Psychosocial distress and health status as risk factors for ten-year major adverse cardiac events and mortality in patients with non-obstructive coronary artery disease.

BACKGROUND: We examined the risk of psychosocial distress, including Type D personality, depressive symptoms, anxiety, positive mood, hostility, and health status fatigue and disease specific and generic quality of life for MACE in patients with non-obstructive coronary artery disease (NOCAD). METHODS: In the Tweesteden mild stenosis (TWIST) study, 546 patients with NOCAD were followed for 10 years to examine the occurrence of cardiac mortality, a major cardiac event, or non-cardiac mortality in the absence of a cardiac event. Cox proportional hazard models were used to examine the impact of psychosocial distress and health status on the occurrence of MACE while adjusting for age, sex, disease severity, and lifestyle covariates. RESULTS: In total 19% of the patients (mean age baseline = 61, SD 9 years; 52% women) experienced MACE, with a lower risk for women compared to men. Positive mood (HR 0.97, 95%CI 0.95-1.00), fatigue (HR 1.03, 95%CI 1.00-1.06), and physical limitation (HR 0.99, 95%CI 0.98-1.00) were associated with MACE in adjusted models. No significant interactions between sex and psychosocial factors were present. Depressive symptoms were predictive of MACE, but no longer after adjustment. CONCLUSIONS: In patients with NOCAD fatigue, low positive mood, and a lower physical limitation score were associated with MACE, without marked sex differences. Type D personality, psychosocial factors, and health status were not predictive of adverse outcomes. Reducing psychosocial distress is a valid intervention goal by itself, though it is less likely to affect MACE in patients with NOCAD.

The role of sex and gender in somatic complaints among patients with coronary heart disease: A longitudinal study on acute and long-term changes.

BACKGROUND: Somatic complaints are persistently reported in patients with coronary heart disease (CHD). Sex and gender influence health and well-being in a variety of ways, but it is unknown how they affect somatic complaints over time after percutaneous coronary intervention (PCI). Therefore, we examined the association between sex and gender on somatic health complaints during the first month (acute) and the first two years (recovery) after PCI. METHODS: 514 patients (Mage = 64.2 ± 8.9, 84.2% male) completed the somatic scale of the Health Complaints Scale (including the subscales: cardiopulmonary complaints, fatigue, sleep problems) at baseline, one, 12-, and 24-months post-PCI. In a follow-up study, they filled in additional questionnaires to gauge gender norms, traits, and identity. Linear mixed modeling analyses were used to assess the influence of sex, gender, their interaction, and covariates on somatic complaints for the acute and recovery phases separately. RESULTS: A general decline in somatic complaints over time was observed during the acute phase, followed by a stabilization in the recovery phase. Females and individuals with more feminine traits, norms, and identities reported increased somatic complaints. Males with more pronounced feminine norms and females with more masculine norms likewise reported more somatic, cardiopulmonary, and fatigue complaints. Furthermore, age, cardiac history, and comorbid diseases partly explained the associations with somatic complaints. CONCLUSION: While somatic complaints improve post-PCI, there are still conspicuous sex and gender differences that need to be considered. Future research should further elaborate upon these discrepancies and incorporate sex and gender in prevention and develop tailored interventions to diminish somatic complaints.

Sex and Gender Differences in Psychosocial Risk Profiles Among Patients with Coronary Heart Disease - the THORESCI-Gender Study.

BACKGROUND: Psychosocial factors tend to cluster and exhibit differences associated with sex assigned at birth. Gender disparities, though, remain uncharted so far. The current study aimed to first explore the clustering of eight established psychosocial risk factors among patients with coronary heart disease (CHD), followed by examining how sex and gender differences characterize these psychosocial risk profiles, while adjusting for the effect of age. METHOD: In total, 532 patients with CHD (Mage = 68.2 ± 8.9; 84% male) completed the comprehensive psychosocial screener and questionnaires to gauge gender identity, traits, and sociocultural norm scores. A three-step latent profile analysis (LPA) was performed to identify latent profiles and their correlates. RESULTS: LPA revealed six psychosocial risk profiles: (1) somewhat distressed overall (32%); (2) low distress (27%); (3) anger, hostility, and Type D (15%); (4) emotional distress and trauma (11%); (5) anxiety (9%); and (6) high overall distress (7%). Masculine traits and older age increased the odds to belong to the low distress profile (#2), while feminine traits and a feminine gender norm score increased the chance to belong to profiles with moderate to high distress. The effects of gender identity and feminine traits were sex dependent. CONCLUSION: The current study's findings explain heterogeneity among patients with CHD by considering the joint occurrence of psychosocial risk factors, and the role of sex, age, and gender within those profiles. Being more sensitive to the roles that sex, gender, and an integrated set of risk factors play may ultimately improve treatment and adherence.

A Network Analysis of Cardiovascular Risk Factors in Patients With Heart Disease: The Role of Socioeconomic Status and Sex.

OBJECTIVE: Diverse risk factors influence the development and prognosis of coronary heart disease (CHD) independently and mutually. Low socioeconomic status (SES) seems to exacerbate these risk factors' influences. In addition, sex differences have been identified for individual risk factors. Network analysis could provide in-depth insight into the interrelatedness of the risk factors, their predictability, and the moderating role of sex, to ultimately contribute to more refinement in prevention and cardiac rehabilitation. METHODS: A total of 1682 participants (78% male; mean [standard deviation] age = 69.2 [10.6] years) with CHD completed questionnaires on psychosocial factors and health behaviors. Cardiometabolic data were retrieved through medical records. An SES index was created based on self-reported occupation, education, and area (i.e., postal code)-based median family income. Using R, we conducted a mixed graphical model network analysis on all risk factors combined with and without the moderating role of sex. RESULTS: SES belonged to the more influential risk factors with moderate to high levels of expected influence and degree centrality, indicating that it plays a considerable role in the risk factor network. When considering the moderating role of sex, relationships between SES and most risk factors were found to be stronger for women ( b = 0.06-0.48). CONCLUSIONS: The current study provided an insight into an interrelated network of psychosocial and medical risk factors among CHD patients. With SES belonging to the more influential risk factors and female sex influencing the strength of all the SES-risk factor relationships, cardiac rehabilitation and prevention techniques could be more refined by accounting for both influences.

Psychosocial factors may serve as additional eligibility criteria for cardiovascular risk screening in women and men in a multi-ethnic population: The HELIUS study.

Cardiovascular disease (CVD) prevention strategies include identifying and managing high risk individuals. Identification primarily occurs through screening or case finding. Guidelines indicate that psychosocial factors increase CVD risk, but their use for screening is not yet recommended. We studied whether psychosocial factors may serve as additional eligibility criteria in a multi-ethnic population without prior CVD. We performed a cross-sectional analysis using baseline data of 10,226 participants of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin aged 40-70 years, living in Amsterdam, the Netherlands. Using logistic regressions and Akaike Information Criteria, we analyzed whether psychosocial factors (educational level, employment status, occupational level, financial stress, primary earner status, mental health, stress, depression, and social isolation) improved prediction of high CVD risk (SCORE-estimated fatal and non-fatal CVD risk ≥5%) beyond eligibility criteria from history taking (smoking, obesity, family history of CVD). Next, we compared the additional predictive value of psychosocial eligibility criteria in women and men across ethnic groups, using the area under the curve (AUC). Of our sample, 32.7% had a high CVD risk. Only socioeconomic eligibility criteria (employment status and educational level) improved high CVD risk prediction (p < .001 for likelihood-ratio tests). These increased AUCs in women (from 0.563 to 0.682) and men (from 0.610 to 0.664), particularly in Dutch, South-Asian Surinamese, African Surinamese and Moroccan women, and Dutch and Moroccan men. Concluding, socioeconomic eligibility criteria may be considered as additional eligibility criteria for CVD risk screening, as they improve detection of women and men at high CVD risk.

ShareHeart: A patient journey map of patients with ischemia and non-obstructive coronary artery disease based on qualitative research.

AIMS AND OBJECTIVES: To visualise the health care experiences and needs of patients with ischemia with non-obstructive coronary arteries in a patient journey map. As such, future design challenges can be provided, and it can be used for future healthcare optimization. BACKGROUND: Ischemia with non-obstructive coronary arteries is a chronic cardiac condition caused by vascular dysfunctions. Ischemia with non-obstructive coronary arteries is often unrecognised, significantly impairs daily functioning, and is more prevalent among women. Patients' experiences remain unexplored, and a clear patient-centered care pathway is lacking. DESIGN: A qualitative interpretative research design was performed and the standards for reporting qualitative research (SRQR) has been used. METHODS: In total, 36 women were included and participated in eight semi-structured focus group interviews. Thematic analysis was used, and identified themes were further classified using 'patient journey mapping.' Additionally, Picker's 'eight principles of patient-centered care' were linked to the results and integrated in the patient journey map. RESULTS: Participants experienced a lack of familiarity with the specific cardiac condition by healthcare providers, repeated hospitalisation, testing and referrals, shortage of specialised cardiologists, and feelings of not being heard. In addition, needs for a multidisciplinary treatment program (including physical and psychological support), better information provision, and an easily accessible contact person were expressed. CONCLUSIONS: The resulting patient journey map shows how patients experienced and interacted with the current healthcare system. Overall, the results show a complex and long healthcare pathway and important themes for healthcare experiences and needs were identified. Future research could focus on the development and implementation of a patient-centered evidence-based clinical pathway optimising experiences and quality of life. RELEVANCE TO CLINICAL PRACTICE: The visual tool can help health care professionals, policy makers, and researchers improve healthcare provision which is patient-centered and tailored to the preferences of patients with ischemia with non-obstructive coronary arteries.

Facial Emotion Expression and the Inducibility of Myocardial Ischemia During Cardiac Stress Testing: The Role of Psychological Background Factors.

OBJECTIVE: Negative emotional states, such as anger and anxiety, are associated with the onset of myocardial infarction and other acute clinical manifestations of ischemic heart disease. The likelihood of experiencing these short-term negative emotions has been associated with long-term psychological background factors such as depression, generalized anxiety, and personality factors. We examined the association of acute emotional states preceding cardiac stress testing (CST) with inducibility of myocardial ischemia and to what extent psychological background factors account for this association. METHODS: Emotional states were assessed in patients undergoing CST (n = 210; mean [standard deviation] age = 66.9 [8.2] years); 91 (43%) women) using self-report measures and video recordings of facial emotion expression. Video recordings were analyzed for expressed anxiety, anger, sadness, and happiness before CST. Psychological background factors were assessed with validated questionnaires. Single-photon emission computed tomography was used to evaluate inducibility of ischemia. RESULTS: Ischemia occurred in 72 patients (34%). Emotional states were not associated with subsequent inducibility of ischemia during CST (odds ratio between 0.93 and 1.04; p values > .50). Psychological background factors were also not associated with ischemia (odds ratio between 0.96 and 1.06 per scale unit; p values > .20) and did not account for the associations of emotional states with ischemia. CONCLUSIONS: Emotional states immediately before CST and psychological background factors were not associated with the inducibility of ischemia. These findings indicate that the well-documented association between negative emotions with acute clinical manifestations of ischemic heart disease requires a different explanation than a reduced threshold for inducible ischemia.

Psychological factors of suspect coronary microvascular dysfunction in patients undergoing SPECT imaging.

BACKGROUND: Patients with myocardial ischemia in the absence of obstructive coronary artery disease (CAD) often experience anginal complaints and are at risk of cardiac events. Stress-related psychological factors and acute negative emotions might play a role in these patients with suspect coronary microvascular dysfunction (CMD). METHODS AND RESULTS: 295 Patients (66.9 ± 8.7 years, 46% women) undergoing myocardial perfusion single-photon-emission computed tomography (MPI-SPECT), were divided as follows: (1) a non-ischemic reference group (n = 136); (2) patients without inducible ischemia, but with a history of CAD (n = 62); (3) ischemia and documented CAD (n = 52); and (4) ischemia and suspect CMD (n = 45). These four groups were compared with regard to psychological factors and acute emotions. Results revealed no differences between the groups in psychological factors (all P > .646, all effect sizes d < .015). State sadness was higher for patients with suspect CMD (16%) versus the other groups (P = .029). The groups did not differ in the association of psychological factors or emotions with anginal complaints (all P values > .448). CONCLUSION: Suspect CMD was not associated with more negative psychological factors compared to other groups. State sadness was significantly higher for patients with suspect CMD, whereas no differences in state anxiety and other psychological factors were found.

Facial Expressions of Emotions During Pharmacological and Exercise Stress Testing: the Role of Myocardial Ischemia and Cardiac Symptoms.

BACKGROUND: Negative emotions have been linked to ischemic heart disease, but existing research typically involves self-report methods and little is known about non-verbal facial emotion expression. The role of ischemia and anginal symptoms in emotion expression was examined. METHODS: Patients undergoing cardiac stress testing (CST) using bicycle exercise or adenosine with myocardial perfusion imaging were included (N = 256, mean age 66.8 ± 8.7 year., 43% women). Video images and emotion expression (sadness, anxiety, anger, and happiness) were analyzed at baseline, initial CST , maximal CST, recovery. Nuclear images were evaluated using SPECT. RESULTS: Ischemia (N = 89; 35%) was associated with higher levels of sadness (p = .017, d = 0.34) and lower happiness (p = .015, d = 0.30). During recovery, patients with both ischemia and anginal symptoms had the highest sadness expression (F (3,254) = 3.67, p = .013, eta2 = 0.042) and the lowest happiness expression (F (3, 254) = 4.19, p = .006, eta2 = .048). CONCLUSION: Sadness and reduced happiness were more common in patients with ischemia. Also, anginal symptoms were associated with more negative emotions.

Anxiety and hemodynamic reactivity during cardiac stress testing: The role of gender and age in myocardial ischemia.

BACKGROUND: The prevalence of myocardial ischemia is associated with anxiety. State and trait anxiety are more common in younger women compared to men, and high anxiety levels could affect hemodynamic reactivity during cardiac stress testing. The aim is to examine whether anxiety plays a role in gender differences in patients ≤ 65 and > 65 years in hemodynamic reactivity and ischemia during cardiac stress testing. METHODS AND RESULTS: Included were 291 patients (66.8 ± 8.7 years, 45% women) with suspect ischemia undergoing myocardial perfusion single-photon emission computed tomography (MPI-SPECT). Primary outcomes were semi-quantitative summed difference score (SDS) and summed stress score (SSS), as continuous indicators of myocardial ischemia. Analyses were stratified by age. Trait anxiety was measured using a validated questionnaire (GAD-7) and state anxiety using facial expression analyses software. Overall, trait and state anxiety were not associated with the prevalence of ischemia (N = 107, 36%). A significant interaction was found between gender and trait anxiety in women ≤ 65 years for SDS (F(1,4) = 5.73, P = .019) and SSS (F(1,10) = 6.50, P = .012). This was not found for state anxiety. CONCLUSION: SDS and SSS were significantly higher in women younger than 65 years with high trait anxiety. This interaction was not found in men and women over 65 years.

Psychological and clinical characteristics of patients with spontaneous coronary artery dissection: A case-control study.

BACKGROUND: The relative frequency of psychological factors in patients with spontaneous coronary artery dissection (SCAD) compared to patients with traditional atherosclerosis-related type 1 acute coronary syndrome (ACS) is unknown. This study examines whether psychological factors and emotional or physical precipitants are more common in SCAD patients versus atherosclerosis-related ACS patients. METHODS: Participants with SCAD were recruited from a Dutch SCAD database. Given the predominance of SCAD in women (>90%), only female patients were included. The age- and sex-matched atherosclerosis-related ACS group was identified from a registry database. Online questionnaires and medical records were used to investigate psychological factors and clinical information. Univariate and multivariate logistic regression models were used to examine differences between 172 SCAD patients and 76 ACS patients on emotional and physical precipitants prior to the event and psychological factors after the event. RESULTS: Patients with SCAD were more likely to experience an emotional precipitant in the 24 h prior to the event (56%), compared with the ACS group (39%) (OR = 1.98, 95%CI 1.14-3.44). Multivariate analyses showed that this association remained significant after adjustment for covariates (OR = 2.17, 95%CI 1.08-4.36). At an average of 3.2 years post-hospitalization for the SCAD or atherosclerosis-related ACS event, both patient groups had similar high levels of perceived stress (50% vs. 45%, p = .471) and fatigue (56% vs. 53%, p = .643). CONCLUSIONS: This study shows that risk profiles for SCAD differ from traditional atherosclerosis-related ACS. Our findings may help health professionals to recognize SCAD and offer tailored rehabilitation and prevention programs.

Sex and gender-stratified risks of psychological factors for adverse clinical outcomes in patients with ischemic heart disease: A systematic review and meta-analysis.

BACKGROUND: Psychological factors are associated with adverse prognosis in patients with ischemic heart disease (IHD). However, it is unknown whether these risk factors differ between women and men. METHODS: PubMed, EMBASE, and PsycINFO were searched to identify studies assessing the risk of psychological factors for major adverse cardiovascular events (MACE) in samples with IHD. Psychological factors included anger/hostility, anxiety, depression, psychological distress, social support, Type A behavior pattern, Type D personality, and Posttraumatic Stress Disorder (PTSD). RESULTS: A total of 44 articles (64 separate reports) including 227,647 women and 321,894 men reporting confounder-adjusted hazard ratios (HRs) or relative risks (RRs) were included in the primary analysis. Results based on random-effects models showed that the association between psychological factors (all combined) and MACE was stronger in men (n = 321,236; 57 reports; HR = 1.37, 95%CI 1.27-1.48) than in women (n = 226,886; 56 reports; HR = 1.21, 95%CI 1.12-1.30; p = .017). A subset of the studies focusing on women showed significant associations between anger/hostility, depression, and distress with MACE. For men, statistically significant associations were found for anxiety, depression, and distress with MACE. CONCLUSIONS: Psychological factors are associated with MACE in samples with IHD in both women and men, with a small, but significant higher risk for men. Because of the limited number of studies on other psychological factors than depression and anxiety and the current major focus on MACE reflecting lesions in the major coronary arteries which is more typical in men than women, more research is needed to better identify sex and gender differences in IHD.

Cancer comorbidity in patients with non-obstructive coronary artery disease: Depressive symptoms related to C-reactive protein.

BACKGROUND: Based on guidelines for cardiovascular risk assessment among non-cancer populations, depression and anxiety can be seen as risk factors for CVD, on top of cardiotoxic cancer treatment and traditional CVD risk factors among cancer survivors. Increased inflammation can be a shared potential pathophysiological mechanism, as higher levels of inflammation (like C-reactive protein, CRP) are known associates of depression and anxiety. In turn, increased inflammation is involved in the pathogenesis of CVDs. Furthermore, both cancer and cancer treatment including chemotherapy and radiation can lead to elevated levels of inflammation. We will therefore examine whether the relation between depression and anxiety with inflammatory markers among patients with either CVD or cancer is different from those with both conditions. METHOD: The TweeSteden Mild Stenosis (TWIST) study among patients with non-obstructive coronary artery disease (NOCAD, luminal narrowing <60%), a type of ischemic heart disease, previously reported a significant association between depressive symptoms and increased inflammation (measured by high-sensitive (hs)CRP). Of the included NOCAD-patients, 6% had a history of cancer. The TWIST patient sample was therefore used to explore whether the association between depression and elevated inflammation (hsCRP) was similar for NOCAD-patients with and without a history of cancer. RESULTS: The association between depressive symptoms and increased hsCRP levels is stronger among NOCAD-patients with a history of cancer than among NOCAD-patients without a history of cancer. Furthermore, whereas this relation is mediated by lifestyle factors among NOCAD-patients without cancer, the association remained significant after adjusting for BMI, smoking, and physical activity among NOCAD-patients with a history of cancer. CONCLUSION: The stronger association between depression and hsCRP among NOCAD-patients with a history of cancer indicates that there may be an additive or synergistic effect of having NOCAD and cancer for general inflammation and possibly depression.

Gender differences in associations of depressive symptoms and anxiety with inflammatory markers in patients with non-obstructive coronary artery disease.

OBJECTIVE: The aim of this study was to examine gender differences of the associations between depressive symptoms and anxiety with inflammatory markers in patients with non-obstructive coronary artery disease (NOCAD). METHODS: Depressive symptoms and anxiety (Beck Depression Inventory BDI and Hospital Anxiety and Depression Scale HADS) were examined in 524 patients with NOCAD (52% women, mean age 64 ±â€¯9 years) as part of the TweeSteden Mild Stenosis (TWIST) observational cohort study. Blood samples were analyzed for neutrophil gelatinase-associated lipocalin (NGAL) levels, high-sensitive C-reactive protein (hsCRP), and leukocyte differentiation. Multivariate analysis for the inflammatory markers with main effects of depressive symptoms or anxiety, gender, and their interactions were observed. RESULTS: Women had elevated levels of hsCRP, and a lower monocyte and eosinophil count than men, with small to medium effect sizes (range η(p)2 = 0.019-0.047). After Holm-Bonferroni correction depressive symptoms according to the BDI were associated with an overall elevated hsCRP level explaining 2.4% of the hsCRP variance. A significant positive association between BDI cognitive symptoms with elevated hsCRP level was observed in men (R2 = 0.045), but not in women (R2 < 0.001). Adjustment for age, body mass index, smoking, and physical activity attenuated this finding. CONCLUSION: Small associations of inflammatory markers with depressive symptoms and anxiety were confounded by lifestyle factors, predominantly smoking. The interacting roles of gender, smoking, and psychological factors on inflammatory markers may point toward different behavioral and inflammatory pathways for women and men with NOCAD, which remains to be further explored. OBSERVATIONAL COHORT REGISTRATION: ClinicalTrials.gov identifier: NCT01788241.

Sex- and Gender-Stratified Risks of Psychological Factors for Incident Ischemic Heart Disease: Systematic Review and Meta-Analysis.

Background Psychological factors are associated with an increased risk of developing ischemic heart disease ( IHD ). Women more often report psychological factors, and sex and gender differences are present in IHD . In this meta-analysis we examine the risks of psychological factors for IHD incidence in women and men. We hypothesize that a broad range of psychological factors are related to a higher risk for incident IHD , with a higher risk for women. Methods and Results PubMed, EMBASE , and Psyc INFO were searched for studies assessing the risk between psychological factors and incident IHD . Psychological factors included depression, anxiety or panic disorder, social support, hostility, anger, personality (type D), type A behavior pattern, posttraumatic stress disorder, and psychological distress. In the primary analyses, 62 studies (77 separate reports) that included 2 145 679 women and 3 119 879 men and reported confounder-adjusted hazard ratios or relative risks were included. Pooled effect confounder-adjusted estimates from random-effects models showed that psychological factors (all combined) were associated with incident IHD in women (hazard ratio: 1.22; 95% CI , 1.14-1.30) and men (hazard ratio: 1.25; 95% CI , 1.19-1.31). No sex and gender differences were found for these pooled effect estimates ( P=0.547). Conclusions Psychological factors are associated with incident IHD in both women and men, but no significant differences were observed between women and men. IHD is predominantly being studied as obstructive coronary artery disease, which is more prevalent in men. Data are needed on psychological predictors and other manifestations of IHD such as coronary microvascular disease, which is more common in women.

[Gender differences in psychological complaints in ischemic heart diseases]. / Genderverschillen in psychologische klachten bij ischemische hartziekte.

Psychological symptoms, such as anxiety, depression, and stress, are a risk factor for the development as well as aggravation of ischaemic heart diseases (IHD). Although women report more psychological symptoms than men, research into gender differences regarding cardiac risk of psychological symptoms is limited. Cardiology studies focus predominantly on the classic pattern of obstructive coronary artery disease, which is three times more prevalent in men than in women. Women more often have variant types of IHD, such as myocardial infarction with non-obstructive coronary arteries, spontaneous coronary artery dissection, ischaemia with non-obstructive coronary arteries, coronary spasm, and microvascular angina. It is precisely for these variants of IHD that evidence is increasing that psychological symptoms play an important role. For patients and their caregivers, it is useful to know that gloomy and anxious feelings are more common in patients with IHD, including non-traditional types of IHD, and that these symptoms are treatable.

Type D personality and social relations in adults with diabetes: results from diabetes MILES - The Netherlands.

OBJECTIVE: To examine whether individual differences in Type D personality (combination of negative affectivity (NA) and social inhibition (SI)) could explain heterogeneity in perceived social support and relationship adjustment (intimate partner relationship) among people living with diabetes. DESIGN: In the Diabetes MILES-The Netherlands survey, 621 adults with type 1 or type 2 diabetes (54% female, age: 56 ± 14 years) completed measures of Type D personality (DS14), perceived social support and relationship adjustment. We used established DS14 cut-off scores to indicate Type D personality, high NA only, high SI only and reference groups. RESULTS: Participants from the Type D and NA only groups perceived lower levels of social support (Welch[3,259] = 37.27, p < 0.001), and relationship adjustment (Welch[3,191] = 14.74; p < 0.01) than those from the SI only and reference groups. Type D was associated with lower social support (lowest quartile; adjusted OR = 8.73; 95%CI = 5.05 ∼ 15.09; p < 0.001) and lower relationship adjustment (lowest quartile; adjusted OR = 3.70; 95%CI = 2.10 ∼ 6.53; p < 0.001). Type D was also associated with increased levels of loneliness. CONCLUSION: Participants with Type D and participants with high NA only tend to experience less social support and less relationship adjustment. Type D personality was also associated with more loneliness. Experiencing lower social support and relationship adjustment may complicate coping and self-management in people with diabetes.

The predictive value of positive affect and Type D personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease.

BACKGROUND: Patients with non-obstructive coronary artery disease (NOCAD) continue to experience disabling symptoms. Positive affect (PA) has shown a cardioprotective potential. Type D personality has previously been shown to have a deleterious effect on adverse outcomes in diverse cardiac populations. Little is known about the predictive value of PA and Type D personality for long-term outcomes in NOCAD patients. The aim was to investigate the effect of PA and Type D personality on clinical outcomes. METHODS: 547 patients (mean age 61 years±9, 48% male) who underwent a coronary angiography or CT-scan between January 2009 and February 2013 answered questionnaires concerning PA (GMS) and Type D personality (DS14). Cox proportional hazards analyses were performed. RESULTS: When analyzed dichotomously, PA was a significant predictor of need for repeat cardiac testing (HR=0.64, 95% CI: 0.41-0.99), but not emergency department (ED) admissions (HR=0.83, 95% CI: 0.52-1.32) after adjustment for age, sex, education, diagnosis by group, BMI and hypertension. Analyzed continuously, the predictive value of PA was non-significant for both repeat testing (HR=0.85, 95% CI: 0.69-1.06) and ED admissions (HR=0.98, 95% CI: 0.77-1.23). Type D personality, both continuously and dichotomously, was not significantly associated with the outcomes. Findings were also examined for men and women separately. CONCLUSION: Although Type D personality was not predictive of adverse events in this sample, PA is an interesting and important variable to take into account in NOCAD patients. Research on psychosocial factors in NOCAD patients should consider the importance of choices of endpoint, given the heterogeneity of NOCAD patients.

Impaired Health Status, Psychological Distress, and Personality in Women and Men With Nonobstructive Coronary Artery Disease: Sex and Gender Differences: The TWIST (Tweesteden Mild Stenosis) Study.

BACKGROUND: Patients with nonobstructive coronary artery disease (NOCAD; wall irregularities, stenosis <60%), and women with NOCAD in particular, remain underinvestigated. We examined sex and gender (S&G) differences in health status, psychological distress, and personality between patients with NOCAD and the general population, as well as S&G differences within the NOCAD population. METHODS AND RESULTS: In total, 523 patients with NOCAD (61±9 years, 52% women) were included via coronary angiography and computed tomography as part of the TWIST (Tweesteden Mild Stenosis) study. Generic health status (12-item Short Form physical and mental scales and fatigue), psychological distress (Hospital Anxiety and Depression Scale anxiety and depressive symptoms and Global Mood Scale negative and positive affect), and personality (Type D personality) were compared between patients with NOCAD and an age- and sex-matched group of 1347 people from the general population. Frequency matching was performed to obtain a similar sex distribution in each age-decile group. Both men and women with NOCAD reported impaired health status, more psychological distress, and Type D personality compared with men and women in the reference group. Women reported more psychosocial distress compared with men, but no significant sex-by-group interaction effects were observed. Women with NOCAD reported impaired health status, more anxiety, and less positive affect, but no differences in depressive symptoms, angina, or Type D personality when compared with men with NOCAD. Age, education, employment, partner, and alcohol use explained these S&G differences within the NOCAD group. CONCLUSIONS: In both men and women, NOCAD was associated with impaired health status, more psychological distress, and Type D personality when compared with a reference population. Factors reflecting S&G differences explained these S&G findings in patient-reported outcomes. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01788241.