Elsevier

Journal of Psychosomatic Research

Volume 104, January 2018, Pages 108-114
Journal of Psychosomatic Research

The predictive value of positive affect and Type D personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease

https://doi.org/10.1016/j.jpsychores.2017.11.003Get rights and content

Highlights

  • We examined positive affect and Type D personality as risk factors for outcomes in NOCAD patients.

  • Positive affect, when analyzed dichotomously, predicted lower incidence of repeat cardiac testing in NOCAD patients.

  • Type D personality did not predict outcomes in this group of NOCAD patients.

Abstract

Background

Patients with non-obstructive coronary artery disease (NOCAD) continue to experience disabling symptoms. Positive affect (PA) has shown a cardioprotective potential. Type D personality has previously been shown to have a deleterious effect on adverse outcomes in diverse cardiac populations. Little is known about the predictive value of PA and Type D personality for long-term outcomes in NOCAD patients. The aim was to investigate the effect of PA and Type D personality on clinical outcomes.

Methods

547 patients (mean age 61 years ± 9, 48% male) who underwent a coronary angiography or CT-scan between January 2009 and February 2013 answered questionnaires concerning PA (GMS) and Type D personality (DS14). Cox proportional hazards analyses were performed.

Results

When analyzed dichotomously, PA was a significant predictor of need for repeat cardiac testing (HR = 0.64, 95% CI: 0.41-0.99), but not emergency department (ED) admissions (HR = 0.83, 95% CI: 0.52-1.32) after adjustment for age, sex, education, diagnosis by group, BMI and hypertension. Analyzed continuously, the predictive value of PA was non-significant for both repeat testing (HR = 0.85, 95% CI: 0.69–1.06) and ED admissions (HR = 0.98, 95% CI: 0.77–1.23). Type D personality, both continuously and dichotomously, was not significantly associated with the outcomes. Findings were also examined for men and women separately.

Conclusion

Although Type D personality was not predictive of adverse events in this sample, PA is an interesting and important variable to take into account in NOCAD patients. Research on psychosocial factors in NOCAD patients should consider the importance of choices of endpoint, given the heterogeneity of NOCAD patients.

Introduction

Coronary artery disease (CAD) is the leading cause of cardiovascular mortality worldwide [1]. Many patients with typical symptoms of CAD or CAD risk factors do not display clinically significant narrowing of the coronary arteries, a condition referred to as non-obstructive coronary artery disease (NOCAD) [2], [3]. NOCAD is defined as luminal irregularities < 50% documented at coronary angiography (CAG) or CT scan [2], [4]. In a study of over 660.000 patients undergoing elective coronary angiography, about 60% displayed NOCAD [5]. The presence of NOCAD is higher in women, inversely related to age and more common in patients reporting atypical chest pain.

Evidence suggests patients with stable angina and normal coronary arteries or NOCAD are at elevated risk for major adverse cardiac events (MACE) and all-cause mortality compared to a reference population without ischemic heart disease [7]. These data indicate that there is no consistent support for the notion that patients with NOCAD are at low risk for myocardial infarction (MI) and cardiovascular mortality, when compared to patients with obstructive CAD [6]. Patients with diffuse non-obstructive coronary artery disease also report a higher prevalence of persistent angina than patients with obstructive CAD [3], [7]. More than half of NOCAD patients continues to experience disabling complaints such as chest pain [8], [9], [10]. Symptoms and complaints among patients with NOCAD are generally treated pharmacologically [8].

There is considerable evidence for the role of psychosocial factors such as depression, poor social support and low socioeconomic status (SES) as potential CAD risk factors [11], [12], [13]. Multiple studies have focused on distress and negative affect as predictors of cardiac events [14], [15], [16]. Type D personality is the joint tendency toward negative affectivity (NA) and social inhibition (SI) [17]. Several studies have shown that Type D personality is related to poor cardiac prognosis [18], [19], [20], [21], [22], [23]. However, the role of positive affect (PA) has been largely neglected [24]. PA commonly refers to positive mood states such as enthusiasm, excitement, happiness, joy and contentment [25]. PA is not merely the opposite of negative affect [26], and there seems to be an independence of positive and negative affect in risk for coronary heart disease [27]. Reduced PA independently predicts death/MI following stent implantation, and it improves risk stratification above and beyond diabetes [28]. Increased PA was associated with a reduced risk of 10-year incident coronary heart disease in a sample of outpatients, even when depressive symptoms, hostility and anxiety were adjusted for [29]. Moreover, PA has also been associated with improved survival in a sample of outpatients with coronary heart disease which was largely explained by physical activity [30], [31]. Thus, both positive affect and personality traits with high levels of NA and SI are related to clinical CAD, but little is known about the association between these psychological factors with NOCAD. Moreover, non-Type D patients low on PA report lower health status as well [32]. In short, it has been shown that both PA and Type D personality have predictive value for outcomes in cardiovascular populations. In our study, we anticipate Type D personality to be related to a higher incidence of adverse outcomes, and PA to be associated with a lower risk of adverse outcomes. However, it is possible that a combination of high PA and Type D personality is not nearly as detrimental as Type D personality by itself, or not nearly as protective as PA by itself. It is therefore of interest to examine the effects of both PA and Type D personality on health status and clinical outcomes in patients with NOCAD.

The primary aim of the present study is to examine the predictive value of PA and Type D personality on clinical outcomes; repeat cardiac diagnostic testing (CAG, Computed Tomography (CT), or myocardial perfusion imaging) and CAD-related emergency department (ED) visits in patients with NOCAD. We will also explore whether PA and Type D personality are predictive of major adverse cardiac events (MACE). We hypothesize that PA will be associated with less subsequent adverse cardiovascular events and that Type D personality will be associated with more adverse cardiovascular events. As for the combination of PA and Type D personality, we hypothesize that patients with low levels of PA and presence of Type D personality will have more adverse clinical outcomes than both patients with high PA and no Type D personality, and patients with high PA and Type D personality.

Section snippets

Patients and procedure

The TWeesteden mIld STenosis (TWIST) study is an observational single center cohort study with as its main focus the association of psychosocial factors with cardiovascular events in patients with NOCAD [33]. All patients who underwent coronary angiography (CAG) (n = 5638) or computed tomography (CT) -scan (n = 852) at the TweeSteden Hospital Tilburg, the Netherlands were screened between January 2009 and February 2013. Inclusion criterion for CAG was visible vascular or coronary wall

Results

Descriptive statistics are presented in Table 1. The mean age was 61.4 ± 9.4 years, with 75% (n = 412) of the patients being over 55 years. In total 52% (n = 284) were women. Patients were included following CAG (70%) or CT (30%). In total, 44% (n = 239) were referred for AP, ischemia or NSTEMI, and 30% (n = 164) for atypical chest pain. In the CAG-group, 37% were categorized as having mild stenosis, 21% as moderate stenosis and 12% as significant stenosis.

Discussion

The present study examined the association of positive affect (PA) and Type D personality with cardiac outcomes in patients with non-obstructive coronary artery disease (NOCAD) based on coronary angiography or CT. During an average follow-up of 3.5 years after the initial CAG or CT scan, 18% (n = 98) had a repeat test, 17% (n = 90) had an ED admission, and 5% (n = 25) had MACE. There were no significant associations between PA and Type D personality for repeat testing and ED admission, when analyzed

Conclusions

We did not find significant risks for positive affect and Type D personality as independent and combined psychosocial predictors for events in NOCAD patients. More large scale and longitudinal studies are needed to examine if PA has a protective effect for adverse cardiac events in these patients. The present study shows that PA is an interesting and important variable to take into account in research on NOCAD.

The following are the supplementary data related to this article.

Acknowledgement

The authors would like to thank Arlette Vrijsen and Josephine Druif for their aid in the data collection of the outcomes.

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