1. CoRPS Disclosures None

2. CoRPS Center of Research on Psychology in Somatic diseases Impact of psychological profile in heart failure patients Susanne S. Pedersen, Professor of Cardiac Psychology

3. 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 & Institute of Psychology, Southern University of Denmark, Denmark E-mail: s.s.pedersen@uvt.nl www.tilburguniversity.nl/corps

4. CoRPS

5. Overview Risky psychological profiles: o Depression o Anxiety o Type D personality Challenges and future directions Take home message

6. CoRPS Overview Risky psychological profiles: o Depression o Anxiety o Type D personality Challenges and future directions Take home message

7. CoRPS Depression and mortality Rumsfeld et al. Am Heart J 2005;150:961-7 N = 634 Depression prevalence: 22.6% HR: 1.75 [95% CI: 1.15-2.68]* HR: 1.41 [95% CI: 1.03-1.93]* * Adjusted analysis

8. CoRPS Depression and mortality Rollman et al. J Cardiac Fail 2012;18:238-45 N = 471 All-cause: HR: 3.1 [95% CI: 1.4-6.7]* Cardiac: HR: 2.7 [95% CI: 1.1-6.6]* * Adjusted analysis

9. CoRPS Cardiovascular death-free survival stratified by depression symptoms and rhythm- versus rate-control Frasure-Smith et al. Circulation 2009;120:134-40 N=947 comorbid AF-HF 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) No differential impact of rate vs. rhythm control within depressed vs. non depressed

10. CoRPS Overview Risky psychological profiles: o Depression o Anxiety o Type D personality Challenges and future directions Take home message

11. CoRPS Anxiety, depression, 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 N = 153

12. CoRPS Anxiety moderates the effect of rhythm versus rate control on mortality Frasure-Smith et al. Circ Heart Fail 2012;322-30 N=947 comorbid AF-HF Adjusted HR: 0.55; 95% CI: 0.32-0.95 ASI = tendency to fear and catastrophize in response to bodily symptoms No main effect of ASI Benefit of rhythm vs. rate control in high ASI patients Adjusted HR: 1.24; 95% CI: 0.91-1.69 Benefit

13. CoRPS Anxiety and heart failure outcomes: Event- free survival De Jong et al. Heart & Lung 2011;40:393-404 N = 147 Highest anxiety group more likely to (i) visit the ED, (ii) be hospitalized, (iii) die - HR: 2.2 [95% CI: 1.1 – 4.3]; p =.03

14. CoRPS Anxiety and heart failure outcomes: Non adherence with medication De Jong et al. Heart & Lung 2011;40:393-404 N = 147

15. CoRPS Non adherence: A mediator of the anxiety / event-free survival relationship De Jong et al. Heart & Lung 2011;40:393-404 N = 147

16. CoRPS Overview Risky psychological profiles: o Depression o Anxiety o Type D personality Challenges and future directions Take home message

17. CoRPS Impact of Type D on cardiac mortality* N = 232 Schiffer et al. Int J Cardiol 2010;142:230-5 * Adjusted for age, sex and LVEF

18. CoRPS Impact of Type D on all-cause mortality N = 641 (Mean FU = 3 yrs) Pelle, Pedersen, Denollet et al. Circ Heart Fail 2010:3:261-7

19. CoRPS Predictors of 12-month disease-specific and generic health status (adjusted) Disease-specific health (MLWHFQ) Mental health (SF-36; MCS) Generic physical health (SF-36; PCS) OR (95%CI) p p p Type-D personality2.5 (.98-6.61).063.8 (1.4-10.2)<.001ns Depressive symptoms3.2 (1.3-8.1).01ns 3.2 (1.3-7.8).009 NYHA functional classns 2.4 (1.0-5.5).04 Diuretics3.3 (1.1-9.9)..04ns Spironolactonens Long-acting nitratesns Psychopharmacans Baseline health status3.4 (1.4-8.1).0079.6 (3.7-24.8)<.0013.9 (1.7-9.0).002 Agens Sexns LVEF1.1 (1.0-1.2).02ns N = 166 Schiffer, Pedersen et al. Eur J Heart Fail 2008;10:802-10

20. CoRPS Schiffer, Denollet et al. Heart 2007;93:814-8 Self-management Heart failure patients with Type D: report more cardiac symptoms (OR: 6.4; 95% CI: 2.5-16.3; p <.001) worry more about their symptoms (OR: 2.9; 95% CI: 1.3-6.6; p <.01) but are less likely to consult doctor/nurse (OR: 2.7; 95% CI: 1.2-6.0; p =.02)

21. CoRPS Overview Risky psychological profiles: o Depression o Anxiety o Type D personality Challenges and future directions Take home message

22. CoRPS Confounding with disease severity Stability of measures – timing of assessment Actionability based on current evidence Challenges

23. CoRPS Confounding of psychological factors with disease severity

24. CoRPS Type D and primary care HF patients Type D personality was not related to measures of disease severity: o NYHA class ( 2 = 3.90; p =.14) o Goldman’s Specific Activity Scale (SAS) ( 2 = 4.50; p =.11) N = 363 Scherer, Herrmann-Lingen et al. Herz 2006;31:347-54

25. CoRPS De Jonge et al. J Psychosom Res 2007;63:477-82 LVEF post-MI in depression and Type D Post-MI depression Type D personality Equality test - (%)+ (%)OR (95% CI) - (%)+ (%)OR (95% CI)Zp LVEF <45%20.141.82.84 (2.05-3.94)23.027.81.29 (0.92-1.76)3.29<.001 Charlson >222.726.01.20 (0.85-1.69)24.019.80.78 (0.55-1.12)1.72.08 Previous MI13.013.21.01 (0.65-1.58)13.312.10.90 (0.58-1.40)0.36.72 PTCA39.952.31.66 (1.23-2.25)40.449.11.42 (1.06-1.90)0.73.46 CABG5.13.90.75 (0.35-1.60)5.14.00.78 (0.38-1.61)-0.07.94 N = 1205 MI patients

26. CoRPS Stability of psychological factors

27. CoRPS Measure X Time Effect F(1,119)=52.0, p<.0001 Entry score End score Measure X Time Effect F(1,119)=42.1, p<.0001 (c) HEALTH COMPLAINTS (b) MOOD: Negative Affect (a) TYPE D PERSONALITY Entry score End score Denollet. Psychosom Med 2005;67:89-97 Entry: baseline assessment N = 121 End: following rehabilitation Stability of mood states and Type D over time

28. CoRPS Incorporation of psychological factors in clinical practice Interventions

29. CoRPS Increase level of evidence – large- scale studies and registries

30. CoRPS Overview Risky psychological profiles: o Depression o Anxiety o Type D personality Challenges and future directions Take home message

31. CoRPS Cardiology & psychology: Perhaps not a such strange marriage...

32. CoRPS Take home message The psychological profile of the patient matters Psychological factors are not standardly assessed in clinical cardiology practice nor can a proxy be derived from the medical records Screen and monitor – we need to know who they are Informed decision with respect to which measures to use (e.g. issue of confounding, stability etc.) Optimalization of HF care (e.g. adjunctive intervention)