Johan Denollet, PhD the heart failure patient ? Why is a dedicated cardiologist not sufficient for The Netherlands

Dutch Heart Foundation, 2005 Dutch Heart Foundation, 2005 Chronic Heart Failure (CHF) Emerging epidemic Prevalence: cases Incidence: cases in the Netherlands

Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Personality & CHF: Overview

Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Personality & CHF: Overview

Negative Affectivity: tendency to Negative Affectivity: tendency to experience negative emotions experience negative emotions (Watson & Pennebaker, 1989) Negative Affectivity: tendency to Negative Affectivity: tendency to experience negative emotions experience negative emotions (Watson & Pennebaker, 1989) What is Type D Personality ?

Negativity Negativity HiLo

Negative Affectivity: tendency to Negative Affectivity: tendency to experience negative emotions experience negative emotions (Watson & Pennebaker, 1989) Social Inhibition: tendency to Social Inhibition: tendency to inhibit emotions and behaviors inhibit emotions and behaviors in social interaction in social interaction (Asendorpf, 1993) (Asendorpf, 1993) Negative Affectivity: tendency to Negative Affectivity: tendency to experience negative emotions experience negative emotions (Watson & Pennebaker, 1989) Social Inhibition: tendency to Social Inhibition: tendency to inhibit emotions and behaviors inhibit emotions and behaviors in social interaction in social interaction (Asendorpf, 1993) (Asendorpf, 1993) What is Type D Personality ?

Negativity Negativity Hi Inhibition HiLo Lo Other Type D

What is Type D Personality ? Negative Affectivity I am often down in the dumps I am often down in the dumps I often find myself worrying about something I often find myself worrying about something I am often irritated I am often irritated Social Inhibition I find it hard to start a conversation I find it hard to start a conversation I am a closed kind of person I am a closed kind of person I often feel inhibited in social interactions I often feel inhibited in social interactions Negative Affectivity I am often down in the dumps I am often down in the dumps I often find myself worrying about something I often find myself worrying about something I am often irritated I am often irritated Social Inhibition I find it hard to start a conversation I find it hard to start a conversation I am a closed kind of person I am a closed kind of person I often feel inhibited in social interactions I often feel inhibited in social interactions

What is Type D Personality ? Negative Affectivity I am often down in the dumps I am often down in the dumps I often find myself worrying about something I often find myself worrying about something I am often irritated I am often irritated Social Inhibition I find it hard to start a conversation I find it hard to start a conversation I am a closed kind of person I am a closed kind of person I often feel inhibited in social interactions I often feel inhibited in social interactions Negative Affectivity I am often down in the dumps I am often down in the dumps I often find myself worrying about something I often find myself worrying about something I am often irritated I am often irritated Social Inhibition I find it hard to start a conversation I find it hard to start a conversation I am a closed kind of person I am a closed kind of person I often feel inhibited in social interactions I often feel inhibited in social interactions

Denollet, Psychosom Med, 2005; 67: Denollet, Psychosom Med, 2005; 67: DS 14 0=FALSE 1=RATHER FALSE 2=NEUTRAL 3=RATHER TRUE 4=TRUE _____________________________________________________________________________ 1 I make contact easily when I meet people - - I often make a fuss about unimportant things I often talk to strangers  I often feel unhappy  I am often irritated  I often feel inhibited in social interactions I take a gloomy view of things  I find it hard to start a conversation  I am often in a bad mood  I am a closed kind of person  I would rather keep other people at a distance I often find myself worrying about something I am often down in the dumps  When socializing, I don’t find the right things to talk about _____________________________________________________________________________

Down in the dumps Feeling blue Angry Worried Bad mood Unhappy The burden of negative emotions and inhibition Type D Type D ? No!! I do not want to share my emotions with others… What is Type D Personality ?

Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Personality & CHF: Overview

23/85 15/218 p<.0001 Denollet et al., Lancet, 1996; 347: Denollet et al., Lancet, 1996; 347: Death 6-10 year FU CAD: Risk of Cardiac Events

Death/MI 5 year FU 16/86 6/206 23/85 15/218 p<.0001 Denollet, Vaes & Brutsaert, Circulation, 2000; 102: Denollet, Vaes & Brutsaert, Circulation, 2000; 102: Death 6-10 year FU CAD: Risk of Cardiac Events

0% 2% 4% 6% Non-Type D Type D 0 m3 m6 m9 months Type D Non-Type D Numbers at risk RESEARCH Trial Erasmus Medical Center Rotterdam Cumulative proportion at risk (%) 5.31 HR = 5.31 * [ CI ].002 p =.002 Pedersen SS et al., J Am Coll Cardiol, 2004; 44: Pedersen SS et al., J Am Coll Cardiol, 2004; 44: Post-PCI Patients: Death / MI

Denollet & Brutsaert, Circulation, 1998; 97: Denollet & Brutsaert, Circulation, 1998; 97: HR = 4.7 Heart Failure: Death / MI 9y FU

OR= 3.75 p=.009 p=.009 LVEF >50% Denollet et al., in preparation Denollet et al., in preparation Death / MI ( n = 103) 6.1 yrs FU ( n = 1068) LVEF <40% LVEF 40-50% OR= 4.89 p=.004 p=.004 OR= 2.90 p<.0001 p<.0001

Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Personality & CHF: Overview

Aquarius, Denollet et al., Am J Cardiol, 2005; 96: Aquarius, Denollet et al., Am J Cardiol, 2005; 96: P=.0001 PAD patients Healthy subjects P=.0001 Type D & PAD: Poor QoL

Independent predictors in multivariable analysis Type D personality3.04[ ]0.002 Diabetes mellitus Diabetes mellitus2.75[ ]0.012 Male sex0.62[ ]0.18 Age1.02[ ]0.25 Multi-vessel disease1.34[ ]0.39 Sirolimus - eluting stent 0.72[ ]0.35 Variable OR [95% CI] p Pedersen, et al., Am Heart J, 2006; 151: 367.e1-367.e6 Post-PCI: Depression (1y FU)

Type D (n = 38) Non-Type D (n =46) Schiffer et al., Eur J Cardiovasc Prev Rehabil, 2005; 12: Heart Failure: Impaired QoL

Schiffer et al., Eur J Cardiovasc Prev Rehabil, 2005; 12: Heart Failure: Impaired QoL

Schiffer et al., Eur J Cardiovasc Prev Rehabil, 2005; 12: Heart Failure: Impaired QoL

Pedersen et al., Psychosom Med, 2004; 66: Pedersen et al., Psychosom Med, 2004; 66: p <.001 ICD: Anxiety & Depression

Non-Type D p=.001 p=.006 Type D Pedersen & Denollet, Eur J Cardiovasc Prev Rehabil 2003; 10: CABG/PCI: Symptoms of Fatigue

Large effect Moderate effect Small effect Type D Effect Gender Effect CABG/PCI: Gender versus Type D Fatigue Pedersen & Denollet, Eur J Cardiovasc Prev Rehabil 2003; 10: 241-8

Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Type D Personality Type D Personality Personality and Prognosis Personality and Prognosis Personality and QoL Personality and QoL Potential mechanisms Potential mechanisms Personality & CHF: Overview

Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment Potential Pathways

Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment inadequate consultation behavior inadequate consultation behavior Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment inadequate consultation behavior inadequate consultation behavior Potential Pathways

Consultation behavior in CHF Consulting doctor/nurse for symptoms that are relevant to CHF (Ekman et al., 2005)Consulting doctor/nurse for symptoms that are relevant to CHF (Ekman et al., 2005)

Consultation behavior in CHF Consulting doctor/nurse for symptoms that are relevant to CHF (Ekman et al., 2005)Consulting doctor/nurse for symptoms that are relevant to CHF (Ekman et al., 2005) Influenced by the patient’s appraisal of the seriousness of the symptomsInfluenced by the patient’s appraisal of the seriousness of the symptoms

Consultation behavior in CHF Consulting doctor/nurse for symptoms that are relevant to CHF (Ekman et al., 2005)Consulting doctor/nurse for symptoms that are relevant to CHF (Ekman et al., 2005) Influenced by the patient’s appraisal of the seriousness of the symptomsInfluenced by the patient’s appraisal of the seriousness of the symptoms Influenced by the patient’s attitudes to help seeking & disclosing personal feelingsInfluenced by the patient’s attitudes to help seeking & disclosing personal feelings

- 178 CHF outpatients, LVEF ≤ 40% -European Heart Failure Self-Care Behaviour Scale (Jaarsma et al., 2003) -4-item subscale: I contact my doctor or nurse, if: My feet/legs become more swollen than usual My shortness of breath increases I experience increased fatigue I gain 2 kg in 1 week Consultation behavior & CHF Schiffer, Denollet et al., Submitted for publication

- 178 CHF outpatients, LVEF ≤ 40% -European Heart Failure Self-Care Behaviour Scale (Jaarsma et al., 2003) -4-item subscale: I contact my doctor or nurse, if: I contact my doctor or nurse, if: My feet/legs become more swollen than usual My feet/legs become more swollen than usual My shortness of breath increases My shortness of breath increases I experience increased fatigue I experience increased fatigue I gain 2 kg in 1 week I gain 2 kg in 1 week Consultation behavior & CHF Schiffer, Denollet et al., Submitted for publication

(1) Type D patients experienced more cardiac symptoms than non-Type D ( OR = 6.4) symptoms than non-Type D ( OR = 6.4) (2) Type Ds more often appraised these symptoms as worrisome ( OR = 2.9) (3) Paradoxically, they were less likely to report their symptoms to their doctor/nurse ( OR = 2.7) Consultation behavior & CHF Schiffer, Denollet et al., Submitted for publication

(1) Type D patients experienced more cardiac symptoms than non-Type D ( OR = 6.4) (2) Type Ds more often appraised these symptoms as worrisome ( OR = 2.9) symptoms as worrisome ( OR = 2.9) (3) Paradoxically, they were less likely to report their symptoms to their doctor/nurse ( OR = 2.7) Consultation behavior & CHF Schiffer, Denollet et al., Submitted for publication

(1) Type D patients experienced more cardiac symptoms than non-Type D ( OR = 6.4) (2) Type Ds more often appraised these symptoms as worrisome ( OR = 2.9) (3) Paradoxically, they were less likely to report their symptoms to their doctor/nurse ( OR = 2.7) their symptoms to their doctor/nurse ( OR = 2.7) Consultation behavior & CHF Schiffer, Denollet et al., Submitted for publication

Consultation behavior & CHF Schiffer, Denollet et al., Submitted for publication p< % of the CHF patients who experienced symptoms but failed to consult were classified as Type D as compared to only 14% of the other patients Sympt -Sympt + Sympt + Sympt -Sympt + Sympt + Consult + Consult -

Denollet, Pedersen SS et al., Eur Heart J, 2006; 27: Denollet, Pedersen SS et al., Eur Heart J, 2006; 27: Modulating Effect of Inhibition

Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment inadequate consultation behavior inadequate consultation behavior Direct, Physiological Pathway: Direct, Physiological Pathway: cortisol, stress hormones cortisol, stress hormones chronic low-grade inflammation chronic low-grade inflammation Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment inadequate consultation behavior inadequate consultation behavior Direct, Physiological Pathway: Direct, Physiological Pathway: cortisol, stress hormones cortisol, stress hormones chronic low-grade inflammation chronic low-grade inflammation Potential Pathways

Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment inadequate consultation behavior inadequate consultation behavior Direct, Physiological Pathway: Direct, Physiological Pathway: cortisol, stress hormones cortisol, stress hormones chronic low-grade inflammation chronic low-grade inflammation pro-inflammatory cytokines pro-inflammatory cytokines Behavioral Pathway: Behavioral Pathway: failure to quit smoking failure to quit smoking poor compliance with treatment poor compliance with treatment inadequate consultation behavior inadequate consultation behavior Direct, Physiological Pathway: Direct, Physiological Pathway: cortisol, stress hormones cortisol, stress hormones chronic low-grade inflammation chronic low-grade inflammation pro-inflammatory cytokines pro-inflammatory cytokines Potential Pathways

p=.005 p=.009 TNF -  sTNFR1sTNFR2 Denollet, Conraads et al., Brain, Behav & Immun, 2003; 17: Denollet, Conraads et al., Brain, Behav & Immun, 2003; 17: Type D & Cytokines in CHF ( n = 42)

Type D personality3.9[ ] Age >60 yrs2.3[ ]0.16 Male sex1.4[ ]0.66 LVEF1.1[ ]0.23 Ischemic heart failure1.5[ ]0.54 NYHA class III / IV 2.4[ ]0.13 Variable OR [95% CI] p Independent predictor sTNFR2 ( n = 91) Conraads, Denollet et al., Int J Cardiol, 2006; In Press Conraads, Denollet et al., Int J Cardiol, 2006; In Press

Type D personality3.9[ ] Age >60 yrs2.3[ ]0.16 Male sex1.4[ ]0.66 LVEF1.1[ ]0.23 Ischemic heart failure1.5[ ]0.54 NYHA class III / IV 2.4[ ]0.13 Variable OR [95% CI] p Independent predictor sTNFR2 ( n = 91) Conraads, Denollet et al., Int J Cardiol, 2006; In Press Conraads, Denollet et al., Int J Cardiol, 2006; In Press

Type D or Not Type D ?