Impaired health status in Type D patients following PCI in the drug-eluting stent era

Abstract

Background

Drug-eluting stenting reduces restenosis post-percutaneous coronary intervention (PCI), but subgroups of patients may not benefit optimally from this procedure. We examined the impact of Type D personality on health status over time and the clinical relevance of Type D as a predictor of impaired health status at 12 months in unselected post-PCI patients.

Methods

Consecutive patients (n = 692) participating in the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed the Type D Scale at 6 months and the Short Form Health Survey 36 (SF-36) at 6 and 12 months post-PCI.

Results

Although there was a significant improvement in health status over time (p < 0.001), Type D patients reported a substantially lower score on all health status domains of the SF-36 compared with non-Type D patients (p < 0.001). Type D personality was an independent predictor of impaired health status on all SF-36 sub domains at 12 months except for physical functioning, adjusting for baseline demographic and clinical variables and health status at 6 months. In these adjusted analyses, Type D personality increased the likelihood of impaired health status at 12 months post-PCI from 60% (OR: 1.60; 95% CI: 1.04–2.46) to almost 300% (OR: 3.99; 95% CI: 2.52–6.32), varying among the parameters analyzed.

Conclusions

Type D personality was associated with impaired health status in post-PCI patients treated in the drug-eluting stent era. The role of personality factors as determinants of clinical outcome and health status should not be overlooked as these factors may have much explanatory power.

Introduction

Despite a significant reduction in the incidence of restenosis and the need for revascularization following percutaneous coronary intervention (PCI) with drug-eluting stent implantation [1], [2], [3], subgroups of patients who have undergone a successful PCI may not benefit optimally from this invasive procedure in terms of improved health status. Health status has been identified as an important determinant of mortality [4], [5], but health status is also increasingly receiving attention as an outcome measure in its own right. Advances in the treatment of cardiovascular disease has led to a shift from hard endpoints, such as mortality and myocardial infarction (MI), to include the patient's perspective and the value of these advances to society [6]; prolonged survival is no longer the “be all and end all” but also the quality of life of the patient has become important. With this shift in outcomes, identification of subgroups at risk of impaired health status is gaining increasing importance, with knowledge of the determinants of impaired health status leading to a closing of the gap between research and clinical practice [6].

From the pre drug-eluting stent era, there is evidence to support the notion that subgroups of patients may benefit differentially from cardiac invasive procedures. In patients following PCI, vital exhaustion has been shown to predict the occurrence of new cardiac events including the need for revascularization [7]. Vital exhaustion is a mental state defined by unusual fatigue, irritability, and feelings of demoralization [7]. Prior history of depression [8] and smoking [9] also have been shown to impede the benefits of PCI on health status. Other factors associated with impaired health status include female gender [10], [11], impaired left ventricular function [12], depression [13], and the distressed (Type D) personality [14], although the majority of these studies were conducted in patients with acute coronary syndromes rather than in patients following PCI.

In a recent study of this sample, we showed that Type D personality was associated with a 5-fold increased risk of death or MI adjusting for all other factors [15]. Type D defines those individuals who tend to experience increased negative emotions and who inhibit the self-expression of these emotions in social interactions [16]. A Type D patient typically worries, has a gloomy view of life, often feels unhappy, and is a closed kind of person who prefers to keep other people at a distance. In the pre drug-eluting stent era, Type D has been associated with adverse health status at 5-years' follow-up [14], major adverse cardiac events despite appropriate treatment [16], [17], [18], and has been found to exert a large and persisting effect on symptoms of vital exhaustion and fatigue pre- and post-intervention compared with that of gender [19]. It is important to note that the impact of Type D remained substantial when adjusting for demographic and clinical risk factors, with the associated risk being 4–8 fold for adverse prognosis [16]. However, to date no study has examined whether Type D personality has a persistent adverse impact on health status. It is also not known whether the impact of Type D on health status seen in the pre drug-eluting stent era still exists in the drug-eluting stent era. Although there is clear evidence to demonstrate that personality is an important explanatory factor of individual differences in outcome [16], paradoxically the inclusion of personality factors in psychosomatic research has become unfashionable since the controversy surrounding the Type A Behavior Pattern.

The objective of the current study was two-fold: (1) To establish the stability of Type D personality as a modulator of health status at 6 and 12 months in post-PCI patients receiving a sirolimus-eluting stent (SES) or bare metal stent (BMS) implantation; (2) To investigate the clinical relevance of Type D personality as a predictor of health status at 12 months.