Unmet supportive care needs, anxiety and depression in haematology patients during watch-and-wait.

OBJECTIVE: There is growing evidence and awareness of the psychological impact of watch-and-wait in patients with indolent haematological malignancy. However, the need for supportive care is unknown. The aims of this study were to investigate prevalence of unmet needs, their psychological associates, and prevalence of anxiety and depressive symptomatology. METHODS: Adult patients with indolent haematological malignancy, during watch-and-wait (n = 122) were included in this cross-sectional single-centre study. Participants filled out questionnaires on anxiety (Generalised Anxiety Disorder), depression (Patient Health Questionnaire), coping (Acceptance and Action Questionnaire II), distress (distress thermometer), disease-specific quality of life (The European Organisation for Research and Treatment of Cancer quality of life questionnaire) and supportive care needs (Supportive care needs survey - Dutch short version). Multiple linear regression analyses were performed to identify patient-factors associated with unmet needs. RESULTS: The prevalence of anxiety and depressive symptomatology were both 7.3%. Unmet needs were reported by 35% (n = 43) of patients. After controlling for covariates, higher levels of distress (ß = 0.23, p = 0.05), depression (ß = 0.41, p = 0.001), poorer coping (ß = 0.35, p = 0.002) and younger age (ß = -0.16, p = 0.05) were independently associated with more supportive care needs. The highest unmet needs were reported in domain health system, information & patient support (mean = 23.6 ± 23.0) and psychological domain (mean = 18.7 ± 21.8). CONCLUSIONS: One third of indolent haematology patients during watch-and-wait report unmet supportive care needs. Screening for unmet needs and design of interventions is required. A joint approach focused on psychological care, especially on improving psychological flexibility, should be combined with promoting accessibility to health-services and optimising disease education.

Positive affect, anhedonia, and compliance with self-care in patients with chronic heart failure.

OBJECTIVE: Optimal self-care is crucial in patients with chronic heart failure (HF). While the focus of research has been on negative mood states, adequate psychological resources may be required to successfully engage in HF self-care. Therefore, the longitudinal associations of multiple positive affect measures in explaining HF self-care including consulting behavior were examined while adjusting for depressive symptoms and potential covariates (e.g., disease severity). METHODS: In this prospective cohort study, 238 patients (mean age: 66.9 ± 8.6 years, 78% men), with chronic HF completed questionnaires at baseline and 1-year follow-up. Positive affect was assessed with the Positive and Negative Affect Schedule (PANAS) and the Global Mood Scale (GMS). Anhedonia, i.e. diminished interest or pleasure, was assessed with a subscale of the Hospital Anxiety and Depression Scale (HADS). The 9-item European Heart Failure Self-care Behaviour scale was completed to assess HF self-care including consultation behavior. RESULTS: Linear mixed modeling results showed that anhedonia was most strongly associated with both poor self-care (estimate=-.72, P<.001) and consulting behavior (estimate=-.44, P<.001) over time, after adjustment for covariates and depressive symptoms. GMS positive affect was related to better HF self-care adjusting for standard depressive symptoms but not when adjusting for anhedonia. PANAS positive affect was not independently related to self-care. CONCLUSION: Anhedonia was associated with worse compliance with self-care among chronic HF patients over time, irrespective of disease severity and depression. Associations between positive affect and self-care were dependent on the measures used in multivariable analyses.

Azithromycin maintenance treatment in patients with frequent exacerbations of chronic obstructive pulmonary disease (COLUMBUS): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Macrolide resistance is an increasing problem; there is therefore debate about when to implement maintenance treatment with macrolides in patients with chronic obstructive pulmonary disease (COPD). We aimed to investigate whether patients with COPD who had received treatment for three or more exacerbations in the previous year would have a decrease in exacerbation rate when maintenance treatment with azithromycin was added to standard care. METHODS: We did a randomised, double-blind, placebo-controlled, single-centre trial in The Netherlands between May 19, 2010, and June 18, 2013. Patients (≥18 years) with a diagnosis of COPD who had received treatment for three or more exacerbations in the previous year were randomly assigned, via a computer-generated randomisation sequence with permuted block sizes of ten, to receive 500 mg azithromycin or placebo three times a week for 12 months. Randomisation was stratified by use of long-term, low-dose prednisolone (≤10 mg daily). Patients and investigators were masked to group allocation. The primary endpoint was rate of exacerbations of COPD in the year of treatment. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00985244. FINDINGS: We randomly assigned 92 patients to the azithromycin group (n=47) or the placebo group (n=45), of whom 41 (87%) versus 36 (80%) completed the study. We recorded 84 exacerbations in patients in the azithromycin group compared with 129 in those in the placebo group. The unadjusted exacerbation rate per patient per year was 1·94 (95% CI 1·50-2·52) for the azithromycin group and 3·22 (2·62-3·97) for the placebo group. After adjustment, azithromycin resulted in a significant reduction in the exacerbation rate versus placebo (0·58, 95% CI 0·42-0·79; p=0·001). Three (6%) patients in the azithromycin group reported serious adverse events compared with five (11%) in the placebo group. During follow-up, the most common adverse event was diarrhoea in the azithromycin group (nine [19%] patients vs one [2%] in the placebo group; p=0·015). INTERPRETATION: Maintenance treatment with azithromycin significantly decreased the exacerbation rate compared with placebo and should therefore be considered for use in patients with COPD who have the frequent exacerbator phenotype and are refractory to standard care. FUNDING: SoLong Trust.

Depressive symptoms in outpatients with heart failure: importance of inflammatory biomarkers, disease severity and personality.

OBJECTIVE: Depressive symptoms are highly prevalent in heart failure (HF) patients, however the underlying etiology of depression in HF patients remains yet unclear. Hence, the goal is to examine the relative importance of inflammation, disease severity and personality as predictors of depression in HF patients. DESIGN: Depressive symptoms (Hospital Anxiety and Depression Scale, depression subscale) were assessed at baseline and one-year follow-up in 268 HF patients (75.6% men; mean age = 66.7 ± 8.7). Markers of inflammation (TNFα, sTNFr1, sTNFr2, IL-6 and IL-10), disease severity (e.g. New York Heart Association (NYHA) classification) and personality (Type D personality, loneliness) were assessed at baseline. RESULTS: At baseline, NYHA class, body mass index, educational level, Type D personality and loneliness were significantly associated with depression. Higher NYHA class (B = 2.25; SE = .83), higher educational level (B = 1.41; SE = .48), Type D personality (B = 2.56; SE = .60) and loneliness (B = .19; SE = .05) were also independently associated with higher depression levels at one-year follow-up (all p-values < .005). Inflammation, brain natriuretic peptide and left ventricular ejection fraction were not related to depression over time. CONCLUSIONS: Personality factors, but not inflammation, were independent concomitants of depressive symptoms in patients with HF. Gaining more insight into the etiology of depression in HF patients is important in order to identify potential targets for novel interventions.

The relationship between Type D personality, affective symptoms and hemoglobin levels in chronic heart failure.

BACKGROUND: Anemia is associated with poor prognosis in heart failure (HF) patients. Contributors to the risk of anemia in HF include hemodilution, renal dysfunction and inflammation. Hemoglobin levels may also be negatively affected by alterations in stress regulatory systems. Therefore, psychological distress characterized by such alterations may adversely affect hemoglobin in HF. The association between hemoglobin and Type D personality and affective symptomatology in the context of HF is poorly understood. AIM: To examine the relationship between Type D personality and affective symptomatology with hemoglobin levels at inclusion and 12-month follow-up, controlling for relevant clinical factors. METHODS: Plasma levels of hemoglobin and creatinine were assessed in 264 HF patients at inclusion and at 12-month follow-up. Type D personality and affective symptomatology were assessed at inclusion. RESULTS: At inclusion, hemoglobin levels were similar for Type D and non-Type D HF patients (p = .23), and were moderately associated with affective symptomatology (r = -.14, p = .02). Multivariable regression showed that Type D personality (ß = -.15; p = .02), was independently associated with future hemoglobin levels, while controlling for renal dysfunction, gender, NYHA class, time since diagnosis, BMI, the use of angiotensin-related medication, and levels of affective symptomatology. Change in renal function was associated with Type D personality (ß = .20) and hemoglobin at 12 months (ß = -.25). Sobel mediation analysis showed significant partial mediation of the Type D - hemoglobin association by renal function deterioration (p = .01). Anemia prevalence increased over time, especially in Type D patients. Female gender, poorer baseline renal function, deterioration of renal function and a longer HF history predicted the observed increase in anemia prevalence over time, while higher baseline hemoglobin was protective. CONCLUSION: Type D personality, but not affective symptomatology, was associated with reduced future hemoglobin levels, independent of clinical factors. The relation between Type D personality and future hemoglobin levels was mediated by renal function deterioration.

What is the use? Application of the short form (SF) questionnaires for the evaluation of treatment effects.

BACKGROUND: Health status has evolved as a clinical outcome measure that is of great interest in medical care. However, there is still debate about the appropriateness of scoring algorithms for the often used short form questionnaires. Therefore, our aim was to evaluate the consequences of the traditional scoring procedure based on orthogonal factor rotation for clinical applications by (a) re-evaluating the results of randomized controlled trials (RCTs) on the effectiveness of antidepressants in improving health status in cardiac patients and (b) comparing empirical evidence on depression and health status using orthogonal and oblique factor rotation (alternative scoring method) in a community sample and a heart failure (HF) sample. METHODS: This is a systematic literature review and cross-sectional analysis among 1,598 community sample participants and 282 HF patients. RESULTS: Orthogonal rotation artificially forces the mental component summary (MCS) and physical component summary (PCS) to be unrelated, which is illustrated in two of the three included RCTs. Two RCTs showed improvements in MCS, but no improvement in PCS over time. Cross-sectional analysis in the two datasets showed that employing the alternative scoring algorithm resulted in higher negative correlations of MCS and PCS with depression, and a gradual decline in MCS with each decile of decline in PCS. CONCLUSION: Our data showed that appropriate carefulness is needed when calculating and interpreting summary scores. The traditional scoring algorithm seems inappropriate to objectively evaluate the effects of interventions on both the MCS and the PCS. Awareness in the design and evaluation of interventions using these outcomes is warranted.

Poor health status and distress in cardiac patients: the role of device therapy vs. underlying heart disease.

AIMS: Implantable cardioverter defibrillator (ICD) therapy, which includes the risk of shocks, is considered the primary culprit of reductions in patient reported outcomes (PROs; e.g. health status and distress), thereby negating the role of underlying disease severity. We examined the relative influence of living with an ICD vs. congestive heart failure (CHF) on PROs and compared (i) ICD patients without CHF (ICD only), (ii) CHF patients without an ICD (CHF-only), and (iii) CHF patients with an ICD (ICD + CHF). METHODS AND RESULTS: Separate cohorts of ICD and CHF patients (N = 435; 75% men) completed PROs at baseline, 6 and 12 months. Groups differed on physical health status only at baseline (F((2,415)) = 7.15, P = 0.001) and on anxiety at 12 months (F((2,415)) = 4.04, P = 0.01); ICD + CHF patients had the most impaired physical health status but the lowest anxiety level followed by the ICD only and CHF only patients. Congestive heart failure only patients had the most impaired mental health status and reported the highest level of anxiety as compared to the ICD only (P < 0.001) and ICD + CHF groups (P = 0.009), while the two latter groups did not differ. The effect sizes ranged from very small (0.03) to moderate-large (0.69). Groups did not differ in depression scores. CONCLUSION: Congestive heart failure patients reported worse PROs as compared to ICD patients, although the magnitude of the differences was relatively small. This suggests that the well being of patients is not necessarily negatively influenced by the implantation of an ICD, and that underlying heart disease may have at least an equal if not greater influence on PROs.

Reduced positive affect (anhedonia) is independently associated with 7-year mortality in patients treated with percutaneous coronary intervention: results from the RESEARCH registry.

AIMS: Negative mood states (e.g., anxiety and depression) have been associated with increased cardiovascular morbidity and mortality in coronary artery disease (CAD), but little is known about the impact of positive emotions on these health outcomes. We examined whether anhedonia (i.e., reduced positive affect) was associated with 7-year mortality in patients treated with percutaneous coronary intervention (PCI). METHODS: Consecutive PCI patients (n = 1206; 71.5% men; mean age 62.0 ± 11.1 years) from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed the Hospital Anxiety and Depression Scale (HADS) to assess anhedonia at baseline. Anhedonia was defined as a score ≤ 7 (i.e., one SD below the mean) on the positive affect scale of the HADS. The endpoint was defined as all-cause mortality. RESULTS: The prevalence of anhedonia was 23.7% (286/1206). After a median follow up of 7.0 ± 1.6 years, 186 deaths (15.4%) from any cause were recorded. The incidence of mortality in anhedonic patients was 22.7% (65/286) vs. 13.2% (121/920) in non-anhedonic patients (HR = 1.66, 95% CI [1.19-2.32], p = 0.003). Cumulative hazard functions were significantly different for anhedonic vs. non-anhedonic patients (log-rank χ(2) = 16.61, p < 0.001). In multivariable analysis, anhedonia remained independently associated with all-cause mortality (HR = 1.51, 95% CI [1.03-2.22], p = 0.036), after adjusting for socio-demographics, clinical characteristics, and negative and relaxed affect. CONCLUSION: Anhedonia was independently associated with a 1.5-fold increased risk for all-cause mortality in patients who survived the first 6 months post-PCI. Enhancing positive emotions, in addition to reducing negative emotions, may constitute an important target for future psychological intervention trials in CAD patients.

Positive affect dimensions and their association with inflammatory biomarkers in patients with chronic heart failure.

BACKGROUND: In cardiac patients positive affect has found to be associated with improved clinical outcomes, with reduced inflammation being one of the potential mechanisms responsible. METHODS: Positive affect was assessed using The Global Mood Scale (GMS), Positive and Negative Affect Schedule (PANAS), and Hospital Anxiety and Depression Scale (HADS) in patient with chronic heart failure (N=210; 67 ± 9 years, 79% men). Markers of inflammation (TNFα, sTNFr1, sTNFr2, IL-6 and CRP) were measured and averaged at three consecutive time points. RESULTS: The positive affect dimensions of the GMS and PANAS were significantly associated with lower averaged levels of sTNFr2, TNFα and IL-6 (p<.1), even after adjustment for clinical and lifestyle confounders. Positive affect of the HADS was significantly associated with lower averaged levels of hsCRP (p<.1), but was no longer significant after correction for lifestyle confounders and depressive symptoms. CONCLUSION: Positive affect is associated with reduced inflammation in patients with heart failure.

Influence of macrolide maintenance therapy and bacterial colonisation on exacerbation frequency and progression of COPD (COLUMBUS): study protocol for a randomised controlled trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterised by progressive development of airflow limitation that is poorly reversible. Because of a poor understanding of COPD pathogenesis, treatment is mostly symptomatic and new therapeutic strategies are limited. There is a direct relationship between the severity of the disease and the intensity of the inflammatory response. Besides smoking, one of the hypotheses for the persistent airway inflammation is the presence of recurrent infections. Macrolide antibiotics have bacteriostatic as well as anti-inflammatory properties in patients with cystic fibrosis and other inflammatory pulmonary diseases. There is consistent evidence that macrolide therapy reduces infectious exacerbations, decreases the requirement for additional antibiotics and improves nutritional measures. Because of these positive effects we hypothesised that maintenance macrolide therapy may also have beneficial effects in patients with COPD who have recurrent exacerbations. The effects on development of bacterial resistance to macrolides due to this long-term treatment are unknown. Until now, studies investigating macrolide therapy in COPD are limited. The objective of this study is to assess whether maintenance treatment with macrolide antibiotics in COPD patients with three or more exacerbations in the previous year decreases the exacerbation rate in the year of treatment and to establish microbial resistance due to the long-term treatment. METHODS/DESIGN: The study is set up as a prospective randomised double-blind placebo-controlled single-centre trial. A total of 92 patients with COPD who have had at least three exacerbations of COPD in the previous year will be included. Subjects will be randomised to receive either azithromycin 500 mg three times a week or placebo. Our primary endpoint is the reduction in the number of exacerbations of COPD in the year of treatment. DISCUSSION: We investigate whether long-term therapy with macrolide antibiotics can prevent exacerbations in patients with COPD. Additionally, our study aims to assess the effect of long-term use of macrolide on the development of antimicrobial resistance and on inflammatory parameters related to COPD. We believe this study will provide more data on the effects of macrolide treatment in patients in COPD and will add more knowledge on its working mechanisms. TRIAL REGISTRATION: http://www.clinicaltrials.gov NCT00985244.

Symptoms of anxiety and cardiac hospitalizations at 12 months in patients with heart failure.

OBJECTIVE: Heart failure (HF) is a leading cause of hospitalization. Clinical and socio-demographic factors have been associated with cardiac admissions, but little is known about the role of anxiety. We examined whether symptoms of anxiety were associated with cardiac hospitalizations at 12 months in HF patients. METHODS: HF outpatients (N = 237) completed the Hospital Anxiety and Depression Scale (HADS) at baseline (i.e., inclusion into the study). A cutoff ≥8 was used to indicate probable clinical levels of anxiety and depression. At 12 months, a medical chart abstraction was performed to obtain information on cardiac hospitalizations. RESULTS: The prevalence of symptoms of anxiety was 24.9% (59/237), and 27.0% (64/237) of patients were admitted for cardiac reasons at least once during the 12-month follow-up period. Symptoms of anxiety were neither significantly associated with cardiac hospitalizations in univariable logistic analysis [OR = 1.13, 95% CI (0.59-2.17), p = 0.72] nor in multivariable analysis [OR = 0.94, 95% CI (0.38-2.31), p = 0.89]. New York Heart Association (NYHA) functional class III [OR = 3.00, 95% CI (1.08-8.12), p = 0.04] and a history of HF-related hospitalizations [OR = 1.18, 95% CI (1.01-1.38), p = 0.03] were independently associated with 12-month cardiac admissions. CONCLUSIONS: The current study found no significant association between symptoms of anxiety and cardiac hospitalizations at 12 months in HF patients. In contrast, clinical indicators (i.e., NYHA class III and a history of HF-related hospitalizations) were significantly associated with admissions due to a cardiac cause. Future studies are warranted to investigate the importance of symptoms of anxiety in HF using a larger sample size and a longer follow-up duration.

Red cell distribution width as a marker of impaired exercise tolerance in patients with chronic heart failure.

AIMS: Exercise intolerance predicts mortality in patients with chronic heart failure (CHF). Recently, increased red cell distribution width (RDW) has emerged as an additional powerful predictor of poor outcome. We investigated the relationship between RDW and exercise capacity in patients with CHF. In addition, the association between training-induced improved maximal aerobic capacity (VO(2)peak) and RDW was studied. METHODS AND RESULTS: Stable and optimally treated CHF patients (n = 118) with a left ventricular ejection fraction (LVEF) <40% were included. RDW and cardiopulmonary exercise testing were obtained at baseline and after 6 months of exercise training (n = 71) or a sedentary lifestyle (n = 47). At baseline, log[RDW] was inversely related to VO(2)peak (P = 0.003), independently of disease severity [LVEF, New York Heart Association class, N-terminal pro brain natriuretic peptide (NT-proBNP)] and haemoglobin. Exercise training was associated with a decrease in RDW compared with controls (P < 0.0001 for interaction), independent of baseline VO(2)peak, haemoglobin, and NT-proBNP levels. The change in RDW after 6 months was significantly related to the change in VO(2)peak (r= -0.248, P = 0.009). CONCLUSIONS: Higher RDW is independently related to impaired exercise capacity in CHF patients. Increased VO(2)peak following exercise training relates to the observed changes in RDW. Whether increased RDW is a marker of impaired exercise tolerance, or plays a pathophysiological role in impaired oxygen transport, deserves further investigation.

Type D personality and course of health status over 18 months in outpatients with heart failure: multiple mediating inflammatory biomarkers.

BACKGROUND: The distressed (Type D) personality is associated with poor health status (HS) and increased inflammatory activation in heart failure (HF). We tested whether multiple inflammatory biomarkers mediated the association between Type D personality and the course of self-reported HS over 18 months. METHODS: HF outpatients (n=228, 80% male, mean age 67.0±8.7 years), filled out the Type D questionnaire (DS14) at inclusion and the Short Form-12 (SF12) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) at 0, 6, 12, and 18 months. Blood samples at inclusion were analyzed for high sensitive C-reactive protein (hsCRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α, and its soluble receptors (sTNFr1, sTNFr2). A multiple mediation latent growth model was tested using structural equation modeling. RESULTS: Type D personality (prevalence=21%) was associated with poorer HS (all scales p<0.001), deterioration of mental HS (p<0.001), and higher TNF-α and sTNFr2 levels in the full mediation model. A higher inflammatory burden was associated with a poorer baseline level and a deterioration of generic physical, mental and disease-specific HS. No mediating effects were found for the multiple inflammatory biomarkers on the association between Type D and baseline self-reported HS, whereas change in physical HS was significantly mediated by the group of five inflammatory biomarkers (p=0.026). CONCLUSIONS: Only the association between Type D personality and change in self-reported physical health status was significantly mediated by inflammatory biomarkers. Future research should investigate whether the association between Type D personality and poor health status may be explained by other biological or behavioral factors.

Intra-individual changes in anxiety and depression during 12-month follow-up in percutaneous coronary intervention patients.

BACKGROUND: Only a paucity of studies focused on intra-individual changes in anxiety and depression over time and its correlates in cardiac patients, which may contribute to the identification of high-risk patients and point to targets for intervention. We examined changes in anxiety and depression over a 12-month period and the demographic and clinical correlates of change scores using an intra-individual approach in patients treated with percutaneous coronary intervention (PCI). METHODS: Consecutive PCI patients (N=715) completed the Hospital Anxiety and Depression Scale (HADS) at baseline and at 12 months post-PCI. Individual change scores were calculated and in secondary analysis, three categories of change were identified (i.e., stable, improved, and deteriorated anxiety or depression). RESULTS: The mean individual change was -.16 (± 3.0) for anxiety and -.02 (± 2.8) for depression. In linear regression analysis, baseline anxiety levels (B = -.25, 95%CI[-.30 to -.20], p = <.001) and baseline depression levels (B = -.28, 95%CI[-.33 to -.22], p =< .001) were significant correlates of individual change scores. Secondary analysis showed that anxiety remained stable in 76.4% (546/715) of patients, while depression remained stable in 81.4% (582/715) of patients. CONCLUSIONS: The findings of the current study showed that levels of anxiety and depression remained stable in the majority of PCI patients from the index PCI to 12 months post-PCI. Future studies using an intra-individual approach are warranted to further examine individual changes in anxiety and depression over time in CAD, and PCI in particular, as a means to bridge the gap between research and clinical practice.

Anhedonia is associated with poor health status and more somatic and cognitive symptoms in patients with coronary artery disease.

PURPOSE: The effectiveness of cardiac rehabilitation (CR) in patients with coronary artery disease (CAD) is moderated by negative emotions and clinical factors, but no studies evaluated the role of positive emotions. This study examined whether anhedonia (i.e. the lack of positive affect) moderated the effectiveness of CR on health status and somatic and cognitive symptoms. METHODS: CAD patients (n = 368) filled out the Hospital Anxiety and Depression Scale (HADS) to assess anhedonia at the start of CR, and the Short-Form Health Survey (SF-36) and the Health Complaints Scale (HCS) at the start of CR and at 3 months to assess health status and somatic and cognitive symptoms, respectively. RESULTS: Adjusting for clinical and demographic factors, health status improved significantly during the follow-up (F(1,357) = 10.84, P = .001). Anhedonic patients reported poorer health status compared with non-anhedonic patients, with anhedonia exerting a stable effect over time (F(1,358) = 34.80, P < .001). Somatic and cognitive symptoms decreased over time (F(1,358) = 3.85, P = .05). Anhedonics experienced more benefits in terms of somatic and cognitive symptoms over time (F(1,358) = 13.00, P < .001). CONCLUSION: Anhedonic patients reported poorer health status and higher levels of somatic and cognitive symptoms prior to and after CR. Somatic and cognitive symptoms differed as a function of anhedonia over time, but health status did not. Anhedonia might provide a new avenue for secondary prevention in CAD.

Psychological distress and mortality in systolic heart failure.

BACKGROUND: Depression, anxiety, and type D ("distressed") personality (tendency to experience negative emotions paired with social inhibition) have been associated with poor prognosis in coronary heart disease, but little is known about their role in chronic heart failure. Therefore, we investigated whether these indicators of psychological distress are associated with mortality in chronic heart failure. METHOD AND RESULTS: Consecutive outpatients with chronic heart failure (n=641; 74.3% men; mean age, 66.6+/-10.0 years) filled out a 4-item questionnaire to assess mixed symptoms of anxiety and depression and the 14-item type D scale. End points were defined as all-cause and cardiac mortality. After a mean follow-up of 37.6+/-15.6 months, 123 deaths (76 due to cardiac cause) were recorded. Cumulative hazard functions for elevated anxiety/depression symptoms differed marginally for all-cause (P=0.06), but not cardiac, mortality (P=0.43); type D personality was associated with neither all-cause mortality (P=0.63) nor cardiac mortality (P=0.87). In multivariable analyses, neither elevated anxiety/depression symptoms nor type D personality was associated with all-cause mortality (hazard ratio [HR]=1.18; 95% CI, 0.76 to 1.84; P=0.45 and HR=1.09; 95% CI, 0.67 to 1.77; P=0.73, respectively) or cardiac mortality (HR=1.13; 95% CI, 0.63 to 2.04; P=0.65 and HR=1.16; 95% CI, 0.62 to 2.18; P=0.67). In secondary analyses, a 1-point increase in anxiety/depression (range, 0 to 16) was associated with an 8% increase in risk for all-cause mortality (HR=1.08; 95% CI, 1.01 to 1.15; P=0.02). CONCLUSIONS: Neither elevated anxiety/depression symptoms nor type D personality was associated with an increased risk for all-cause or cardiac mortality. Future studies with adequate power and a longer follow-up duration are needed to further elucidate the role of psychological distress in chronic heart failure.

The relationship between type D personality and chronic heart failure is not confounded by disease severity as assessed by BNP.

Psychological factors, like Type D personality (i.e., the tendency to experience negative emotions and to inhibit emotional distress) have been linked to impaired health outcomes. Criticism on the role of psychological factors in cardiac disease has postulated that such constructs may be confounded by disease severity. Hence, we examined whether Type D personality is associated with brain natriuretic peptide (BNP), a sensitive marker of disease severity in chronic heart failure (CHF), in 202 consecutive CHF outpatients. No differences in logBNP levels were found between Type D and non-Type D patients (t(200) = -1.03, p = .30). After adjusting for demographic and clinical confounders, Type D personality remained unassociated with logBNP levels (ß=.04, p = .55), whereas older age (ß = .27, p<.001), being prescribed beta-blockers (ß = .15, p = .02), lower left ventricular ejection fraction (ß = -.38, p<.0001), and kidney dysfunction (ß = .17, p = .01) were associated with higher logBNP. To conclude, Type D personality was not associated with BNP in CHF outpatients, whereas clinical variables were associated with BNP. These findings oppose the suggestion that Type D personality is confounded by indicators of disease severity.

Inadequate consultation behavior modulates the relationship between type D personality and impaired health status in chronic heart failure.

BACKGROUND: Psychological risk factors for impaired health outcomes have been acknowledged in chronic heart failure (CHF), with Type D personality being such a risk factor. Inadequate consultation behavior, a specific aspect of self-management, might be one mechanism in explaining the adverse effect of Type D on health outcomes. In this study we examined the relationship between Type D personality, impaired disease-specific health status, and inadequate consultation behavior. METHODS AND RESULTS: CHF outpatients (n=313) completed the Type D Scale (DS14) at baseline, and the European Heart Failure Self-care Behaviour Scale (EHFScBS) and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) at 6-month follow-up. Type D personality independently predicted inadequate consultation behavior (OR=1.80, 95%CI [1.03-3.16], p=.04) and impaired health status (OR=3.61, 95%CI [1.93-6.74], p<.001) at 6-month follow-up, adjusting for demographic and clinical variables. Inadequate consultation behavior (OR=1.80, 95%CI [1.11-2.94], p=.02) and NYHA-class (OR=2.83, 95%CI [1.17-4.71], p<.001) were associated with impaired health status, after controlling for demographics, clinical variables, and Type D personality. Post-hoc multivariable analysis pointed out that Type D patients who displayed inadequate consultation behavior were at a 6-fold increased risk of reporting impaired health status, compared to the reference group of non-Type D patients who displayed adequate consultation behavior (OR=6.06, 95%CI [2.53-14.52], p<.001). CONCLUSIONS: These findings provide evidence for inadequate behavior as a mechanism that may explain the link between Type D personality and impaired health status. Future studies are warranted to elaborate on these findings.