1. CoRPS Center of Research on Psychology in Somatic diseases Cardiac Psychology: A match made in heaven for patients Susanne S. Pedersen, Professor of Cardiac Psychology

2. CoRPS Affiliations Prof.dr. Susanne S. Pedersen CoRPS - Center of Research on Psychology in Somatic diseases, Tilburg University, The Netherlands Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Department of Cardiology, Odense University Hospital, Denmark Phone: + 31 (0) 13 466 2503 E-mail: s.s.pedersen@uvt.nl www.tilburguniversity.nl/corps

3. CoRPS Overview Cardiac psychology – adding the patient perspective Psychological factors – risk markers across cardiac diagnoses? How does it work – mind-body(heart) links Take home message

4. CoRPS Overview Cardiac psychology – adding the patient perspective Psychological factors – risk markers across cardiac diagnoses? How does it work – mind-body(heart) links Take home message

5. CoRPS What is cardiac psychology? “Cardiac psychology is the field of health psychology that identifies psychosocial risk factors for the development of cardiovascular illness and proposes lifestyle changes to help prevent and heal heart disease.”

6. CoRPS “When the minds of the people are closed and wisdom is locked out they remain tied to disease”. (Yellow Emperor, Han Dynasty, 2697-2597 B.C.) “A mental disturbance provoking pain, excessive joy, hope or anxiety extends to the heart, where it affects temper and rate”. (William Harvey, 1578-1657) Later on, Osler described the typical atherosclerosis patient as “a keen and ambitious man, the indicator of whose engine is always at ‘full speed ahead’ ”. (Osler, 1910) Origins of cardiac psychology...

7. CoRPS ICD shock Fractured leads Home monitoring Where is the patient? Do we need cardiac psychology?

8. CoRPS The implantable cardioverter defibrillator (ICD) Ahmad et al. PACE 2000;23:931-3 Crespo et al. Am J Med Sci 2005;329:238-46 Used as primary and secondary prevention of sudden cardiac death ICD is superior to anti-arrhythmic drugs in saving lives The ICD can shock with up to 700-800 volts “It’s like getting kicked in the chest by a big horse!” TRANSVENOUS ICD: Leads in or on the heart

9. CoRPS ICD described as a life-saver by most patients Anxiety/depression ≈ 25%-33% Posttraumatic stress ≈ 12%-19% A high level of chronicity of anxiety at 12 months post implantation → 51.8% (115/222) of patients anxious prior to ICD implantation Prevalence of psychological distress in ICD patients Von Känel et al. J Affect Disord 2011;131:344-52; Versteeg et al. Int J Cardiol 2011;146:438-9; Pedersen et al. Int J Cardiol 2011;147:420-3

10. CoRPS Prevalence of psychological distress in ICD patients A subset of patients: 1 in 4 (25%) 1.Who are these patients? 2.Does distress in these patients matter? 3.Can we reduce distress?

11. CoRPS 1.Who are these patients?

12. CoRPS Sears et al. Psychosomatics 2005;46:451-7 Predictors of quality of life (8 months) * Social support, optimism, depression, anxiety Age, LVEFPsychological variables* ShocksTotal variance General health 21.2%39.9%3.5%64.5% Mental health13.7%27.4%0.7%41.8% Physical health 23.4%24.1%7.3%54.8% N = 88

13. CoRPS Prevalence of anxiety and depression in patients stratified by Type D and shocks Pedersen, Erdman, Theuns et al. Psychosom Med 2004;66:714-9 % N = 182

14. CoRPS Von Känel et al. J Affect Disord 2011;131:344-52 Predictors of posttraumatic stress at baseline and follow-up N = 107

15. CoRPS Shocks, Type D and anxiety sensitivity as predictor of interview-rated anxiety Van den Broek et al. PACE 2008;31:850-7 N = 308

16. CoRPS Correlates of anxiety and depression Johansen, Pedersen et al. Europace 2008;10:545-51 AnxietyDepressionOR [95% CI] Female gender 2.38 [1.32-4.29]† ns Age ns ns Living with a spouse ns ns Non-ischaemic etiology ns ns Symptomatic CHF 5.15 [3.08-8.63]‡ 6.82 [3.77-12.39]‡ Co-morbidity ns ns ICD-related complications ns ns ICD shocks 2.21 [1.32-3.72]† 2.00 [1.06-3.80]* Years with ICD therapy ns ns Current smoking ns ns Amiodaronens ns Other antiarrhythmic medication ns ns Psychotropic medication ns 2.75 [1.40-5.40]† * P < 0.05; † P < 0.01; ‡ P < 0.001 N = 610

17. CoRPS Correlates of poor device acceptance (FPAS) Pedersen, Sears et al. PACE 2008;31:1168-77 OR[95% CI]p Demographic Female gender0.62[0.32-1.20].16 Age1.03[1.01-1.05].003 Partner/living together0.53[0.31-0.91].021 Clinical Non-ischemic etiology1.17[0.69-1.98].56 Symptomatic heart failure3.59[2.12-6.08]<.001 Cardiac resynchronization therapy0.91[0.51-1.62].74 Co morbidity1.13[0.65-1.97].67 Device-related complications1.46[0.61-3.49].40 Shocks0.87[0.51-1.47].59 Years since implantation0.93[0.86-1.02].12 Psychological Type D personality3.51[1.95-6.30]<.001 Anxiety2.33[1.24-4.38].009 Depressive symptoms2.24[1.00-5.00].049 ICD concerns4.16[2.55-6.80]<.001 N = 566

18. CoRPS 18 Predictors of persistent depression Pedersen, Hoogwegt, Theuns et al. Am J Cardiol 2011; ahead-of-print 27 April HR: 2.60 [95% CI: 2.44-1.71] HR: 8.30 [95% CI: 4.42-15.58] HR: 2.09 [95% CI: 1.01-4.29] HR: 1.92 [95% CI: 1.05-3.52] HR: 2.47 [95% CI: 1.36-4.48] HR: 2.29 [95% CI: 1.26-4.15]

19. CoRPS 2. Does distress in these patients matter?

20. CoRPS Whang, Sears et al. J Am Coll Cardiol 2005;45:1090-5 Depression and ventricular tachyarrhythmias Adjusted analysis: HR: 3.2 – time to first shock for VT/VF HR: 3.2 – all shocks for VT/VF including recurrent episodes

21. CoRPS Anxious Type D patients and ventricular tachyarrhythmias van den Broek, Denollet et al. JACC 2009;54:531-7 N = 391

22. CoRPS Posttraumatic stress and mortality Ladwig et al. Arch Gen Psychiatry 2008;65:1325-30 N = 147 HR: 3.45 (95%CI: 1.57-7.60; p =.003)

23. CoRPS Pedersen, Erdman et al. Europace 2010;12:1446-52 Type D personality and high ICD pre- implantation concerns and mortality N = 371 HR: 3.65; 95%CI: 1.57-8.45; p =.003 18.2% 5.2%

24. CoRPS Poor health status and mortality Steinberg et al. Heart Rhythm 2008;5:361-5 N = 738 Overall poorer patient-rated health status in patients who died....

25. CoRPS ICD shock - the paradox Braunschweig, Boriani,... Pedersen et al., Europace 2010;12:1673-90 Stressed out… Me ???!!

26. CoRPS 3. Can we reduce distress?

27. CoRPS ICD shock - the paradox Cardiac psychology has something to offer to patients Reduce catastrophic thinking Alleviate symptoms of anxiety and depression Improve quality of life Effect on survival? Pedersen et al. PACE 2007;30:1546-54; Lewin et al. Heart 2009;95:63-9 Irvine et al. Psychosom Med 2011;73:226-33

28. CoRPS ICD intervention trial - WEBCARE Pedersen et al. Trials 2009;10:120

29. CoRPS Intervention – web application Pedersen et al. Trials 2009;10:120

30. CoRPS Overview Cardiac psychology – adding the patient perspective Psychological factors – risk markers across cardiac diagnoses? How does it work – mind-body(heart) links Take home message

31. CoRPS 0% 2% 4% 6% Non-Type D Type D 0 m3 m 6 m 9 months Type D 254 253 244 242 Non-Type D 621 620 616 609 Numbers at risk RESEARCH Registry Erasmus Medical Center Rotterdam Cumulative proportion at risk (%) HR = 5.31 * [CI 2.1-13.7] p =.002 Pedersen, Erdman et al. J Am Coll Cardiol 2004;44:997-1001 PCI-DES patients: Type D and mortality/MI N = 875

32. CoRPS Peripheral arterial disease: Depression and mortality Cherr al. J Gen Intern Med 2008;23:629-34

33. CoRPS Chronic heart failure: Depression, anxiety, social isolation and mortality Friedmann et al. Am Heart J 2006;152:940.e1-940.e8 Cumulative hazard functions: Adjusted HR: 2.25; 95% CI: 1.05-4.73 Adjusted HR: 0.55; 95% CI: 0.42-0.95 Adjusted HR: 1.03; 95% CI: 0.99-1.07

34. CoRPS Atrial fibrillation: Depression symptoms and rhythm- versus rate-control and mortality Frasure-Smith et al. Circulation 2009;120:134-40 N=947 comorbid AF-CHF Atrial Fibrillation and Congestive Heart Failure trial Rate-control (i.e., beta- blockers and digoxin) versus rhythm-control (i.e., antiarrhythmic medications and electrical cardioversion) 32% had BDI-II scores 14 (mild to moderate symptoms of depression)

35. CoRPS Overview Cardiac psychology – adding the patient perspective Psychological factors – risk markers across cardiac diagnoses? How does it work – mind-body(heart) links Take home message

36. CoRPS Why would depression be bad for the heart? Depression CAD Hemostatic changes Elevated blood pressure Activation of the HPA-axis  HRV Health- related behaviours Release of stress hormones Endothelial damage Inflammation Poor prognosis Risk factor clustering Non- compliance Also effects on QoL, adherance, and compliance !!!

37. CoRPS Overview Steptoe et al. Eur Heart J 2011 Jun 1. [Epub ahead of print]

38. CoRPS Overview Pedersen et al. Eur Heart J 2011 Jun 1. [Epub ahead of print]

39. CoRPS Overview Cardiac psychology – adding the patient perspective Psychological factors – risk markers across cardiac diagnoses? How does it work – mind-body(heart) links Take home message

40. CoRPS Take home message A subset (25%-33%) are at risk of psychological morbidity Psychological factors are independent predictors of prognosis despite state-of-the-art treatment Information on psychological risk and health status are not standardarly assessed nor available as a proxy from patient medical records Screen and monitor – we need to know who they are Multi-factorial psychosocial/behavioral interventions targeted to the individual most likely to be successful

41. CoRPS Institute of Medicine, USA A NEW HEALTH SYSTEM FOR THE 21ST CENTURY Guidelines set out to provide consistent, high-quality medical care to all people: Safe, effective, timely, equitable, efficient and patient- centered…. The Institute of Medicine. Washington DC: National Academy Press 2001 Matlock. Circulation (Editorial TRUST trial) 2010;122:319-21 Big brother is watching you: What do patients think about ICD home monitoring? “To move the care of patients with ICDs, and the entire field of cardiology for that matter, into the next strata of quality, the field must become more patient-centered. Patients’ perspectives, goals, and values should guide all medical trials, guidelines, and decisions.”

42. CoRPS Cardiac psychology – a happy marriage for patients.... Pedersen SS, Kupper N, Denollet J. Psychological factors and heart disease (Chapter 35). The ESC Textbook of Cardiovascular Medicine, 2nd ed. (Eds. J Camm, T Lüscher, P Serruys). Oxford University Press 2009. CARDIOLOGY PSYCHOLOGY

43. CoRPS Living in a Device World: Focus on Recent Challenges and Tools to Improve Clinical Care for Patients with an Implantable Cardioverter Defibrillator Device Conference, 3-4 November 2011, Tilburg, the Netherlands Themes OVERCOMING THE SHOCK OF THE ICD ICD REGISTRIES AND THE INCLUSION OF THE PATIENT PERSPECTIVE DEACTIVATION OF THE ICD AND END OF LIFE ISSUES NEGLECTED SUBGROUPS CRT SELECTION AND RESPONSE THE DO’S AND DON’TS OF PATIENT COMMUNICATION SEXUALITY IN ICD PATIENTS BEHAVIORAL INTERVENTIONS LOOKING INTO THE FUTURE Selection of invited faculty Nico Blom (MD, PhD), Leiden University Medical Center, NL Matthew Burg (PhD), Yale School of Medicine, USA Viviane Conraads (MD, PhD), University Hospital Antwerpen, BE Dorothy Frizelle (PhD), University of Hull, UK Jens Brock Johansen, (MD, PhD), Odense University Hospital, DK Karl-Heinz Ladwig (MD, PhD), Helmholtz Institute, Munich, GE Mathias Meine (MD, PhD), University Medical Center Utrecht, NL Susanne S. Pedersen (PhD), CoRPS, Tilburg University, NL Samuel Sears (PhD), East Carolina University, USA Steen Pehrson (MD, PhD), Copenhagen University Hospital, DK Dominic Theuns (PhD), Erasmus Medical Center Rotterdam, NL More information available on: www.tilburguniversity.edu/device2011