Cloninger’s Temperament Traits as Predictors of Clinical Events after Acute Coronary Syndrome: A Three-Year Prospective Study

gate the effects of Cloninger’s temperament traits on prognosis at a 3-year follow-up in patients hospitalized for acute coronary syndrome (ACS). The study protocol was described in details in a recent paper examining the effects of anhedonia in the same sample [8] . The study subjects were consecutive patients with suspected ACS admitted to the cardiac/coronary intensive care unit of Montereau Fault-Yonne general hospital in France. When considered appropriate by the staff, the patients were invited to participate in a 3-year follow-up survey that included psychiatric assessment at initial admission. The patients were eligible for inclusion if they had either acute myocardial infarction with or without ST segment elevation or unstable angina. The patients completed the French version of the Tridimensional Personality Questionnaire (TPQ) 1–4 days after admission. They provided written informed consent to participate and the study was approved by the hospital research ethics committee. Two hundred and ninety-six patients (226 males, 70 females) completed the TPQ. The patients were aged between 26.4 and 96.2 years [mean = 67.8, standard deviation (SD) = 13.4]. Eleven potential covariates were taken into account: 2 demographic variables (age and gender), 7 medical factors: current tobacco use, hypertension, diabetes mellitus, hypercholesterolemia, obesity, previous and family history of ACS and left ventricular hypertrophy diagnosed by echocardiography, and 2 psychometric variables: anhedonia and depression respectively rated by the revised Physical Anhedonia Scale (PAS) and the Depression subscale of the Hospital Anxiety and Depression Scale (HAD-D). The score ranges of the PAS and HAD-D are respectively 0–61 and 0–21. The independent variables were the TPQ subscores. The TPQ is a 100-item true-false questionnaire divided into 3 subscales rating NS, HA and RD. The ranges of the subscale scores are respectively 0–34, 0–34 and 0–30. The French version of this scale, which has been shown to have satisfactory validity and reliability, was used in this study [9] . The total score for NS, HA and RD was used in statistical analyses. The psychometric characteristics of the study participants are summarized in table 1 . Moreover, to explore the predictive power of high NS, HA or RD, 2 cutoff scores were used for each subscale to classify the subjects into ‘high TPQ subscale’ or ‘low TPQ subscale’. The cutoff scores corresponded to 1 and 2 SD above the mean of the corresponding TPQ subscale calculated in the sample, respectively. The 2 dependent variables selected for the current study were severe cardiac events and clinical events. Severe cardiac events comprised death and myocardial infarction. Clinical events comprised severe cardiac events (death and myocardial infarction) and nonsevere clinical events including recurrence of ACS, hospital readmission and onset or deterioration of heart failure. The patients included in the study were interviewed by a physician (M.L) who collected demographic and medical history information. All subjects were reinterviewed by phone every 6 months for 3 years to obtain information about readmissions and vital status. Additional cardiac data were extracted from hospital charts. The Recent studies have reported an association between either Cloninger’s temperament traits and atherosclerosis [1] or between these temperaments and coronary heart disease risk factors of the metabolic cardiovascular syndrome (insulin resistance syndrome) [2] . However, Cloninger’s model contributed to autonomic cardiac control, a potential mediating mechanism between these temperaments and coronary heart disease risk [3] . Cloninger’s model of temperament consists of 3 temperament traits: novelty seeking (NS), harm avoidance (HA) and reward dependence (RD) [4] . According to Cloninger’s model [4] , NS reflects behavioral activation, HA reflects behavioral inhibition, and RD reflects behavioral maintenance. High-NS subjects are characterized by impulsivity, exploratory excitability, wastefulness and disorderliness, whereas high-HA subjects are cautious, fearful, and prone to anxiety, fatigue and inhibition. High-RD subjects are empathic, sentimental and sensitive to social cues. NS and HA have been previously associated with biological and behavioral risk factors for CHD, but the findings have been somewhat mixed. In a study [2] using a sample of 190 healthy, young adult men divided into 4 temperament groups by cluster analysis, subjects characterized by a high level of RD, an average level of NS and a low level of HA had a high level of physiological CHD risk factors. In another study [3] examining the associations between Cloninger’s temperament traits and autonomic cardiac regulation in a resting situation in 2 large samples of healthy men and women, the authors reported that a high HA level was associated with lower vagal control and higher resting heart rate, an autonomic nervous system profile reflecting higher CHD risk. In contrast, NS showed positive associations with indices of parasympathetic control activity and lower heart rate, reflecting a lower CHD risk. The results concerning RD are also conflicting. One study reported that higher RD was associated with lower blood pressure and nonsmoking status in women [5] . Cloninger’s temperament traits could be a risk factor for cardiac events and personality traits such as hostility and type D behavior have been previously associated with cardiac events [6, 7] . To our knowledge, no study has explored the potential predictive power of Cloninger’s temperament traits on CHD events and CHD progression. The aim of this study was therefore to investiPublished online: January 4, 2011