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

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

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

PersonalityPersonality & & CHF: CHF: OverviewOverview

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

• 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)

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

NegativityNegativity

HiHi LoLo

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

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

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

(Asendorpf, 1993)(Asendorpf, 1993)

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

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

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

(Asendorpf, 1993)(Asendorpf, 1993)

What is Type D What is Type D PersonalityPersonality ??

NegativityNegativity

NegativityNegativity

HiHi

InhibitionInhibition

HiHi LoLo

LoLo

OtherOtherType DType D

What is Type D What is Type D PersonalityPersonality ??

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

What is Type D What is Type D PersonalityPersonality ??

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…

What is Type D What is Type D PersonalityPersonality ??

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

PersonalityPersonality & & CHF: CHF: OverviewOverview

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

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

PersonalityPersonality & & CHF: CHF: OverviewOverview

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

PAD patients Healthy subjects

PAD patients Healthy subjects

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

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

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

• TypeType D PersonalityD Personality

• Personality and Personality and PrognosisPrognosis

• Personality and QoLPersonality and QoL

• Potential mechanismsPotential mechanisms

PersonalityPersonality & & CHF: CHF: OverviewOverview

Behavioral Pathway:Behavioral Pathway:

failure to quit smokingfailure to quit smoking

poor compliance with treatmentpoor compliance with treatment

Behavioral Pathway:Behavioral Pathway:

failure to quit smokingfailure to quit smoking

poor compliance with treatmentpoor compliance with treatment

Potential PathwaysPotential Pathways

Behavioral Pathway:Behavioral Pathway:

failure to quit smokingfailure to quit smoking

poor compliance with treatmentpoor compliance with treatment

inadequate consultation inadequate consultation behaviorbehavior

Behavioral Pathway:Behavioral Pathway:

failure to quit smokingfailure to quit smoking

poor compliance with treatmentpoor compliance with treatment

inadequate consultation inadequate consultation behaviorbehavior

Potential PathwaysPotential Pathways

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)

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)

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

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)

• 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

Consultation behaviorConsultation behavior & &

CHFCHF

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

(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)

Consultation behaviorConsultation behavior & &

CHFCHF

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

(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)

Consultation behaviorConsultation behavior & &

CHFCHF

Schiffer, Denollet et al., Schiffer, Denollet et al., Submitted for publicationSubmitted 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 (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)

Consultation behaviorConsultation behavior & &

CHFCHF

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

Consultation behaviorConsultation behavior & &

CHFCHF

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

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

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

Potential PathwaysPotential Pathways

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 pro-inflammatory cytokinespro-inflammatory cytokines

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 pro-inflammatory cytokinespro-inflammatory cytokines

Potential PathwaysPotential Pathways

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 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 ?