Transcript Chronic anxiety in ICD patients: A multi

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Disclosures
None
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Center of Research
on Psychology
in Somatic diseases
Impact of psychological profile in heart failure patients
Susanne S. Pedersen, Professor of Cardiac Psychology
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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: [email protected]
www.tilburguniversity.nl/corps
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Overview
• Risky psychological profiles:
o
Depression
o
Anxiety
o
Type D personality
• Challenges and future directions
• Take home message
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Overview
• Risky psychological profiles:
o
Depression
o
Anxiety
o
Type D personality
• Challenges and future directions
• Take home message
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Depression and mortality
Depression prevalence: 22.6%
HR: 1.75 [95% CI: 1.15-2.68]*
* Adjusted analysis
Rumsfeld et al. Am Heart J 2005;150:961-7
N = 634
HR: 1.41 [95% CI: 1.03-1.93]*
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Depression and mortality
N = 471
All-cause: HR: 3.1 [95% CI: 1.4-6.7]*
* Adjusted analysis
Rollman et al. J Cardiac Fail 2012;18:238-45
Cardiac: HR: 2.7 [95% CI: 1.1-6.6]*
Cardiovascular death-free survival stratified by
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No differential impact
depression symptoms and rhythm- versus
rate-control
of rate vs. rhythm
N=947 comorbid AF-HF
Atrial Fibrillation and Congestive
Heart Failure trial
• Rate-control (i.e., betablockers and digoxin) versus
rhythm-control (i.e.,
antiarrhythmic medications
and electrical cardioversion)
• 32% had BDI-II scores 14 (mild
to moderate symptoms of
depression)
Frasure-Smith et al. Circulation 2009;120:134-40
control within
depressed vs. non
depressed
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Overview
• Risky psychological profiles:
o
Depression
o
Anxiety
o
Type D personality
• Challenges and future directions
• Take home message
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Anxiety, depression, social isolation and
mortality
N = 153
Cumulative hazard functions:
Friedmann et al. Am Heart J 2006;152:940.e1-940.e8
Anxiety
moderates
the
effect
of
rhythm
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versus rate control on mortality
N=947 comorbid AF-HF
Benefit
• 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
Frasure-Smith et al. Circ Heart Fail 2012;322-30
Anxiety
and
heart
failure
outcomes:
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free survival
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
De Jong et al. Heart & Lung 2011;40:393-404
N = 147
Anxiety
and
heart
failure
outcomes:
Non
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adherence with medication
N = 147
De Jong et al. Heart & Lung 2011;40:393-404
Non
adherence:
A
mediator
of
the
anxiety
/
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event-free survival relationship
N = 147
De Jong et al. Heart & Lung 2011;40:393-404
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Overview
• Risky psychological profiles:
o
Depression
o
Anxiety
o
Type D personality
• Challenges and future directions
• Take home message
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Impact of Type D on cardiac mortality*
Type-D
Non type-D
p =.04
p =.02
35
Cardiac mortality (%)
15/48
30
13/46
25
20
32/184
15
23/175
p =.83
10
2/48
5
0
Total cardiac mortality
9/184
Early cardiac mortality
(≤6 months)
* Adjusted for age, sex and LVEF
Schiffer et al. Int J Cardiol 2010;142:230-5
Late cardiac mortality
(>6 months)
N = 232
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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
Predictors of 12-month disease-specific and
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generic health status (adjusted)
N = 166
Disease-specific
health (MLWHFQ)
Mental health
(SF-36; MCS)
Generic physical health
(SF-36; PCS)
OR (95%CI)
p
OR (95%CI)
p
OR (95%CI)
p
Type-D personality
2.5 (.98-6.61)
.06
3.8 (1.4-10.2)
<.001
ns
ns
Depressive symptoms
3.2 (1.3-8.1)
.01
ns
ns
3.2 (1.3-7.8)
.009
NYHA functional class
ns
ns
ns
ns
2.4 (1.0-5.5)
.04
3.3 (1.1-9.9).
.04
ns
ns
ns
ns
Spironolactone
ns
ns
ns
ns
ns
ns
Long-acting nitrates
ns
ns
ns
ns
ns
ns
Psychopharmaca
ns
ns
ns
ns
ns
ns
3.4 (1.4-8.1)
.007
9.6 (3.7-24.8)
< .001
3.9 (1.7-9.0)
.002
Age
ns
ns
ns
ns
ns
ns
Sex
ns
ns
ns
ns
ns
ns
LVEF
1.1 (1.0-1.2)
.02
ns
ns
ns
ns
Diuretics
Baseline health status
Schiffer, Pedersen et al. Eur J Heart Fail 2008;10:802-10
Self-management
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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)
Schiffer, Denollet et al. Heart 2007;93:814-8
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Overview
• Risky psychological profiles:
o
Depression
o
Anxiety
o
Type D personality
• Challenges and future directions
• Take home message
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Challenges
• Confounding with disease severity
• Stability of measures – timing of assessment
• Actionability based on current evidence
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Confounding of
psychological factors
with disease severity
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Type D and primary care HF patients
N = 363
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)
Scherer, Herrmann-Lingen et al. Herz 2006;31:347-54
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LVEF post-MI in depression and Type D
N = 1205 MI patients
Post-MI depression
Type D personality
- (%)
+ (%)
OR (95% CI)
- (%)
+ (%)
OR (95% CI)
Z
p
LVEF <45%
20.1
41.8
2.84 (2.05-3.94)
23.0
27.8
1.29 (0.92-1.76)
3.29
<.001
Charlson >2
22.7
26.0
1.20 (0.85-1.69)
24.0
19.8
0.78 (0.55-1.12)
1.72
.08
Previous MI
13.0
13.2
1.01 (0.65-1.58)
13.3
12.1
0.90 (0.58-1.40)
0.36
.72
PTCA
39.9
52.3
1.66 (1.23-2.25)
40.4
49.1
1.42 (1.06-1.90)
0.73
.46
CABG
5.1
3.9
0.75 (0.35-1.60)
5.1
4.0
0.78 (0.38-1.61)
-0.07
.94
De Jonge et al. J Psychosom Res 2007;63:477-82
Equality test
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Stability of
psychological factors
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Stability of mood states and Type D over time
Entry: baseline assessment
End: following rehabilitation
(a) TYPE D PERSONALITY
16
14
12
10
8
6
4
2
Negative Affectivity
Social Inhibition
N = 121
(b) MOOD: Negative Affect
16
14
31
12
28
10
25
8
22
6
19
4
16
2
Measure X Time Effect
F(1,119)=52.0, p<.0001
0
0
Entry score
End score
(c) HEALTH COMPLAINTS
34
13
Measure X Time Effect
F(1,119)=42.1, p<.0001
10
Entry score
Denollet. Psychosom Med 2005;67:89-97
End score
Entry score
End score
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Incorporation of
psychological factors in
clinical practice
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Increase level of
evidence – largescale studies and
registries
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Overview
• Risky psychological profiles:
o
Depression
o
Anxiety
o
Type D personality
• Challenges and future directions
• Take home message
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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)