Does Type D Personality Inhibit Benefits of Cardiac Rehabilitation?

Correspondence (İletişim): Başak Bilir Kaya, M.D. Saglik Bakanligi Erenkoy Fizik Tedavi ve Rehabilitasyon Hastanesi, Fiziksel Tip ve Rehabilitasyon Bolumu, Ethem Efendi Cad, Hat Boyu Sok, No: 36, Erenkoy, İstanbul, Turkey Phone (Telefon): +90 505 260 46 49 E-mail (E-posta): basakbilir@gmail.com Submitted Date (Başvuru Tarihi): 24.07. 2019 Accepted Date (Kabul Tarihi): 26.07. 2019 Copyright 2019 Haydarpaşa Numune Medical Journal OPEN ACCESS This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/). 245 Bilir Kaya et al., Type D Personality and Cardiac Rehabilitation / doi: 10.14744/hnhj.2019. 42103 ated with inflammation and can predict mortality in CVD [6, 7]. Because Type D personality is linked to inflammation, ESC has included Type D personality as an independent risk factor of CVD [8]. Type D personality is also associated with low scores of health-related quality of life (HRQoL) in CVD populations [9]. Cardiac rehabilitation (CR) is a multi-component rehabilitation program for cardiac patients designed to decrease mortality and morbidity and also maximize secondary prevention from heart disease [10]. CR consists of internationally accepted core components which are nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE) and exercise training (ET) [11]. A Cochrane review showed that CR reduces mortality and morbidity by 20% for CVD [12]. CR is also shown to decrease depression and increase HRQoL and functional capacity in CVD [13, 14]. Our study is focused on these benefits of CR on HRQoL, depression and functional capacity like most of the studies. The new highlight of this study to the literature is that these known benefits of CR are analysed for Type D personality positive and negative patients. The present study aims to investigate the potential effects of Type D personality on CR related improvement of HRQoL, depression and functional capacity of CVD patients. Materials and Methods A single-center, retrospective cohort study was conducted with the evaluation of all CR participants at the University Hospital of Cardiovascular and Thoracic Surgery between 01.02. 2017 and 01.02. 2019. The study population was the patients who were 18 years and older and completed all 30 sessions of CR program and also completed both preand post-tests. Exclusion criteria were as follows: psychosis, cancer, untreated mental illness and systemic inflammatory disease. This study was approved by a local ethics committee and was performed in accordance with the Declaration of Helsinki. Informed consent was obtained from all the subjects. Patients’ demographic data were collected. All patients were outpatient patients of the CR unit. Type D personality was assessed with DS14 which was also validated for the Turkish population [5, 15]. DS14 is based on subjective assessment of individuals; 14 substance scale contains questions that measure negative affectivity (NA) and social inhibition (SI) [5]. Patients who have high scores from NA subscale are inclined to experience negative emotions (e.g. anxiety and irritability) about situations and the environment they are surrounded. SI score high patients have a tendency to consciously inhibit self-expression during social activities. Reason for this social inhibition is thought to be fear of being rejected and disapproval of society. Subscales’ points can be maximum 28 points, and cut-off point for subscales is 10. Patients with high scores (≥10) from both subscales NA and SI are classified as Type D personality positive [5]. Depression was assessed with the Beck Depression Inventory which was also validated for the Turkish population [16, 17]. Beck Depression Inventory is used to assess patients’ depression symptom severity. Beck Depression Inventory contains 21 items, and each item consist of four statements which points to different classes of symptom severity. Patients were asked to answer the questions according to past one week time. A total score was calculated, which shows bigger scores for more depressive symptoms [16]. Quality of life was assessed using SF 36, which is also validated for the Turkish population for various illnesses [18–20]. SF 36 can be summarized with two dimensions which are physical health and mental health of 36 items for measuring eight health concepts: physical functioning, role limitations due to physical health problems, pain, general health perception, vitality, social functioning, role limitations due to emotional problems and general mental health [18]. Functional capacity was assessed using a 6-minute walk test (6MWT). Patients were asked to walk back and forth as much as possible around cones in six minutes on a 30-foot path. They were allowed to slow down or stop if necessary. Talking to the patients while they take the 6MWT was prohibited. Submaximal cycle ergometer test was performed to evaluate endurance. During the test for every 2-minute, watt was increased by 25 watts and the Borg scale was asked to the patient. Assessing the situation of the patient for breath and muscle fatigue according to the patient, the Borg scale was asked during the test. Arterial blood pressure (ABP) was measured at the beginning of the test and every two minutes afterwards, and at the end of the test automatically by the computer system. Electrocardiogram, heart rate and saturation of oxygen were monitored continuously right before, during the test and recovery period. If any lightheadedness, angina, cyanosis, dyspnea, hypoxia, confusion, significant muscle pain (patient declares Borg Scale ≥5) occurred, ABP exceeded 180/100 or submaximal heart rate is reached according to Karvonen formula (for patients who does not use beta-blockers), the test was 246 Bilir Kaya et al., Type D Personality and Cardiac Rehabilitation / doi: 10.14744/hnhj.2019. 42103 ended and the maximum watt was calculated according to the time of the taken test. A special CR program was planned for each patient based on the cycle ergometer test peak workload. Low-intensity interval training was prescribed for patients with low initial test performance. Exercise program for patients using beta-blockers was given independent of heart rate. All core components of CR were administered according to patients’ specific needs. Each patient's CR program was evaluated after 10 sessions and was updated by the physiatrist according to Borg scales assessed by the rehabilitation nurse during the exercise sessions. Each exercise program started with a warm-up and ended with a recovery period, which is also monitored continuously for heart rate, oxygen saturation, ABP and electrocardiogram. All of the patients who attend CR program received NC from the dietician, PC from the psychologist, and patient education according to their special health conditions (e.g. diabetes) from CR nurse. Smokers were guided to the tobacco cessation outpatient clinic. In one week of completion of CR sessions, all the tests were repeated. The primary endpoint was the observation of changes in Beck Depression Inventory, SF-36 scores and the secondary endpoint of this study was the observation of improvement in functional capacity and endurance according to patients’ type D personality. Statistical Analysis NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) program was used for statistical analysis. Descriptive statistical methods (mean, standard deviation, median, frequency, percentage, minimum, maximum) were used when evaluating the study data. The Mann-Whitney U test was used in comparisons between two groups of quantitative variables that did not show Normal distribution. The T-test was used in the in-Group comparisons of quantitative variables with Normal distribution. Wilcoxon signed-ranks test was used for in-Group comparisons of quantitative variables that did not show Normal distribution. Statistical significance was considered p<0.05.