Research report
Type-D personality but not depression predicts severity of anxiety in heart failure patients at 1-year follow-up

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Abstract

Background

Chronic heart failure (CHF) is a debilitating condition associated with poor outcome, including increased anxiety. However, anxiety and its determinants have not yet been studied systematically in CHF. We examined whether type-D personality and depressive symptoms would predict clinically significant anxiety at 1-year follow-up.

Methods

Consecutive patients with systolic CHF (n = 149; 79% men; mean age 66 ± 8.6) completed the type-D Scale (DS14), the Beck Depression Inventory, and the Anxiety Sensitivity Index at baseline. A clinical interview (Hamilton Anxiety Rating Scale) was used to assess clinically significant anxiety at 1-year follow-up.

Results

At 12 months follow-up, 26% (9/35) of type-D patients had clinically significant anxiety versus only 6% (7/114) of the non type-Ds (p = 0.001). In univariable analyses, type-D personality (OR = 5.3; p = 0.002) and anxiety sensitivity (OR = 4.5; p = 0.009), but not depressive symptoms (p = 0.27) predicted clinically significant anxiety. Type-D remained an independent predictor of anxiety at 1 year (OR = 5.7; p = 0.01), controlling for depressive symptoms, anxiety sensitivity, socio-demographic and clinical variables. Adding type-D in a hierarchical logistic regression model, comprising standard and psychological risk factors, enhanced the level of prediction of clinically significant anxiety substantially (− 2LL = 75.16 χ2 = 26.46; p = 0.009).

Conclusions

Type-D personality, but not depressive symptoms predicted 1-year clinically significant anxiety. The type-D scale could be used to identify CHF patients at high risk of anxiety, as these patients may be at an increased risk of adverse prognosis and impaired quality of life.

Introduction

Chronic heart failure (CHF) is a major health problem, with the incidence and prevalence of this potentially fatal disorder increasing tantamount to an epidemic (Hunt et al., 2005, Davis et al., 2000). Despite an impressive development of various treatment options, CHF is still associated with poor prognosis and functional capacity, frequent (re)hospitalisation, and escalating health costs (Hunt et al., 2005, Krumholz et al., 2002, Krumholz et al., 1997). Importantly, CHF is also associated with increased psychological distress (Schiffer et al., 2005, Gottlieb et al., 2004), and there is an urgent need to focus on this patient-centred outcome and its determinants in CHF (Krumholz et al., 2005).

Depression has received the most attention in CHF, with only few studies focusing on anxiety (Konstam et al., 2005, MacMahon and Lip, 2002). However, there is evidence to suggest that 8–16% of CHF patients suffer from clinically significant anxiety, such as generalised anxiety disorder or panic disorder (Haworth et al., 2005, Griez et al., 2000). Moreover, anxiety in heart patients is frequently under-recognised in clinical practice (Grace et al., 2004). Although anxiety has been linked in some (although not all) studies to prognosis, morbidity, and functional status in CHF (Ingle et al., 2006, Jiang et al., 2004, Clarke et al., 2000, Konstam et al., 1996), few studies have investigated the determinants of anxiety, and all of these have been cross-sectional (Haworth et al., 2005, Dracup et al., 2003, Majani et al., 1999). In these cross-sectional studies, higher New York Heart Association (NYHA) functional class (Haworth et al., 2005, Majani et al., 1999), co-morbid physical conditions (Haworth et al., 2005), and lower perceived control (Dracup et al., 2003) were associated with increased levels of anxiety.

The distressed (type-D) personality may be another important, but overlooked, determinant of anxiety in CHF patients. Type-D patients have elevated scores on two normal and stable personality traits, negative affectivity (tendency to experience negative emotions) and social inhibition (tendency to inhibit self-expression in social interaction) (Denollet, 2005) (Table 1). Type-D personality has been associated with several negative outcomes in patients with cardiac disease, such as worse prognosis (e.g. Denollet et al., 2000, Denollet and Brutsaert, 1998) and impaired quality of life (e.g. Al-Ruzzeh et al., 2005). Type-D personality is also independently associated with an increased risk of depressive symptoms and anxiety in patients with CHF, in patients with an implantable cardioverter defibrillator (ICD), and in coronary patients (van Gestel et al., 2007, Spindler et al., 2007, Schiffer et al., 2005, Pedersen et al., 2004). Increasing our knowledge of the prevalence and determinants of anxiety may enhance secondary prevention and further improve management of CHF (Haworth et al., 2005, MacMahon and Lip, 2002). However, to date no prospective study has directly examined the relationship between type-D personality and anxiety in CHF patients. Hence, the objective of this 1-year follow-up study was to examine whether type-D personality would predict clinically significant anxiety in CHF patients.

Section snippets

Study population and procedure

Consecutive CHF outpatients visiting the cardiology clinic of the TweeSteden teaching hospital in Tilburg, the Netherlands, were approached for inclusion in the current study. CHF patients with a left ventricular ejection fraction (LVEF) ≤ 40%, younger than 80 years, and pharmacologically stable 1 month preceding inclusion were asked to participate in this study. Patients older than 80 years, with diastolic heart failure, incapable of understanding and reading Dutch, or with cognitive

Patient characteristics

At baseline, 35 patients (23.5%) were classified as type-D and 47 patients (31.5%) as having probable depression (BDI ≥ 10). There were no significant differences (all p > 0.05) between type-D and non type-D patients on baseline characteristics, including medication (Table 2). The mean score was 8.6 ± 6.2 (range 0–34) for self-reported depression and 12.1 ± 9.7 (range 0–47) for anxiety sensitivity.

Prevalence of mild to severe anxiety

The prevalence of clinically significant anxiety at 1-year follow-up in this sample was 11%. A

Discussion

This is the first study examining the relative impact of type-D personality, depressive symptoms, and anxiety sensitivity on severity of anxiety at 1-year follow-up in patients with CHF. We found that type-D personality incurred an almost 6-fold increased risk of clinically significant anxiety at 1-year follow-up, adjusting for depressive symptoms, anxiety sensitivity, and socio-demographic and clinical baseline characteristics, including LVEF, NYHA class and aetiology of CHF. Only type-D

Funding Source

The study was supported by grants from Medtronic and St. Jude Medical. Medtronic and St. Jude Medical had no further role in study design, the collection, analysis and interpretation of the data, the writing of the report and in the decision to submit the paper for publication.

Acknowledgement

The authors wish to thank Eric Hendriks for his assistance in data collection.

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