Transcript Emotional Distress and Subjective AF Symptoms before and

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Type D personality & haemoglobin in CHF
Center of Research
on Psychology
in Somatic diseases
Nina Kupper PhD
Aline Pelle PhD
Balázs M. Szabó MD PhD
Johan Denollet PhD
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Acknowledgment & disclosure
Data were collected in two large prospective cohort studies:
St. Elisabeth hospital Tilburg (PhD thesis dr. Pelle 2009)
TweeSteden hospital (PhD thesis dr. Schiffer 2007)
Acknowledge dr. Ramakers (Clinical-Chemistry & Haematology lab) for
performing biomedical assays
Funding: NWO VICI grant (NWO 453-04-004) and a Dutch Heart Foundation
(2003B038) both awarded to Prof.dr. Johan Denollet
No conflicts of interest to disclose
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Background
• Anaemia is a common comorbidity in CHF
• Related to
– chronic kidney dysfunction
– increased CHF morbidity and mortality
Chronic kidney
dysfunction
Anemia
CHF
• Triggers:
– Kidney dysfunction (decrease in erythropoietin levels)
– Pro-inflammatory cytokines inhibit haematopoietic proliferation
– hemodilution due to the increased plasma volume (preserved kidney)
Casadevall 1995, Anand 2008, Adlbrecht, Kommata et al. 2008
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Background and research question
• Animal research: psychological stress may promote anaemia
– acute psychological stress  decrease blood and bone marrow iron, inhibit erythropoiesis 1
– chronic distress  even lower plasma iron levels 1
• Research in humans: depressed mood associated with anaemia in
patient populations 2 and community-dwelling elderly pops 3
• EPO treatment in CHF: improvement in depressive symptoms 4
• Type D (Distressed) personality: increased mortality in CHF 5
Mechanism?
Examine the prospective association of Type D personality with
haemoglobin levels, while controlling for clinical correlates of CHF.
1
Teng, Sun et al. 2008; Wei, Zhou et al. 2008
2 Krishnan, Grant et al. 2006
3 Onder,
Penninx et al. 2005; Lucca, Tettamanti et al. 2008
Kourea, Parissis et al. 2008
5 Denollet and Brutsaert 1998
4
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Methods: participants & procedure
Sample
Inclusion
Exclusion
318 consecutive CHF outpatients (response rate = 77%)
stable, LVEF≤ 40%; age ≤ 80 years; NYHA-class I-III
life-threatening comorbidities; presence of evident
cognitive impairments; psychiatric comorbidity (except
for mood disorders); insufficient understanding of the
Dutch language, or signs of acute infection (blood)
Baseline
12 months FU
Questionnaire
Questionnaire
Blood sample
Blood sample
Type D (Distressed) personality
• Prevalence
No!!13-32.5%
– Normal population:
I do not
want to
– Cardiac patients:
26-53%
share my emotions
• Construct
with others…
– Negative affectivity
Tendency to experience negative
emotions
– Sociale inhibition
Tendency to suppress emotions in social
interaction
Denollet. Psychosom Med 2005; 67:89-97
Denollet, Pedersen et al. Eur Heart J 2006;27:171-7
p=.014 *
38/254
15
p=.94 *
Adverse Cardiac Events (%)
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10
49/485
13/136
Type D ?
5
0
Inhibition - Inhibition +
NEGATIVITY -
NEGATIVITY +
Presence of both NA and SI essential for
negative effect on prognosis (RESEARCH
Registry)
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Methods: blood measures
• Plasma Hb was used as an indicator of anaemia (K-DOQI guidelines)
• Anaemia: Hb levels of ≤12g/dL (7.5 mmol/L) for women and <13g/dL (8.1
mmol/L) for men (WHO guidelines)
• Kidney dysfunction: creatinin was determined and used to calculate GFR
(MDRD-equation); GFRcreat <60 mL/min per 1.73m2
• Hb levels (ric=.51, p<.001) and kidney function (ric=.85, p<.001) were relatively
stable over 1 year
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Results: Type D, Hb levels and anaemia
prevalence
Inclusion:
Hb levels similar for non-Type D and Type D CHF
patients (p=.23)
12-mo FU:
Hb levels significantly lower in patients with a
Type D personality (β= -.14, t=-2.28, p=.02)
Inclusion:
Prevalence of anaemia (WHO): 15.5% in nonType Ds and 15.7% in Type D patients
12-mo FU:
17% of non-Type Ds and 28.6% of Type D patients
were classified as anaemic
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Results: Multivariate regression
Type D personality predicted Hb levels at 12 months follow-up
independent from gender, kidney dysfunction & CHF severity
Haemoglobin
Type D personality
Female sex
Kidney dysfunction
NYHA-class
LVEF
Stand. β
t
p
-.12
-.32
-.26
-.15
-.07
-2.16
-5.73
-4.75
-2.61
-1.29
.03
<.001
<.001
.01
.57
Collinearity statistics: acceptable tolerance, inter-predictor r=-.23 - .17 (low)
25% of variance was explained
R2 due to Type D personality = equal in proportion to the effect of NYHA class
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Conclusion & discussion
• In CHF patients, Type D personality was independently associated with
decreased Hb levels at 12-month follow-up, along with kidney dysfunction,
gender, and higher NYHA functional class
• In line with previous studies on depression/poor QoL & anaemia
• Results suggest distress may affect cardiac prognosis a.o. by affecting anaemia
– targeting haemoglobin in emotionally distressed patients?
– In renal failure pt, increasing Hb levels may have deleterious side-effects (e.g.
vasoconstriction, venous thrombosis) that may challenge the benefit of anaemia
correction in CHF (CREATE, CHOIR, van der Meer, Groenveld et al. 2009)
• Results support recommendation to screen for psychological factors (MacMahon &
Lip 2002)
– might contribute to the identification of CHF patients at increased risk for adverse health
outcomes.
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Limitations
• No information on iron blood levels or iron intake
• Although our study design was longitudinal, no
final conclusions can be drawn regarding causality
• CHF patients are characterized by multimorbidity
and polypharmacy. This was slightly more
pronounced for some biomedical variables,
although not significantly, in Type D patients.
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Take home message
• Type D personality independently predicted
decreased Hb levels at 12-month follow-up
• Important to consider/screen for psychological
distress as this does affect somatic health
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Discussion (2) BACK UP SLIDE
• Potential mechanism:
Type D
personality
IL-6
inhibit erythropoietin production in
the kidney
TNF-α
Inhibit proliferation of bone marrow
erythroid progenitor cells
Denollet et al. 2008
Denollet, Kupper et al. 2009
Anaemia
CHF
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BACK UP SLIDE descriptives 1
Demographics
Male sex
Age (yrs), mean (SD)
Living without a partner
Biomedical risk factors
BMI (kg/m2) b
Smoking
Hypertension
Hypercholesterolemia
Diabetes
Disease characteristics
Ischemic aetiology b
LVEF, mean (SD)
NYHA class III c
Time since diagnosis (yrs), mean (SD)b
Total
(n=312)
Type D
(n=64)
non-Type D
(n=248)
p
75.3 (235)
65.9 (9.9)
25.6 (80)
71.9 (46)
67.2 (10.4)
29.7 (19)
76.2 (189)
65.5 (9.8)
24.6 (61)
.47
.25
.41
27.9 (5.0)
22.8 (71)
35.6 (111)
54.8 (171)
23.7 (74)
28.0 (5.5)
15.6 (10)
37.5 (24)
57.8 (37)
26.6 (17)
27.9 (4.9)
24.6 (61)
35.1 (87)
54.0 (134)
23.0 (57)
.89
.13
.72
.59
.55
58.1 (180)
31.7 (6.7)
31.7 (99)
7.2 (4.5)
53.2 (33)
32.2 (6.3)
35.9 (23)
7.7 (5.2)
59.3 (147)
31.6 (6.8)
30.6 (76)
7.0 (4.2)
.39
.53
.42
.23
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BACK UP SLIDE descriptives 2
Interventions
PCI
CABG
Device therapy d
Prescribed medications
Diureticse
Lisdiuretics only
Thiazides only
Combined
Beta-blockers
ACE-inhibitors
ARB
Digoxin
Calcium-antagonists
Oral anticoagulants
Aspirin
Statins
Psychotropic medication
16.0 (50)
26.9 (84)
12.5 (39)
15.6 (10)
29.7 (19)
12.5 (8)
16.1 (40)
26.2 (65)
12.5 (31)
62.2 (194)
3.2 (10)
6.1 (19)
66.5 (206)
71.8 (224)
19.9 (62)
25.3 (79)
13.5 (42)
47.4 (148)
38.1 (93)
53.5 (167)
13.8 (43)
76.6 (49)
1.6 (1)
4.7 (3)
68.3 (43)
75.0 (48)
21.9 (14)
32.8 (21)
25.0 (16)
40.6 (26)
40.6 (26)
53.1 (34)
18.8 (12)
58.5 (145)
3.6 (9)
6.5 (16)
66.0 (163)
71.0 (176)
19.4 (48)
23.4 (58)
10.5 (26)
49.2 (122)
37.5 (93)
53.6 (133)
12.5 (31)
.92
.58
.99
.06
.73
.52
.65
.12
.002
.22
.65
.94
.20