**10. Negative affectivity and social inhibition**

large number of differences makes the comparison difficult, and studies are not corrected for so many potential imbalances that may influence sex differences in outcome. Additional large prospective studies with substantial numbers of women are needed to evaluate gender-related differences in autonomic responses to myocardial infarction, complications related to cardio‐ pulmonary bypass, susceptibility to abnormalities in coagulation, and other biological factors that might account for discrepant outcomes in men versus women undergoing CABG. Furthermore, specific pharmacologic and therapeutic considerations, such as the role of estrogen replacement therapy, need to be clarified [49]. Compared to conducted studies in this topic the POST CABG Biobehavioral Study enrolled the highest number of women (n = 269) and physical, social, and emotional functioning were investigated after CABG surgery. Both male and female patients improved in physical, social, and emotional functioning after CABG, and recovery over time was similar in men and women. However, women's health-related quality-of-life scale scores remained less favourable than men's women did show less benefit with regard to the symptoms of shortness of breath and tiredness through 1 year after surgery [50]. In another prospective cohort study on quality of life women did not reach the same degree of improvement after 1 year as men, even after adjusting for pre-existing risk factors. Women were at greater risk for subjective cognitive difficulties, increased anxiety and decreased ability to perform tasks for daily living, diminished work-related activities, and

Socially isolated persons are single and/or have small social network. Social isolation is associated with poor outcome in established CAD, while high levels of social support is known to promote psychologic and physical well being [52]. Social support can be divided into two broad categories: social networks, which describe the size, structure, and frequency of contact with the network of people surrounding an individual; and functional support, which may be further divided into received social support, which highlights the type and amount of resources provided by the social network, and perceived social support, which focuses on the subjective satisfaction with available support or the perception that support would be available if needed [2]. The underlying mechanisms remain to be identified. Several factors may confound the effect of isolation such as disease severity, or its associations with demographic measures, because socially isolated patients are generally older and of lower socioeconomic status, which are known to reduce survival. Another possible mechanism is the influence of disease progression via its effect on psychosocial functioning. Psychological distress in CAD patients is more severe in patients with lack of adequate social support. Description of the demographic and psychosocial characteristics of those with few social contacts might aid our understanding of the link between isolation and mortality [52]. Previous studies showed the pivotal role of family ties in preserving cardiovascular health [53, 54]. A strong and consistent inverse gradient was reported between the magnitude of social support and adverse clinical outcomes among both initially healthy subjects and those with known CAD [55]. In our study on cardiac surgery patients (180 patients) 17% of patients admitted living alone, however when

reduced exercise capacity [51].

**9. Social support**

476 Artery Bypass

Type D personality unifies psychosocial factors related to high cardiovascular risk in one model. Particularly negative affectivity (NA) and social inhibition (SI) are relevant in this context. NA refers to the stable tendency to experience negative emotions across time/ situations. Persons with high-NA experience more feelings of dysphoria, anxiety, and irritability; have a negative view of self; and are looking for signs of impending trouble. NA overlaps with neuroticism and trait anxiety; includes subjective feelings of tension, worry, anxiety, anger, and sadness. SI patients tend to inhibit the expression of emotions/behaviours in social interactions to avoid disapproval by others. They feel inhibited, tense, and insecure when with others. Individuals who are high in both NA and SI have a distressed or Type D personality, given their vulnerability to chronic distress [59]. Type D patients are at increased risk for a wide range of adverse health outcomes, mortality and morbidity, in various cardio‐ vascular populations, including those with ischemic heart disease [60], coronary intervention [61], cardiac arrhythmias [62], peripheral arterial disease [63]. Global left ventricular dysfunc‐ tion and type D personality were independent predictors of long-term cardiac events in patients with a reduced ejection fraction after myocardial infarction [64]. Type D personality independently predicted mortality and early allograft rejection after heart transplantation [65]. In our 5-year follow-up, there was no link between the occurrence of major cardiac and cerebral event and NA and SI after CABG [44]. Additionally, severity of illness intrusiveness, sleeping problems and SI increased in the MACCE positive patients during the three-year period Unfavourable effect of Type D is linked to physiological hyperreactivity, immune activation, and inadequate response to cardiac treatment [59].


Pedersen SS. Type D personality is associated with increased anxiety and depressive symptoms in patients with an implantable cardioverter

221 Patients with implantable

cardioverter defibrillator and their

Short and Long Term Effects of Psychosocial Factors on the Outcome of Coronary Artery Bypass Surgery

In patients, Type D personality was independently related to anxiety (OR: 7.03; 95% CI: 2.32-21.32) and depressive symptoms (OR: 7.40; 95% CI: 2.49-21.94) adjusting for all other variables. In partners, Type D personality was

independently associatedwith increased sym

http://dx.doi.org/10.5772/54622

479

Type D patients reported significantly poorer quality of life than non-type D patients across peripheral arterial disease and healthy subgroups (p < 0.0001). After controlling for disease status (presence or absence of peripheral arterial disease), type D personality remained associated with increased risk for impaired quality of life (odds ratio [OR] 7.35, 95% confidence interval [CI] 3.39 to 15.96, p < 0.0001) and perceived stress (OR 6.45, 95%

ptoms of anxiety (OR: 8.77; 95% CI: 3.19-24.14) and depression (OR: 4.40; 95%

CI 3.42 to 12.18, p < 0.0001).

compared with non-type

 Patients with Type D personality were more likely to experience an event over time

D patients (P=0.00005). Cox proportional hazards analysis yielded LVEF of < or =30% (relative risk, 3.0; 95% confidence interval, 1.2 to 7.7; P=.02) and type D (relative risk, 4.7; 95% confidence interval, 1.9 to 11.8; P=0.001) as independent predictors.

Type D recipients had a 10-fold higher mortality rate after hospital discharge (5 of 15, or 33%) as compared with non-Type D recipients (1 of 34, or 3%) (p = 0.013, adjusting for age and gender). Among surviving recipients, the rate of Grade "/> or =3A rejection for both groups was 40% vs 27%, respectively (p = 0.45). The risk of unfavorable outcomes (death, Grade "/> or =3A rejection, or number rejection-free

days < or =14) was greater

in Type D recipients (12 of 15, or 80%) than in

CI: 1.76-11.01).

Hospital Anxiety and Depression Sca le, the Type D Personality Scale, and the Perceived Social Support Scale.

disease were assessed with the Type

partners completed the

150 Patients with peripheral arterial

D Scale-14, World Health Organization Quality of Life Assessment Instrument-100, and Perceived Stress Scale-10 Item assessed type D personality, QOL,

and perceived stress

infarction with a decreased left ventricular ejection fraction (LVEF).

87 Patients with myocardial

51 Patients with transplanted heart

DS14 scale.

were identified to have or not to have Type D personality by using the

defibrillator and their

Aquarius AE. Role of disease status and Type D personality in outcomes in patients with peripheral arterial disease.

partners.

Denollet J. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction.

Denollet J.

of heart

personality.

Unfavorable outcome

transplantation in recipients with type D First author and title Number of

Cserép Z.

478 Artery Bypass

surgery.

Psychosocial factors and major adverse cardiac and cerebrovascular events after cardiac

Denollet J. Personality as independent predictor of longterm mortality in patients with coronary heart disease.

Pedersen SS. Type D personality predicts death or myocardial infarction after bare metal stent or sirolimus-eluting stent implantation: a Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry

sub-study.

patients

268 men and 35 women

causes.

875 Patients completed

Methods Results

At the end of the second year after adjustment for medical and perioperative factors worse self-rated health [adjusted hazard ratio (AHR): 0.67, P=0.006], sleeping disorders (AHR: 1.14, P=0.001), higher illness intrusiveness (AHR: 1.03, P=0.018), higher BDI (AHR: 1.12, P=0.001), STAI-S (AHR: 1.09, P=0.001) and higher STAI-T scores (AHR: 1.08, P=0.002) showed higher risk for MACCE. Significant individual elevation in scores of sleeping disorders, illness intrusiveness and SI were observed over the three-year period in

the MACCE group.

medial variables.

variables.

The rate of death was higher for type-D patients than for those without type-D (23 [27%]/85 vs 15 [7%]/218; p < 0.00001). The association between type-D personality and mortality was still evident more than 5 years after the coronary event and was found in both men and women.Type-D was an independent predictor of both cardiac and non-cardiac mortality after controlling for

Type D patients were at a cumulative increased risk of adverse outcome compared with non-Type D patients: 5.6% versus 1.3% (p < 0.002). Type D personality (odds ratio [OR] 5.31; 95% confidence interval [CI] 2.06 to 13.66) remained an independent predictor of adverse outcome adjusting for all other

180 Depression [Beck depression

inventory (BDI)], anxiety [state anxiety subscale in Spielberger State-Trait Anxiety Inventory (STAI-S) and trait anxiety subscale in Spielberger State-Trait Anxiety Inventory (STAI-T)] were investigated annually, social support, negative affectivity, social inhibition (SI), illness intrusiveness, self-rated health and sleeping disorders were investigated by standardized tests at the second and fifth year after cardiac surgery. The end-point was the major adverse cardiac and cerebrovascular event (MACCE) including death.

Patients with angiographically documented CHD, who were taking part in an outpatient rehabilitation programme. All patients completed personality questionnaire at entry to the programme. Survival status was followed up for mean 7-9 years. The main endpoint was death from all

the Type D Personality Scale (DS14) six months after PCI. The end point was a composite of death and MI.


non-Type Ds (13 of 34, or 38%), adjusting for other risk factors (odds ratio: 6.75; 95% confidence interval: 1.47 to 30.97) (p = 0.014).

academic degree in the survival analysis. Patients with less education had a worse life expectancy. There was no significant difference between patients with 9 to 12 years of education and those with an academic degree [13]. Patients with a high level of education are likely to have a higher income and therefore can afford the more expensive "healthy" diet and sport activities [70]. In a recent study, however, the risk for major cardiac event after primary percutaneous coronary intervention depended only on employment status and income, but not education level [72]. More prospective studies are needed to establish the relationship.

Short and Long Term Effects of Psychosocial Factors on the Outcome of Coronary Artery Bypass Surgery

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481

The American Heart Association has recommended routine screening by self- reporting meas‐ ures to rapid identification of likely depressed CAD patients. The Patient Health Questionnaire is one such depression assessing measurement, focuses on two requisite symptoms for a depres‐ sion or major depressive episode diagnosis, i.e., (1) little interest or pleasure in doing things, (2) feeling down, depressed, or hopeless. Patients with positive screening results should be evaluat‐

There are currently several empirically validated treatments for depression. A national survey of cardiovascular physicians reported nearly 50% of respondents treat the symptoms of depression once identified in patients with CAD [73]. The Selective serotonin re-uptake inhibitors (SSRI) are currently considered the safest to use with CAD patients, in contrast to the tricyclics, which may have pro-arrhythmic and cardio-toxic effects. The SSRI have been hypothesized as safe among cardiac patients due to the serotonin transporter affinity and attenuation of platelet functioning. The SADHART trial compared the effects of sertraline and placebo for 24 weeks in major depressive patients with unstable angina or recent MI. The SSRI treatment did not adversely affect cardiac function and was considered to be safe for most patients [74]. However, in the ENRICHD trial, improvements in depression were rather modest. Patients with at least 1 prior episode of depression or more severe depression showed consistent improvement in depression relative to control, suggesting that treatment with SSRIs is a good option for this subset of depressed CAD patients. The ENRICHD trial also found that antidepressant treatment improved prognosis for myocardial infarction patients, they were at decreased risk for death and reinfarction compared with those who did not take antidepres‐ sants [75]. In a systematic review [76] only 2 studies had follow-up periods that were long enough to assess cardiac outcomes [76, 77]. None of them found evidence of an effect of depression treatment. Two studies reported that selective serotonin reuptake inhibitors did not affect cardiac function [74, 79]. Possible side effects of SSRIs for CABG surgery patients include increased bleeding, but have not been consistently supported [80]. One study sug‐ gested an increased long-term mortality and rehospitalization after CABG surgery attributable to SSRIs [81]. Another study indicated greater renal morbidity and ventilation times, but not greater mortality or bleeding risk [82]. In two recent systematic reviews of randomized, controlled trials in CAD patients both established SSRI vs. placebo there was no difference in

ed by a professional qualified in the diagnosis and management of depression [5].

**12. Interventions**

**12.1. Antidepressants**

**Table 3.** Some important studies about negative affectivity and socal inhibition in cardiology

#### **11. Education**

Previous research showed that educational level is an important health determinant, with gender-related differences and ethnic and cultural variations. Low educated men and women, in particular with required schooling only, have usually low income and thus lower socioeconomic status may be expected. The lower education level of older persons leads to greater burden for medical services and lower awareness of how to lead a healthy lifestyle, and lower adherence to medication and utilisation of preventive measures. In general, women take part more often in screening programs, are more interested in health prevention and visit their general practitioners more often. Their activity may also relate to a higher rate of diagnosis of depression and anxiety disorders. Besides biological factors including oestradiol, psychosocial factors, culture and education may be responsible for the prevalence of these mental disorders among women [66]. Less education was showed an important risk factor for late-life depres‐ sion [67]. In survey in South America women's higher education was associated with lower risk for diabetes and hypertension and lower BMI in all areas but more strongly in urban areas. There was no association or even an adverse association between education and these risk factors among men in less urban areas [68]. Controversially, men with low level of education were related to higher BMI, prevalence of diabetes and smoking. Less-educated women had higher blood pressure and BMI and low education in both sexes was associated with twofold increased incidence of stroke and CHD [69]. In an Austrian study both men and women with lower educational levels were associated with unhealthy behaviours, overweight and higher cardiovascular risk. There was in inverse relationship in both men and women between overweight and obesity and educational level. The odds of daily smoking, eating a diet rich in meat and doing no regular vigorous exercise decreased with increasing educational level. Among women, the odds of suffering from diabetes or from hypertension decreased gradually with increasing educational level. There was no clear association between educational level and the risk of diabetes or hypertension in men. Depression among women with only required schooling was frequent, but showed no relationship with education in men [66]. Low education and income are important determinants of all-cause mortality and cardiovascular mortality [70] among patients with myocardial infarction. Low income and education are related to a higher risk profile and poorer treatment [71]. In accordance, in our study, a higher level of education was associated with a longer survival time after CABG. Those patients who had an academic degree had a mean survival time of 8.01 years, patients with 9 to 12 years of education had a mean survival time of 7.73 years and the group with 8 years or less of education had a mean survival time of 7.03 years. There were significant differences among patients with 8 years or less of education and patients with 8 to 12 years of education and patients with an academic degree in the survival analysis. Patients with less education had a worse life expectancy. There was no significant difference between patients with 9 to 12 years of education and those with an academic degree [13]. Patients with a high level of education are likely to have a higher income and therefore can afford the more expensive "healthy" diet and sport activities [70]. In a recent study, however, the risk for major cardiac event after primary percutaneous coronary intervention depended only on employment status and income, but not education level [72]. More prospective studies are needed to establish the relationship.
