Type D personality, cardiovascular risk factors and risk of recurrent major adverse cardiac events in outpatients with coronary heart disease
Authors: Torgersen KS , Sverre E , Weedon-Fekjaer H , Andreassen OA , Munkhaugen J , Dammen T 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Kristin S. Torgersen received founding from the University of Oslo, Research Council of Norway.

Introduction
The mechanisms linking type D personality to cardiac prognosis in terms of major adverse cardiac events (MACE) and the association between Type D and MACE after controlling for symptoms of anxiety and depression is largely unknown.

Propose
To investigate the relationship between Type D personality and the Type D characteristics of negative affectivity (NA) and social inhibition (SI) and i) cardiovascular risk factors and ii) risk of recurrent MACE in CHD outpatients.

Methods
This prospective multicenter cohort study included 1083 patients 2-36 (mean 16) months after a myocardial infarction and/or a revascularization procedure. At baseline, patients underwent a clinical examination and answered a questionnaire including assessment of Type D personality (DS14), anxiety and depression (Hospital Anxiety and Depression Scale (HADS), medication adherence and risk factors (hypertension, smoking, diabetes, low physical activity, waist circumference, low-density lipoprotein cholesterol and C-reactive Protein). The primary composite endpoint of MACE defined as cardiovascular death, hospitalization for myocardial infarction, revascularization, stroke/transitory ischemic attacks or heart failure were obtained from hospital records on average 4.2 (SD 0.4) years after baseline. Data were analyzed by Cox proportional hazard regression stratified for prior coronary events.

Results
The prevalence of Type D was 18% at baseline. Type D patients were younger at the index event (59.3 vs 62.1 years, p= 0.001), more likely to be female (26.4 vs 19.8 %, p=0.038), scored higher on HADS anxiety (8.4 vs 3.9, p &lt; 0.001), HADS depression (3.2 vs 7.0, p &lt;0.001), reported lower medication adherence (14.2 vs 9.2 %, p=0.042), and were more likely to report smoking (29.0 vs 18.9%, p=0.002) compared to those without type D personality. There were no significant differences in other risk factors between the Type D and non-Type D group. A total of 352 MACE occurred in 230 patients (21%, 95% CI 19% to 24%) during follow-up. Higher NA score was associated with MACE in analyses adjusted for age, cardiovascular risk factors and somatic comorbidity (RR 1.02 per unit increase, 95% CI 1.00-1.05, p=0.037), but not after additional adjustment for symptoms of anxiety and depression (RR 1.01 per unit increase, 95% CI 0.98-1.05, p=0.53). Type D personality was not significantly associated with increased risk for MACE, neither was higher SI score.

Conclusions
Type D personality was only associated with low medication adherence and smoking which may represent potential mechanisms linking type D to cardiovascular prognosis. In our study, only negative affectivity was associated with MACE, suggesting that this is the most important type D characteristic for prognosis. However, NA was no longer associated with MACE after adjusting for anxiety and depression raising the question whether NA, depression and anxiety may have common underlying factors or are overlapping constructs.