1. CoRPS Center of Research on Psychology in Somatic diseases Positive and negative emotions and heart disease 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 E-mail: s.s.pedersen@uvt.nl www.tilburguniversity.nl/corps

3. CoRPS Negative emotions and heart health

4. CoRPS Stress Type D Type A Depression Anger Anxiety PTSD Vital exhaustion Social isolation Hostility

5. CoRPS Prevalence of negative emotions in patients with heart disease A subset of patients: 1 in 4 (25%)

6. CoRPS Depression and death/MACE: Peripheral arterial disease Cherr al. J Gen Intern Med 2008;23:629-34 N = 257 Adjusted HR: 2.05 [95% CI: 1.16-1.86]

7. CoRPS Depression and clinical and functional status: Chronic heart failure Parissis et al. Heart J 2008;94:585-9 N = 155

8. 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 [95% CI: 2.1-13.7] Pedersen et al. J Am Coll Cardiol 2004;44:997-1001 Type D personality and mortality/MI: PCI patients N = 875

9. CoRPS Depression symptoms and mortality: Atrial fibrillation Frasure-Smith et al. Circulation 2009;120:134-40 N=947 comorbid AF-CHF 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)

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

11. CoRPS Impact of negative emotions on heart disease Enhanced morbidity Increased mortality (2-fold risk) Decreased quality of life Poor compliance Doctor-patient communication Attenuated health-care costs Negative emotions cluster together  clustering leads to worse prognosis Pedersen SS et al. ESC TEXTBOOK OF CARDIOVASCULAR MEDICINE (Chapter 37), 2 nd edition. Oxford University Press, 2009.

12. CoRPS Why would negative emotions be bad for the heart? Negative emotions 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

13. CoRPS What about positive emotions and heart health?

14. CoRPS Positive affect and anhedonia Positive affect: Joy Cheerfulness Interest or pleasure in (almost) all activities Davidson et al. Eur Heart J 2010:31:1065-70 Rozanski et al. Psychosom Med 2005;67:47-53 Lack of positive affect (anhedonia): Markedly diminished interest or pleasure in all, or almost all activities

15. CoRPS Positive and negative emotions – mutually exclusive or co-occurring? High positive affect Low positive affect Low negative affect Tellegen et al. Psych Science 1999;10:297-303 Larsen et al. J Person Soc Psychol 2001:81:684-96 High negative affect 1. Polar opposites and mutually exclusive Negative affectPositive affect 2. Separable and mixed feelings Anhedonia

16. CoRPS Matthews et al. Psychosom Med 2004;66:640-4 Optimism and progression of carotid disease: Healthy women Figure 1. Percent increase in IMT during 3 years according to quartiles of LOT scores at study entry 10.4 years earlier where highest quartile is most pessimistic and the lowest quartile is most optimistic. Linear trend, p <.002; quadratic trend, p <.06 N = 209 Optimistic Pessimistic

17. CoRPS Versteeg, Pedersen et al. Qual Life Res 2009;18:953-60 Positive affect moderates the impact of high negative affect on health status: PCI patients N = 562

18. CoRPS Positive and negative emotions and mortality: ICD patients N = 591 van den Broek, Denollet et al. Int J Cardiol In Press

19. CoRPS Davidson et al. Arch Gen Psychiatry 2010;67:480-88 Depression, anhedonia and MACE/mortality: ACS patients Two core symptoms of depression: (1) Depressed mood; (2) Anhedonia (lack of pleasure / interest) N = 453 HR:2.17 [95% 1.26-3.73]* * Adjusted HRs HR:0.80 [95% 0.47-1.35]* The two symptoms are distinct with differential impact on prognosis

20. CoRPS Enjoyment of usual activities and mortality: Medical inpatients N = 572 Scherer et al. Gen Hospital Psychiatry 2009;31:8-13 HADS item # 1: “I still enjoy things that I used to enjoy” Anhedonia

21. CoRPS Denollet, Pedersen, van Domburg et al. J Intern Med 2008;263:203-11 Reduced positive affect (anhedonia) and 2- year MI/mortality: PCI patients RESEARCH registry

22. CoRPS Reduced positive affect (anhedonia) and 7- year mortality: PCI patients Damen, van Domburg, Pedersen et al. Submitted P <.001 22.7% 13.2% * Also for negative emotions! RESEARCH registry Adjusted* HR: 1.51 [95% CI:1.03-2.22] Poster # 81860 28/8 14.00-18.00

23. CoRPS Take home message Negative and positive emotions likely form two separate constructs and not opposite ends of a continuum Negative emotions (e.g. depression) and positive emotions (e.g. optimism) are associated with morbidity and mortality Difference between presence and absence of positive emotions  e.g. optimism = protective; lack of positive emotions = risk Association likely influenced by assessment tool and outcome

24. CoRPS Don’t worry, be happy! Take emotions seriously New target for rehabilitation: INCREASING POSITIVE EMOTIONS

25. 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