Inadequate response to treatment in coronary heart disease - Adverse effects of type D personality and younger age on 5-year prognosis and quality oflife

Background-Improvement in treatment of patients with coronary heart disease (CHD) has caused longer survival but also an increase in the number of pat ients at risk for subsequent cardiac events and impaired quality of life (Q OL). We hypothesized that chronic emotional distress confers an increased r isk of poor outcome despite appropriate treatment. Methods and Results -This prospective study examined the 5-year prognosis o f 319 patients with CHD. Baseline assessment included symptoms of depressio n/anxiety and distressed personality type (type D-ie, high negative affecti vity and social inhibition). The main end points were cardiac death or nonf atal myocardial infarction and impaired QOL. There were 22 cardiac events ( 16 nonfatal): they were related to left ventricular ejection fraction (LVEF ) less than or equal to 50%, poor exercise tolerance, age less than or equa l to 55 years, symptoms of depression, and type D personality. Multivariate analysis yielded LVEF less than or equal to 50% (OR, 3.9; P=0.009), type D personality (OR, 8.9; P=0.0001), and age less than or equal to 55 years (O R, 2.6; P=0.05) as independent predictors of cardiac events. Convergence of these risk factors predicted the absence of the expected therapeutic respo nse that was observed in 10% of the patients. When 2 or 3 risk factors occu rred together, the rate of poor outcome was 4-fold higher (P=0.0001). Estim ates of medical costs increased progressively with an increasing number of risk factors. Smoking, symptoms of depression, and type D personality were independent predictors of impaired QOL. Conclusions-Decreased LVEF, type D personality, and younger age increase th e risk of cardiac events; convergence of these factors predicts nonresponse to treatment. Emotionally stressed and younger patients with CHD represent high-risk groups deserving of special study.