johan denollet, phd the heart failure patient ? why is a dedicated cardiologist not sufficient for...

Johan Denollet, PhDJohan Denollet, PhD

the heart failure patient ?the heart failure patient ?

Why is a dedicated Why is a dedicated cardiologist not sufficient cardiologist not sufficient

forfor

The Netherlands

Dutch Heart Foundation, 2005 Dutch Heart Foundation, 2005

Chronic Heart Failure (CHF)Chronic Heart Failure (CHF)

Emerging epidemicEmerging epidemic

Prevalence: Prevalence:

163.800-176.400 cases 163.800-176.400 cases

Incidence: Incidence:

37.400-43.400 cases 37.400-43.400 cases

in the Netherlandsin the Netherlands

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms





PersonalityPersonality & & CHF: CHF: OverviewOverview

NegativeNegative Affectivity:Affectivity: tendency tendency toto experience negative emotionsexperience negative emotions

(Watson & Pennebaker, 1989)(Watson & Pennebaker, 1989)



What is Type D What is Type D PersonalityPersonality ??

NegativityNegativity


HiHi LoLo



Social Inhibition:Social Inhibition: tendency totendency to inhibit emotions and behaviorsinhibit emotions and behaviors in social interactionin social interaction

(Asendorpf, 1993)(Asendorpf, 1993)



Social Inhibition:Social Inhibition: tendency totendency to inhibit emotions and behaviorsinhibit emotions and behaviors in social interactionin social interaction

(Asendorpf, 1993)(Asendorpf, 1993)




HiHi

InhibitionInhibition

HiHi LoLo

LoLo

OtherOtherType DType D


Negative AffectivityNegative Affectivity

I am often down in the dumpsI am often down in the dumps

I often find myself worrying about I often find myself worrying about somethingsomething

I am often irritatedI am often irritated

Social InhibitionSocial Inhibition

I find it hard to start a conversationI 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 I often feel inhibited in social interactionsinteractions

Negative AffectivityNegative Affectivity

I am often down in the dumpsI am often down in the dumps

I often find myself worrying about I often find myself worrying about somethingsomething

I am often irritatedI am often irritated

Social InhibitionSocial Inhibition

I find it hard to start a conversationI 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 I often feel inhibited in social interactionsinteractions

DenolletDenollet, , Psychosom MedPsychosom Med, , 20020055; ; 67:67: 89-9789-97

DS14 0=FALSE 1=RATHER FALSE 2=NEUTRAL 3=RATHER TRUE 4=TRUE_____________________________________________________________________________ 1 I make contact easily when I meet people - - 0 1 2 3 4 2 I often make a fuss about unimportant things 0 1 2 3 4 3 I often talk to strangers - - - - - - - - - - - - - 0 1 2 3 4 4 I often feel unhappy - - - - - - - - - - - - - - 0 1 2 3 4 5 I am often irritated - - - - - - - - - - - - - - 0 1 2 3 4 6 I often feel inhibited in social interactions 0 1 2 3 4 7 I take a gloomy view of things - - - - - - - - 0 1 2 3 4 8 I find it hard to start a conversation - - - - - 0 1 2 3 4 9 I am often in a bad mood - - - - - - - - - - - 0 1 2 3 4 10 I am a closed kind of person - - - - - - 0 1 2 3 4 11 I would rather keep other people at a distance 0 1 2 3 4 12 I often find myself worrying about something 0 1 2 3 4

13 I am often down in the dumps - - - - - - - - 0 1 2 3 4 14 When socializing, I don’t find the right things 0 1 2 3 4 to talk about_____________________________________________________________________________

Down in the dumpsFeeling blue

AngryWorried

Bad mood

Unhappy

The burden of negative emotions and inhibitionThe burden of negative emotions and inhibition

TypeType DD ?

No!! I do not want to

share my emotionswith others…


0

3

6

9

12

15

18

21

24

27

% o

f pa

tien

ts

Non-Type DType D

23/85

15/218

pp<.0001<.0001

DDeenolletnollet et al., et al., LancetLancet, , 1996; 1996; 347: 417-421347: 417-421

Death 6-10 year FUDeath 6-10 year FU

CAD:CAD: RiskRisk ofof CCardiacardiac EEventsvents

0

3

6

9

12

15

18

21

24

27

% o

f pa

tien

ts

Non-Type DType D

Death/MI 5 year FUDeath/MI 5 year FU

16/86

6/206

23/85

15/218

pp<.0001<.0001pp<.0001<.0001

DDeenollet, Vaes & Brutsaertnollet, Vaes & Brutsaert, , CirculationCirculation, , 2000; 2000; 102: 630-635102: 630-635

Death 6-10 year FUDeath 6-10 year FU

CAD:CAD: RiskRisk ofof CCardiacardiac EEventsvents

0%

2%

4%

6%

Non-Type Non-Type DD

Type DType D

0 m 3 m 6 m 9 months

Type D 254 253 244 242Type D 254 253 244 242Non-Type D 621 620 616 609Non-Type D 621 620 616 609Numbers at risk

RESEARCH TrialRESEARCH TrialErasmus Erasmus

Medical Center Medical Center RotterdamRotterdam

Cu

mu

lati

ve p

rop

ort

ion

at

risk

(%

) HR = 55..3131 * [CI 2.1-13.7] p = .002.002

Pedersen SS et al., Pedersen SS et al., J Am Coll CardiolJ Am Coll Cardiol, , 2004; 44:2004; 44: 997-1001997-1001

Post-PCI Patients:Post-PCI Patients: DeathDeath // MIMI

DDeenolletnollet & Brutsaert& Brutsaert, , CirculationCirculation, , 1998; 1998; 97: 167-17397: 167-173

HR = 4.7

HeartHeart Failure:Failure: DeathDeath // MIMI 9y9y

FUFU

0

5

10

15

20

25

30

35

% o

f Sub

ject

s

Other Type DOR=OR= 3.753.75 pp== .00.0099

LVEF >50%LVEF >50%

DDeenollet nollet et al., et al., in preparationin preparation

DeathDeath // MI MI ((nn==103)103) 6.1 6.1 yrsyrs FUFU

((nn==1068)1068)

LVEF <40%LVEF <40%LVEF 40-50%LVEF 40-50%

OR=OR= 4.894.89 pp== .00.0044

OR= OR= 2.902.90 pp<<.00.000101

Aquarius, DenolletAquarius, Denollet et al., et al., Am J CardiolAm J Cardiol, , 20020055; ; 96:96: 996-1001 996-1001

11

12

13

14

15

16

17

Physi

cal H

ealt

h

10

12

14

16

18O

vera

ll Q

OL

Type D Non-Type D

11

13

15

17

19

Level of

Independence

16

18

20

22

24

Perc

eiv

ed S

tress

P= .0001

P= .0001

PAD patients Healthy subjects




P= .0001

P= .0001

Type DType D & & PAD:PAD: Poor QoLPoor QoL

Independent predictors in multivariable analysis

Type D personalityType D personality 3.043.04[1.50-6.16][1.50-6.16] 0.0020.002

Diabetes mellitusDiabetes mellitus 2.752.75[1.25-6.05] 0.0120.012

Male sex 0.62[0.31-1.24] 0.18

Age 1.02[0.99-1.05] 0.25

Multi-vessel disease1.34[0.69-2.63] 0.39

Sirolimus-eluting stent 0.72[0.37-1.43]0.35

Variable OR [95% CI] p

Pedersen, et al.,Pedersen, et al., Am Heart J, 2006; Am Heart J, 2006; 151: 367.e1-367.e6151: 367.e1-367.e6

Post-PCI:Post-PCI: Depression (1yDepression (1y FU)FU)

Type D (n = 38) Non-Type D (n =46)

Impaired Health Status1

0

5

10

15

20

OR = 2.8; p = .027

Perc

enta

ge

Depressive symptoms2

0

5

10

15

20

OR = 6.00; p = .001

Perc

enta

ge

Positive affect3

0

6

12

18

24

OR = 0.27; p = .008

Perc

enta

geSchiffer et al.,Schiffer et al., Eur J Cardiovasc Prev Rehabil, Eur J Cardiovasc Prev Rehabil, 2005;2005; 12:341-34612:341-346

Heart Failure:Heart Failure: Impaired QoLImpaired QoL

Schiffer et al.,Schiffer et al., Eur J Cardiovasc Prev Rehabil, Eur J Cardiovasc Prev Rehabil, 2005;2005; 12:341-34612:341-346

Heart Failure:Heart Failure: Impaired QoLImpaired QoL

7267

6157

32

1913 14

0

10

20

30

40

50

60

70

80

Anxiety Depression

Pre

vale

nce

Type D - shocks

Type D - no shocks

Non-Type D - shocks

Non-Type D - no shocks

Pedersen et al., Pedersen et al., Psychosom Med, Psychosom Med, 2004; 66:2004; 66: 714-719714-719

p <.001 p <.001

ICD:ICD: Anxiety & DepressionAnxiety & Depression

14

16

18

20

22

24

26

28PRE - Treatment

POST-Treatment

Non-TypeNon-Type DD

p=.001

p=.006

Type DType DPedersenPedersen && DDeenolletnollet, , EurEur JJ CardiovascCardiovasc PrevPrev Rehabil Rehabil 2003;2003; 10:10: 241-8241-8

CABG/PCICABG/PCI:: SymptomsSymptoms ofof FatigueFatigue

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8 PRE - TreatmentPOST-Treatment

Largeeffect

Moderateeffect

Smalleffect

TypeType D EffectD EffectGender EffectGender Effect

CABG/PCICABG/PCI:: GenderGender vversuersuss TypeType DDFatigue

PedersenPedersen && DDeenolletnollet, , EurEur JJ CardiovascCardiovasc PrevPrev Rehabil Rehabil 2003;2003; 10:10: 241-8241-8

Behavioral Pathway:Behavioral Pathway:

failure to quit smokingfailure to quit smoking

poor compliance with treatmentpoor compliance with treatment




Potential PathwaysPotential Pathways




inadequate consultation inadequate consultation behaviorbehavior




inadequate consultation inadequate consultation behaviorbehavior


ConsultationConsultation behaviorbehavior inin

CHFCHF

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


CHFCHF

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

• Influenced by the Influenced by the patient’s appraisalpatient’s appraisal of of the the seriousness seriousness of the of the symptomssymptoms


CHFCHF

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

• Influenced by the Influenced by the patient’s appraisalpatient’s appraisal of of the seriousness of the symptoms the seriousness of the symptoms

• Influenced by the Influenced by the patient’s attitudespatient’s attitudes to to help seekinghelp seeking & & disclosing personal disclosing personal feelingsfeelings

- 178 CHF outpatients, LVEF - 178 CHF outpatients, LVEF ≤ 40%≤ 40%- European Heart Failure Self-Care European Heart Failure Self-Care

Behaviour Scale (Jaarsma et al., 2003)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 behaviorConsultation behavior & &

CHFCHF

Schiffer, Denollet et al., Schiffer, Denollet et al., Submitted for publicationSubmitted for publication

- 178 CHF outpatients, LVEF - 178 CHF outpatients, LVEF ≤ 40%≤ 40%- European Heart Failure Self-Care European Heart Failure Self-Care

Behaviour Scale (Jaarsma et al., 2003)Behaviour Scale (Jaarsma et al., 2003)- 4-item subscale:4-item subscale:

I contact my doctor or nurse, if:I contact my doctor or nurse, if:

My feet/legs become more swollen than My feet/legs become more swollen than usual 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


CHFCHF


(1) Type D patients experienced (1) Type D patients experienced more cardiac more cardiac

symptomssymptoms than non-Type D ( than non-Type D (OROR== 6.4)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)


CHFCHF


(1) Type D patients experienced more cardiac symptoms than non-Type D (OR= 6.4)

(2) Type Ds more often appraised these(2) Type Ds more often appraised these

symptoms as worrisomesymptoms as worrisome ( (OROR== 2.9)2.9)

(3) Paradoxically, they were less likely to report their symptoms to their doctor/nurse (OR=

2.7)


CHFCHF


(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 (3) Paradoxically, they were less likely to report less likely to report

their symptomstheir symptoms to their to their doctor doctor/nurse (/nurse (OROR== 2.7)2.7)


CHFCHF



CHFCHF


p<.00p<.0011 43%43% of the CHF of the CHF

patients who patients who experienced experienced symptoms but symptoms but failed to failed to consult wereconsult were classified asclassified as Type DType D

as compared toas compared toonlyonly 14% 14% of of the the other other patientspatients

Sympt -Sympt - Sympt + Sympt + Sympt +Sympt +

Consult + Consult + ConsultConsult --

Denollet, Denollet, Pedersen SS et al., Pedersen SS et al., Eur Heart JEur Heart J, 2006; 27:171-177, 2006; 27:171-177

Modulating Effect of InhibitionModulating Effect of Inhibition

Behavioral Pathway:Behavioral Pathway: failure to quit smokingfailure to quit smoking poor compliance with treatmentpoor compliance with treatment inadequate consultation inadequate consultation behaviorbehavior

Direct, Physiological Pathway:Direct, Physiological Pathway: cortisol, stress hormonescortisol, stress hormones chronic low-grade inflammationchronic low-grade inflammation


Direct, Physiological Pathway:Direct, Physiological Pathway: cortisol, stress hormonescortisol, stress hormones chronic low-grade inflammationchronic low-grade inflammation



Direct, Physiological Pathway:Direct, Physiological Pathway: cortisol, stress hormonescortisol, stress hormones chronic low-grade inflammationchronic low-grade inflammation pro-inflammatory cytokinespro-inflammatory cytokines


Direct, Physiological Pathway:Direct, Physiological Pathway: cortisol, stress hormonescortisol, stress hormones chronic low-grade inflammationchronic low-grade inflammation pro-inflammatory cytokinespro-inflammatory cytokines


0

10

20

30

40

50

60

70

80

90

100

% o

f Sub

ject

s

Other Type D

pp=.00=.0055

pp=.00=.0099

pp=.00=.0099

TNFTNF- - sTNFR1sTNFR1 sTNFR2sTNFR2

DDeenollet, Conraadsnollet, Conraads et al., et al., Brain, Behav & Immun, Brain, Behav & Immun, 2003; 2003; 17: 304-917: 304-9

TypeType DD & & CCytokinesytokines inin CHFCHF

((nn==42)42)

Type D personalityType D personality 3.3.99 [1.[1.33--1212.1].1] 0.00.01818

Age >60 yrs 2.3 [0.7 - 7.1] 0.16

Male sex 1.4 [0.3 - 5.6] 0.66

LVEF 1.1 [1.0 - 1.1] 0.23

Ischemic heart failure1.5[0.4 - 4.9] 0.54

NYHA class III / IV 2.4 [0.8 - 7.8] 0.13

Variable OR [95% CI] p

IndependentIndependent predictorpredictor sTNFR2sTNFR2

((nn==91)91)

Conraads,Conraads, DDeenollet nollet et al., et al., Int J CardiolInt J Cardiol, , 2006; In Press2006; In Press

Type D or Not Type D ?Type D or Not Type D ?

johan denollet, phd the heart failure patient ? why is a dedicated cardiologist not sufficient for...

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prognosis personality

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closed kind of person

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johan denollet