|Year : 2019 | Volume
| Issue : 3 | Page : 115-120
A comparative study of left ventricular function of people with and without D-type personality hospitalized for first-time myocardial infarction
, Gholamreza Kheirabadi2
, Maryam Malek Mohammad3, Avat Feizi4, Hamid Saneai5
1 Department of Health Psychology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Psychiatry, Behavioral Sciences Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
3 Behavioral Sciences Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Statistic and Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
5 Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||17-May-2019|
|Date of Decision||08-Jun-2019|
|Date of Acceptance||12-Jun-2019|
|Date of Web Publication||26-Aug-2019|
Dr. Gholamreza Kheirabadi
Departments of Psychiatric, Behavioral Sciences Research Center, School of Medicine, Isfahan
Source of Support: None, Conflict of Interest: None
Aim: This study is aimed to comparison between left ventricular (LV) function for people with and without type D personality hospitalized for the first time of myocardial infarction (MI). Materials and Methods: In a descriptive-analytical study, 150 patient hospitalized in heart care centers in Isfahan with definite MI diagnosis were selected by simple available sampling method. Data regarding the determination of D and non-D type of personality were collected by a 14-item questionnaire (DS14) and the results from LV performance evaluation using echocardiograph after 1st time heart attack and before clearance from hospital. Collected data were analyzed using SPSS software and t-test, Chi-square, linear and multiple regression tests. Results: The average of ejection fraction (EF) index in total patient was 43 ± 9.47 with the range of 15–60, 14 people (9.3%) normal EF and 136 people (90.7%) had abnormal EF. The average of EF index in 2 groups with D and non-D type of personality were 43.2 ± 10.5 and 42.9 ± 9, respectively, and based on t-test, the average of EF index in 2 groups had no significant difference (P = 0.86). Furthermore, 7 people (12.7%) in group D and 7 people (7.4%) in non-D group had normal EF, and in these two groups, 48 and 88 people had abnormal EF, respectively (87.3% vs. 92.6%), but according to Chi-square test, EF distribution in 2 personality types had no significant difference (P = 0.28). Conclusion: There is no significant relationship of type D personality with LVEF in people with first-time MI.
Keywords: Left ventricular function, myocardial infarction, Type D personality
|How to cite this article:|
Bagherian-Sararoudi R, Kheirabadi G, Mohammad MM, Feizi A, Saneai H. A comparative study of left ventricular function of people with and without D-type personality hospitalized for first-time myocardial infarction. Int Arch Health Sci 2019;6:115-20
|How to cite this URL:|
Bagherian-Sararoudi R, Kheirabadi G, Mohammad MM, Feizi A, Saneai H. A comparative study of left ventricular function of people with and without D-type personality hospitalized for first-time myocardial infarction. Int Arch Health Sci [serial online] 2019 [cited 2020 Sep 26];6:115-20. Available from: http://www.iahs.kaums.ac.ir/text.asp?2019/6/3/115/265442
| Introduction|| |
Myocardial Infarction (MI) occurs when coronary artery blood flow is reduced due to thrombotic obstruction of atherosclerotic coronary artery. Clinical spectrum of coronary artery disease varies from silent ischemia to chronic stable angina, unstable angina, acute MI, and sudden cardiac death.
More than 7 million people suffer from MI in the United States, and approximately, 650,000 new cases of acute MI and 450,000 patients with acute MI are referred to healthcare centers. This disease causes highest mortality and morbidity and financial burden in the developed countries, and it is at the top of the list of predisposing factors of health care. Left ventricle dysfunction (marker of increased myocardial wall tension), as an important MI complication, is associated with increased mortality.
Recent studies suggest that anxiety, anger, worry, and psychological stresses are associated with coronary heart disease, cardiac death, and MI.,,,,,, Psychological stress may lead to coronary artery spasm, platelet activation, reduction of heartbeat variability, myocardial ischemia, thrombotic obstruction, cardiac arrhythmia, MI, and cardiac death, and in this meanwhile, personality variable is an important determinant factor in stress experience. Personality can alter their autonomic system and lead to ischemia via reduction of coronary artery blood flow.
Recently, a theoretical structure has been purposed by Pedersen and Denollet on type D personality which seems to be an important factor in explanation of individual differences in response to stress, comorbidities, cardiac complications, psychological consequences, and mortality risk in heart diseases., This personality type is based on two main and constant personality characteristics in psychological and physiological aspects. These characteristics include negative affectivity (NA) and social inhibition (SI). NA means individual's desire to experience negative effects in different type and situations.,, These people tend to worry so much and have a negative point of view toward both the environment and themselves and demonstrate symptoms of anxiety, depression, anger, and irritability. SI represents individual's desire to avoid emotion and behavior expression in social communications for the fear of other's reactions.
Although negative emotions are measured in this personality type, it is the association of tendency to experience negative emotions and avoidance from expressing them which brings about more negative consequences for their health rather than experiencing negative emotions. Rate of cardiac events is 52% in type D personality, while it is 12% in nontype D personality.
This personality type is 13% to 32.5% prevalent among general population, while it is reported to account for 26% to 53% of patients with cardiovascular diseases., Previous studies proved the relationship between cardiac risk factors and type D personality. For example, in Schiffer et al. study, this personality type, whether as a biological phenomenon (temperament) or as a habitual behavioral pattern, may be considered as a risk factor in the incidence of cardiac diseases, increased negative outcomes and mortality of cardiac diseases and other physical diseases including hypertension, diabetes, osteoporosis, and peptic ulcer disease. This personality type is also associated with hyperlipidemia in which elevated cortisol level may be a mediator in the association between type D personality and increased risk of hyperlipidemia, while hyperlipidemia is an important and common risk factor of cardiovascular diseases.
Nowadays, it is proved that left ventricle function is a predicting factor for long-term survival after acute MI recovery which is explained by ejection fraction (EF).,,,
EF below 40% indicated increased risk of coronary events and poor prognosis in MI patients. Patients with EF below 50% are at 3-fold risk of cardiac events compared with patients with EF above 50%. On the other hand, Staniute et al. study suggested that type D personality and EF below 50% are independent prognostic factors for all cardiac events. Zhang et al. study proved that personality type affects clinical course of patients with low EF. In their study, 21 patients of 87 patients experienced cardiac complications of MI in 5–10 years. These complications were associated with EF below 30%, low exercise compliance, previous MI, anxiety, anger, and depression, and patients with type D personality were at higher risk of cardiac complications compared with non-type D personality.
Consequently, several evidences have shown the mediator role of type D personality between life events and stress and NA experience through which it leads to exacerbating some cardiac risk factors by increasing some pathophysiologic mechanisms. It appears that severity of these risk factors be involved in determination of MI extent and post-MI EF reduction. Limited studies have been performed on the relationship between personality type and MI patients and left ventricle function, though approving this relationship requires further investigations to definitely show which patients are at real risk of cardiac events. Thus, due to the limited studies, lack of similar domestic study, and relatively high prevalence of type D personality in the society, the current study was conducted to determine and compare left ventricular EF (LVEF) in type D personality and nontype D personality patients with first episode of MI.
| Materials and Methods|| |
The research method was descriptive from type of a cross-sectional study conducted in 2013 in educational therapeutic centers affiliated to Isfahan University of Medical Sciences. Statistical society of this study included MI patients hospitalized in those centers in 2013. Sample size of this study was calculated to be 120 according to the sample size estimation formula for correlation studies considering 95% confidence level and 80% power of test, and correlation between EF index and score of personality type was considered approximately 20%. For more assurance, 150 patients entered this study. The sampling method was random.
Inclusion criteria of this study included approved MI diagnosis by cardiologist according to MI diagnostic criteria which included characteristic angina pectoris for myocardial ischemia lasting for at least 20 min, the presence of pathologic changes implying ischemia, infarction in electrocardiogram waves, elevated cardiac enzymes, as well as patients' consent to participate in the study. Exclusion criteria consisted of secondary MI to coronary artery bypass graft surgery or angioplasty, other serious physical disease affecting function of left ventricle, and major psychological disorder.
Score above 10 for both features is used for determination of type D personality. Those who catch the score above 10 are categorized as individuals with type D personality and those who catch the score below 10 are categorized as individuals with non-D personality.
After coordination with hospitals with CCU (Al-Zahra, Khorshid, and Chamran Hospitals), cardiac patients with first episode of MI approved by cardiologist entered this study successively. Afterward, by evaluation of last echocardiogram report taken after MI, EF of patients were extracted and entered in a special form as well as demographic information of patients. Then, they were asked to fill out type D personality questionnaire (DS14).
DS14 is a standardized questionnaire consisting of 14 questions to assess NA and SI personality features. This 14-question version takes 5 min to be filled out. Questions of this questionnaire are scored based on 5-score Likert scale as true, partially true, no idea, partially false, and false with 0, 1, 2, 3, and 4 scores, respectively. The highest score for NA and SI is 28. Score above 10 for both features is used for determination of type D personality. The cutoff point of the scale is 10 score. A study on psychological feature on DS14 by Denollet showed that NA and SI scales include n = 3678; a = 0.88/0.86, and it is persistent for 3 months. NA (test-retest r = 0.72/0.82) has a correlation coefficient (r = +0.68) with neuroticism. SI has a correlation coefficient (r = −0.59/−0.65) with extroversion. Persian version of this questionnaire provided by Bagherian and Bahrami Ehsan is used in this study.
Finally, the collected data were entered to and analyzed with SPSS software version 20 (IBM, Armonk, NY, United states of America), and Chi-square, t-test, linear regression test, simple, and multiple logistic statistical tests were used for data analysis. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 in Medical University of Isfahan in a research project with code of 390612. Informed consent was obtained from all participants for being included in the study.
| Results|| |
Distribution of demographic variables in both D and non-D personality types are presented in [Table 1]. T-test showed that the mean age of the two groups were not significantly different (P = 0.3). Sex distribution was assessed by Chi-square test. Female sex ratio was higher in D group compared with non-D group which was slightly statistically significant (P = 0.058). However, the distribution of other demographic variables including education, residence, and marital status did not show significant differences among the two groups (P > 0.05).
|Table 1: Frequency distribution of demographic variables of the two groups|
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Mean EF index in all patients in this study were 43 ± 47.9 ranging from 15 to 60, and accordingly, 14 patients (9.3%) had normal EF while 136 patients (90.7%) had abnormal EF. Mean EF index in D and non-D personality type were 43.2 ± 10.5 and 42.9 ± 9, respectively, and T-test proved no significant difference (P = 0.86). Furthermore, 7 patients (12.7%) in type D group and 7 patients (7.4%) in type non-D group had normal EF, while 48 patients (87.3%) in type D group and 87 patients (92.6%) in type non-D group had abnormal EF. Although based on Chi-square test, distribution of EF in two personality type groups did not show a significant difference (P = 0.28) [Table 2].
|Table 2: Comparison of ejection fraction in D and non-D personality types|
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As it is shown in [Table 3], 25 patients (45.5%) in type D personality group had EF above 40% and 30 patients (54.5%) had EF equal to or below 40%. In type non-D personality, 48 patients (50.5%) had EF above 40% and 47 patients (49.5%) had EF equal to or below 40% (P = 0.16)
|Table 3: Comparison of ejection fraction above and below 40% in D and non-D personality type|
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Linear regression was used to evaluate the relationship between personality type and EF score. In simple model, only the relationship between personality type and EF score was assessed. Regression coefficient was calculated to be −0.110 which was not statistically significant (P = 0.99).
In multiple model, confounding variables such as age, sex, residence, marital status, and education were controlled. Though, the coefficient did not change and the relationship was not significant, as well.
Logistic regression was used to assess the relationship between personality type and EF status (normal or abnormal). In the simple model, only the relationship of personality type was assessed. Odds ratio of 1.83 with confidence interval of 0.61–5.4 was calculated which was not statistically significant (P = 0.282).
The relation of personality type and normal EF was assessed with multiple logistic regression in which the confounding effect of age, sex, residence, marital status, and education were modulated which leaded t OR = 21 with 95% confidence interval of 0.53–8.19 which was not statistically significant as well.
The below charts show distribution of EF score according to age, sex, residence, marital status, and education variables which does not imply statistically significant difference [Chart 1], [Chart 2], [Chart 3], [Chart 4], [Chart 5].
| Discussion|| |
The main goal of this study is to determine and compare the function of left ventricle in patients with and without type D personality who are hospitalized for first episode of MI. According to the results of this study, mean EF index in D and non-D personality types were not significantly different, and distribution of normal and abnormal EF index was not different in the two groups. Moreover, no significant difference was observed on the distribution of patients with EF equal to or below 40% in the two groups of personality type. Frequency of type D personality was significantly higher among women, but no other significant differences were observed in terms of age, education, marital status, and residence. In addition, according to multiple regression test, demographic variable which has a significant effect on the dependent variable, EF index here, did not imply confounding effect. Nowadays, it is proved that left ventricle function is a predicting factor for survival after acute MI recovery which is explained by EF, and on the other hand, other studies showed that this index is related to individual's personality type. For example, Denollet and Vase study proved that LVEF below 50%, type D personality, and age below 55 years increase the risk of cardiac events, and association of these factors predicts treatment failure. On the other hand, it is proved that D personality type and LVEF below 50% are independent predicting factors for all cardiac events inclining revascularization processes. In Denollet and Brutsaert's study, it was demonstrated that personality type affects clinical course of patients with low EF. In this study, 21 patients of 87 MI patients showed cardiac complications which were associated with EF below 30%, low exercise compliance, previous MI, anxiety, anger, and depression. Moreover, patients with D personality type were more prone to cardiac complications compared with patients with non-D personality type. Thus, the relationship between these personality factors and left ventricle dysfunction may be assumed, although such a relationship was not proved in our study. Yet, higher prevalence of type D personality in patients compared with general population in our study was consistent with other studies.
Statistical society of this study were patients with MI, and their personality type was assessed after MI. As numerous studies have shown, MI patients are at risk of psychological disorders due to MI such as depression which can affect their responses to the questionnaire and confound the accurate evaluation of personality characteristics.
| Conclusion|| |
According the results of the research, there is no significant relationship between type D personality with LVEF in people with first-time MI. Therefore, it can be concluded that the type D personality have no direct effect on LVEF among MI patients.
Cross-sectional design of this study and lack of control for factors affecting LVEF are limitations of this study.
Conduction prospective longitudinal studies by controlling confounding factors affecting function of left ventricle is our main suggestion for future studies.
Authors declare their sincere thanks to all patients who participated in this study as well as medical staff of cardiac ward of hospital engaged in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Antman EM, Selwyn AP, Braunwald E, Loscalzo J. Ischemic heart disease. In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al
., editors. Harrison's Internal Medicine. 17th
ed. United States of America: McGraw Hill; 2008. p. 1514-26.
Huxley R, Woodward M, Barzi F, Wong JW, Pan WH, Patel A. Does sex matter in the associations between classic risk factors and fatal coronary heart disease in populations from the Asia-Pacific region? J Womens Health (Larchmt) 2005;14:820-8.
Meijer A, Conradi HJ, Bos EH, Thombs BD, van Melle JP, de Jonge P, et al.
Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: A meta-analysis of 25 years of research. Gen Hosp Psychiatry 2011;33:203-16.
Taylor GJ, Humphries JO, Mellits ED, Pitt B, Schulze RA, Griffith LS, et al
. Predictors of clinical course, coronary anatomy and left ventricular function after recovery from acute myocardial infarction. Circulation 1980;62:960-7.
Kawachi I, Colditz GA, Ascherio A, Rimm EB, Giovannucci E, Stampfer MJ, et al.
Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation 1994;89:1992-7.
Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The normative aging study. Circulation 1994;90:2225-9.
Mittleman MA, Maclure M, Sherwood JB, Mulry RP, Tofler GH, Jacobs SC, et al.
Triggering of acute myocardial infarction onset by episodes of anger. Determinants of myocardial infarction onset study investigators. Circulation 1995;92:1720-5.
Kawachi I, Sparrow D, Spiro A 3rd
, Vokonas P, Weiss ST. A prospective study of anger and coronary heart disease. The normative aging study. Circulation 1996;94:2090-5.
Kubzansky LD, Kawachi I, Spiro A 3rd
, Weiss ST, Vokonas PS, Sparrow D. Is worrying bad for your heart? A prospective study of worry and coronary heart disease in the normative aging study. Circulation 1997;95:818-24.
Blumenthal JA, Jiang W, Waugh RA, Frid DJ, Morris JJ, Coleman RE, et al.
Mental stress-induced ischemia in the laboratory and ambulatory ischemia during daily life. Association and hemodynamic features. Circulation 1995;92:2102-8.
Garcia-Retamero R, Petrova D, Arrebola-Moreno A, Catena A, Ramírez-Hernández JA. Type D personality is related to severity of acute coronary syndrome in patients with recurrent cardiovascular disease. Br J Health Psychol 2016;21:694-711.
Staniute M, Brozaitiene J, Burkauskas J, Kazukauskiene N, Mickuviene N, Bunevicius R. Type D personality, mental distress, social support and health-related quality of life in coronary artery disease patients with heart failure: A longitudinal observational study. Health Qual Life Outcomes 2015;13:1.
Afshar H, Roohafza HR, Keshteli AH, Mazaheri M, Feizi A, Adibi P. The association of personality traits and coping styles according to stress level. J Res Med Sci 2015;20:353-8.
] [Full text]
Mardaga S, Hansenne M. Autonomic aspect of emotional response in depressed patients: Relationships with personality. Neurophysiol Clin 2009;39:209-16.
Pedersen SS, Denollet J. Type D personality, cardiac events, and impaired quality of life: A review. Eur J Cardiovasc Prev Rehabil 2003;10:241-8.
Denollet J. Biobehavioral research on coronary heart disease: Where is the person? J Behav Med 1993;16:115-41.
Denollet J. DS14: Standard assessment of negative affectivity, social inhibition, and type D personality. Psychosom Med 2005;67:89-97.
Al-Qezweny MN, Utens EM, Dulfer K, Hazemeijer BA, van Geuns RJ, Daemen J, et al.
The association between type D personality, and depression and anxiety ten years after PCI. Neth Heart J 2016;24:538-43.
Pedersen SS, van Domburg RT, Theuns DA, Jordaens L, Erdman RA. Type D personality is associated with increased anxiety and depressive symptoms in patients with an implantable cardioverter defibrillator and their partners. Psychosom Med 2004;66:714-9.
Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, Brutsaert DL. Personality as independent predictor of long-term mortality in patients with coronary heart disease. Lancet 1996;347:417-21.
Kupper N, Denollet J, de Geus EJ, Boomsma DI, Willemsen G. Heritability of type-D personality. Psychosom Med 2007;69:675-81.
Conraads VM, Denollet J, De Clerck LS, Stevens WJ, Bridts C, Vrints CJ. Type D personality is associated with increased levels of tumour necrosis factor (TNF)-alpha and TNF-alpha receptors in chronic heart failure. Int J Cardiol 2006;113:34-8.
Schiffer AA, Pedersen SS, Widdershoven JW, Hendriks EH, Winter JB, Denollet J. The distressed (type D) personality is independently associated with impaired health status and increased depressive symptoms in chronic heart failure. Eur J Cardiovasc Prev Rehabil 2005;12:341-6.
Brown ES, Varghese FP, McEwen BS. Association of depression with medical illness: Does cortisol play a role? Biol Psychiatry 2004;55:1-9.
Sutin AR, Terracciano A, Deiana B, Uda M, Schlessinger D, Lakatta EG, et al.
Cholesterol, triglycerides, and the five-factor model of personality. Biol Psychol 2010;84:186-91.
Tziallas D, Kostapanos MS, Skapinakis P, Milionis HJ, Athanasiou T, S Elisaf M, et al.
The association between type D personality and the metabolic syndrome: A cross-sectional study in a university-based outpatient lipid clinic. BMC Res Notes 2011;4:105.
Sanz G, Castañer A, Betriu A, Magriña J, Roig E, Coll S, et al.
Determinants of prognosis in survivors of myocardial infarction: A prospective clinical angiographic study. N Engl J Med 1982;306:1065-70.
Zhang JK, Fang LL, Zhang DW, Jin Q, Wu XM, Liu JC, et al.
Type D personality in gastric cancer survivors: Association with poor quality of life, overall survival, and mental health. J Pain Symptom Manage 2016;52:81-91.
Roubin GS, Harris PJ, Bernstein L, Kelly DT. Coronary anatomy and prognosis after myocardial infarction in patients 60 years of age and younger. Circulation 1983;67:743-9.
Bagherian R, Bahrami Ehsan H. Psychometric properties of the Persian version of type D personality scale (DS14). Iran J Psychiatry Behav Sci 2011;5:12-7.
Denollet J, Brutsaert DL. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Circulation 1998;97:167-73.
[Table 1], [Table 2], [Table 3]