1562. [Abstract] [Full Text] [PDF]
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H. Spindler and S. S. Pedersen Posttraumatic Stress Disorder in the Wake of Heart Disease: Prevalence, Risk Factors, and Future Research Directions Psychosom Med, September 1, 2005; 67(5): 715 - 723. [Abstract] [Full Text] [PDF]
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G. J.M. Verkerk, J. Denollet, G. L. Van Heck, M. J.M. Van Son, and V. J.M. Pop Personality Factors as Determinants of Depression in Postpartum Women: A Prospective 1-Year Follow-up Study Psychosom Med, July 1, 2005; 67(4): 632 - 637. [Abstract] [Full Text] [PDF]
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 L. Sher Type D personality: the heart, stress, and cortisol QJM, May 1, 2005; 98(5): 323 - 329. [Abstract] [Full Text] [PDF]
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J. Denollet DS14: Standard Assessment of Negative Affectivity, Social Inhibition, and Type D Personality Psychosom Med, January 1, 2005; 67(1): 89 - 97. [Abstract] [Full Text] [PDF]
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J. Barth, M. Schumacher, and C. Herrmann-Lingen Depression as a Risk Factor for Mortality in Patients With Coronary Heart Disease: A Meta-analysis Psychosom Med, November 1, 2004; 66(6): 802 - 813. [Abstract] [Full Text] [PDF]
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S. S. Pedersen, P. A. Lemos, P. R. van Vooren, T. K.K. Liu, J. Daemen, R. A.M. Erdman, P. C. Smits, P. W.J.C. Serruys, and R. T. van Domburg Type D personality predicts death or myocardial infarction after bare metal stent or sirolimus-eluting stent implantation: A rapamycin-eluting stent evaluated at rotterdam cardiology hospital (RESEARCH) registry substudy J. Am. Coll. Cardiol., September 1, 2004; 44(5): 997 - 1001. [Abstract] [Full Text] [PDF]
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S. S. Pedersen, R. T. van Domburg, D. A. M. J. Theuns, L. Jordaens, and R. A. M. Erdman Type D Personality Is Associated With Increased Anxiety and Depressive Symptoms in Patients With an Implantable Cardioverter Defibrillator and Their Partners Psychosom Med, September 1, 2004; 66(5): 714 - 719. [Abstract] [Full Text] [PDF]
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A. Schins, A. Honig, H. Crijns, L. Baur, and K. Hamulyak Increased Coronary Events in Depressed Cardiovascular Patients: 5-HT2A Receptor as Missing Link? Psychosom Med, September 1, 2003; 65(5): 729 - 737. [Abstract] [Full Text] [PDF]
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A. M. Schwarz, H. Schachinger, R. H. Adler, and S. M. Goetz Hopelessness Is Associated With Decreased Heart Rate Variability During Championship Chess Games Psychosom Med, July 1, 2003; 65(4): 658 - 661. [Abstract] [Full Text] [PDF]
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P. A. Lemos, C.-h. Lee, M. Degertekin, F. Saia, K. Tanabe, C. A. Arampatzis, A. Hoye, M. van Duuren, G. Sianos, P. C. Smits, et al. Early outcome after sirolimus-eluting stent implantation in patients with acute coronary syndromes: Insights from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry J. Am. Coll. Cardiol., June 4, 2003; 41(11): 2093 - 2099. [Abstract] [Full Text] [PDF]
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N. Frasure-Smith and F. Lesperance Depression and Other Psychological Risks Following Myocardial Infarction Arch Gen Psychiatry, June 1, 2003; 60(6): 627 - 636. [Abstract] [Full Text] [PDF]
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M. D. Sullivan, A. Z. LaCroix, J. A. Spertus, J. Hecht, and J. Russo Depression Predicts Revascularization Procedures for 5 Years After Coronary Angiography Psychosom Med, March 1, 2003; 65(2): 229 - 236. [Abstract] [Full Text] [PDF]
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 J. Denollet and D. L. Brutsaert Reducing Emotional Distress Improves Prognosis in Coronary Heart Disease: 9-Year Mortality in a Clinical Trial of Rehabilitation Circulation, October 23, 2001; 104(17): 2018 - 2023. [Abstract] [Full Text] [PDF]
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