Download Risk of Ventricular Arrhythmia After Implantable Defibrillator

Journal of the American College of Cardiology
© 2009 by the American College of Cardiology Foundation
Published by Elsevier Inc.
Vol. 54, No. 6, 2009
ISSN 0735-1097/09/$36.00
doi:10.1016/j.jacc.2009.04.043
Risk of Ventricular Arrhythmia After Implantable
Defibrillator Treatment in Anxious Type D Patients
Krista C. van den Broek, PHD,* Ivan Nyklı́ček, PHD,* Pepijn H. van der Voort, MD,†
Marco Alings, MD, PHD,‡ Albert Meijer, MD, PHD,† Johan Denollet, PHD*
Tilburg, Eindhoven, and Breda, the Netherlands
Objectives
We sought to examine the combination of adverse psychological factors (anxiety, depression, and distressed or
Type D personality) as a predictor of ventricular arrhythmias in patients with implantable cardioverterdefibrillators (ICDs).
Background
Little is known about the role of psychological factors and their clustering in the occurrence of life-threatening
arrhythmias.
Methods
In this prospective study, 391 patients with an ICD (81% men, age 62.3 ⫾ 10.4 years) completed anxiety, depression, and Type D personality scales at the time of implantation. The end point was occurrence of ventricular
arrhythmia, defined as appropriate ICD therapies, in the first year after implantation.
Results
Ventricular arrhythmias occurred in 19% (n ⫽ 75) of patients. Increased symptoms of depression (p ⫽ 0.81) or
anxiety (p ⫽ 0.31) did not predict arrhythmias. However, anxious patients with a Type D personality had a significantly increased rate of ventricular arrhythmias (21 of 71; 29.6%) as compared with other ICD patients (54 of
320; 16.9%; hazard ratio [HR]: 1.89; 95% confidence interval [CI]: 1.14 to 3.13; p ⫽ 0.013). When controlled for
the effects of sex, age, ischemic etiology, left ventricular dysfunction, prolonged QRS duration, and medication,
anxious Type D patients (HR: 1.72; 95% CI: 1.03 to 2.89; p ⫽ 0.039) and secondary prevention patients (HR:
1.91; 95% CI: 1.14 to 3.20; p ⫽ 0.014) were at increased risk of ventricular arrhythmias.
Conclusions
Personality modulated the effect of emotional distress; anxiety predicted a 70% increase in risk of arrhythmia in
Type D patients but not in other patients. Anxious Type D patients may be identified and offered additional behavioral support after ICD implantation. (J Am Coll Cardiol 2009;54:531–7) © 2009 by the American College
of Cardiology Foundation
Implantable cardioverter-defibrillator (ICD) treatment provides an opportunity to study factors associated with ventricular arrhythmia as the most common cause of sudden
cardiac death (1). Guidelines (2,3) advocate ICD implantation in patients who have survived life-threatening arrhythmias and in patients with severe left ventricular dysfunction. The use of an ICD does not prevent ventricular
arrhythmias, but the ICD can terminate ventricular arrhythmias by antitachycardia pacing (ATP) or high-voltage
From the *CoRPS (Center of Research on Psychology in Somatic diseases), Tilburg
University, Tilburg, the Netherlands; †Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; and the ‡Department of Cardiology, Amphia
Hospital, Breda, the Netherlands. This study was supported by the Netherlands
Organization for Scientific Research, The Hague, the Netherlands with a VICI grant
(453-04-004) to Dr. Denollet. Dr. van der Voort has received speaker’s fees from
Medtronic. Dr. Alings reports that the Department of Clinical Electrophysiology has
received unrestricted grants from Boston Scientific Nederland, Medtronic Nederland,
and St. Jude Medical Nederland. Dr. Meijer has received lecturing fees, research
support, and consultancy fees from Medtronic, Boston Scientific, and St. Jude
Medical.
Manuscript received February 9, 2009; revised manuscript received March 30,
2009, accepted April 26, 2009.
shocks (4). However, patient selection for ICD implantation remains an important clinical issue, and better knowledge of risk factors for ventricular arrhythmias is needed
(1,5). Moreover, sudden cardiac death caused by ventricular
arrhythmias may still occur in a small proportion of ICD
patients (6), which points out the importance of studying
triggers and risk factors of ventricular arrhythmias after ICD
treatment.
Clinical risk factors for ventricular arrhythmia include
ischemic heart disease (1), New York Heart Association
functional class III (7) or IV (8), previous ventricular
arrhythmias (8), low left ventricular ejection fraction, QRS
duration, and atrial fibrillation (9), but an unresolved issue is
the role of emotional distress (10). Some studies found that
shocked patients experience anxiety (11–14), depression
(15), and impaired quality of life (16), although others
(17–19) did not find this association. However, only a few
studies have evaluated the role of emotional distress as
precipitant of ventricular arrhythmias in patients with an
ICD (20 –23), with 2 studies (21,22) investigating emo-
532
van den Broek et al.
Anxiety, Personality, and Ventricular Arrhythmia
tional states as risk factors for
arrhythmias, and 1 study (23)
investigating acute emotional
ACE ⴝ angiotensintriggers.
converting enzyme
Depression has been associated
ATP ⴝ antitachycardia
with ventricular arrhythmias (20),
pacing
whereas others found that anxiety,
BDI ⴝ Beck Depression
but not depression and anger
Inventory
(21), or anger, but not sadness
CI ⴝ confidence interval
and anxiety (23), may trigger
DS14 ⴝ Type D scale
ventricular arrhythmias. These
HR ⴝ hazard ratio
mixed findings indicate that
ICD ⴝ implantable
other factors may modulate the
cardioverter-defibrillator
effect of emotional distress, and
STAI ⴝ State Trait Anxiety
evidence suggests that stable perInventory
sonality traits may increase the
risk of emotion-triggered appropriate shocks in ICD patients (23). Of note, psychological
risk factors do not occur in isolation (24) but rather tend to
cluster together within cardiac patients to increase the risk
of clinical events (25).
Therefore, the objective of this prospective study was to
examine the extent to which Type D personality (i.e., the
tendency to experience emotional and social distress) may
modulate the association between anxiety/depression and
ventricular arrhythmia. Previously, we have argued that
research should focus on the interaction of psychological
factors (24,26), and we have shown that clustering of Type
D personality with other psychological factors increases the
risk of adverse outcomes (12,27). In the present study, we
examined the role of anxiety, depression, and their combination with Type D personality as predictors of ventricular
arrhythmias during the 12-month period after ICD implantation, adjusting for sex, age, ICD indication, etiology,
ejection fraction, QRS duration, and medical treatment.
Abbreviations
and Acronyms
Methods
Patient sample. Patients who underwent ICD implantation between May 2003 and December 2006 were included
from 2 referral hospitals in the Netherlands (Catharina
Hospital, Eindhoven; Amphia Hospital, Breda). Inclusion
criteria were implantation with an ICD and age between 18
and 80 years. Exclusion criteria were significant cognitive
impairments (e.g., dementia), life-threatening comorbidities (e.g., cancer), and insufficient knowledge of the Dutch
language. Patients who died during the 12-month
follow-up period were not excluded from the analyses
because these patients could also have experienced ventricular arrhythmias during their follow-up period. The study
was approved by the Medical Ethics Committees of both
participating hospitals. The study was conducted in accordance with the Helsinki Declaration, and all patients
provided written informed consent.
Psychological measures. Patients completed questionnaires on depressive symptoms, anxiety, and personality in
JACC Vol. 54, No. 6, 2009
August 4, 2009:531–7
the period between 1 day before ICD implantation and 3
weeks after ICD implantation.
The Beck Depression Inventory
(BDI) is a 21-item self-report measure developed to assess
the presence and severity of depressive symptoms (28). Each
item is rated on a Guttmann scale from 0 to 3. The BDI is
a reliable and valid measure of depressive symptomatology
and the most frequently used self-report measure of depressive symptoms in cardiac patients. Scores ⱖ10 were used to
indicate clinically relevant levels of depression (28,29).
DEPRESSIVE SYMPTOMS.
The State Trait Anxiety Inventory (STAI) was
used to assess general symptoms of anxiety (30). In the
current study, we only used the state measure because the
purpose of this study was to assess the current presence of
symptoms of anxiety at baseline. The STAI state version
consists of 20 items and each item is rated on a 4-point
Likert scale from 1 (not at all) to 4 (very much so), with total
scores ranging from 20 to 80, with higher scores indicating
greater levels of state-anxiety. The STAI has adequate
validity and reliability, with Cronbach’s alpha ranging from
0.87 to 0.92 (30). To indicate clinically elevated levels of
general anxiety, a cut-off of ⱖ40 was used, which was
previously used in studies on ICD (31).
ANXIETY.
The Type D scale (DS14) was used to
assess Type D personality. Type D patients tend to experience increased negative emotions (e.g., worry and have a
gloomy view of life) paired with emotional nonexpression
(32). The DS14 contains 2 scales of 7 items each: Negative
Affectivity (e.g., “I often feel unhappy”) and Social Inhibition (e.g., “I am a closed kind of person”) (32). Items are
answered on a 5-point Likert scale, ranging from 0 (false) to
4 (true), with total scores ranging from 0 to 28 for both
subscales. Patients scoring ⱖ10 on both subscales are
classified as Type D (32,33). The DS14 has good reliability,
with a Cronbach’s alpha of 0.88 and 0.86 and 3-month
test-retest reliability of 0.72 and 0.82 for Negative Affectivity and Social Inhibition, respectively (32). The DS14 is
a stable personality measure during an 18-month period
after an acute event (34), and scores are not confounded by
cardiac disease severity or symptoms of anxiety and depression (34,35). Previous studies have shown an association
between Type D personality and adverse clinical outcome,
including mortality and morbidity (36 – 40).
Demographic and clinical variables. Demographic variables included sex and age. Clinical variables included ICD
indication (primary vs. secondary prevention), etiology
(ischemic vs. nonischemic), severely decreased ejection fraction (left ventricular ejection fraction ⱕ35% vs. ⬎35%),
prolonged QRS duration (QRS duration ⱖ120 ms vs. ⬍120
ms), and prescription of angiotensin-converting enzyme
(ACE) inhibitors or beta-blockers. These variables were
obtained from medical records at baseline.
Ventricular arrhythmias. Ventricular arrhythmias were
defined by appropriate ICD therapies, either ATPs or
TYPE D PERSONALITY.
van den Broek et al.
Anxiety, Personality, and Ventricular Arrhythmia
JACC Vol. 54, No. 6, 2009
August 4, 2009:531–7
shocks, which were delivered for ventricular tachycardia or
ventricular fibrillation. Patients visited the center of implantation at regular intervals (mostly 3 or 6 months). During
these visits arrhythmic events were recorded from the ICD
and stored. Only a small number of patients did not visit the
center of implantation but instead went to their own
hospital. Therefore, these hospitals were contacted for
information on arrhythmic events. None of the patients had
remote monitoring systems. Because the study extended
during a 12-month period, beginning with ICD implantation, we specifically included patients who already had their
12-month check-up in the hospital. Only the most aggressive treatment per episode was counted, meaning that if a
patient experienced a ventricular arrhythmia for which first
ATPs were delivered and then shocks, this episode was only
counted as one shock. The occurrence of appropriate ATPs
and shocks were obtained from medical records, with
electrophysiologists judging the appropriateness of ICD
therapies on the basis of electrocardiograms.
Statistical analyses. Differences between groups were examined with a chi-square test (likelihood ratio where
appropriate) for dichotomous variables and a t test for
independent samples for continuous variables. To enhance
clinical interpretability, anxiety and depression scores were
dichotomized. As has been advocated previously, research
on adverse outcomes should not only focus on the prognostic value of isolated psychological factors but also on the
prognostic value of the interaction of these factors (24,25).
This approach was adopted in our analyses. A series of
univariable Cox regression analyses were performed to
determine whether increased depressive symptoms, increased anxiety, Type D personality, and clustering of these
factors predicted ventricular arrhythmias in the first year
after ICD implantation. If a clustering of psychological
factors was significant, the independent value of this clustering was tested first in a multivariable Cox analysis (enter
method) that also included the main effects of these factors.
Next, a multivariable Cox regression analysis (enter
method) was performed, including the psychological predictor(s), and age, sex, ICD indication, etiology, severely
decreased ejection fraction, prolonged QRS duration, and
prescription of ACE inhibitors or beta-blockers.
533
Because multicollinearity may affect parameters in regression analyses, we performed a linear regression analysis to
obtain tolerance and variance inflation factor (VIF) values
(41), with a tolerance value ⬍0.10 or a VIF value ⬎10
indicating multicollinearity. The Kaplan-Meier method was
used to graphically present the time to first ventricular
arrhythmia, and the log-rank test was performed to test for
significant differences between the groups. All data were
analyzed with the use of SPSS version 16.0 for Windows
(SPSS Inc., Chicago, Illinois), and p ⫽ 0.05 was used to
indicate statistical significance.
Results
Patient characteristics. Of the 432 patients who agreed to
participate in the study, 391 (90.5%) patients were included
in the analyses. Patients who were not included had missing
data on self-report measures (n ⫽ 10) or clinical variables
(n ⫽ 31). Included patients did not differ from excluded
patients on any of the baseline characteristics. Table 1 shows
demographic and clinical characteristics of the 391 patients
included in the study, both for the total sample and
stratified by occurrence of appropriate ICD therapies. The
mean anxiety score (STAI) was 39.5 ⫾ 11.7, and the mean
depressive score (BDI) was 8.9 ⫾ 6.7. Increased levels of
anxiety were experienced by 47.8% (187 of 391) of patients
and increased levels of depression by 35.3% (138 of 91) of
patients. Finally, 23% (90 of 391) of patients were classified
as a Type D.
Ventricular arrhythmias. During the first year after implantation, 75 patients (19.2%) experienced ventricular arrhythmias with appropriate therapies, and 21 patients
(4.6%) died. Of the 75 patients, 52.1% of patients only had
appropriate ATP-only episode(s), 23.3% only had shockonly episodes, and 24.7% had both ATP-only and shockonly episodes. The median number of appropriate ICD
therapies was 2, with a range from 1 to 1,100 episodes.
Psychological predictors of ventricular arrhythmias.
Univariable Cox regression analyses showed that secondary
prevention (p ⫽ 0.004) was a significant predictor of
occurrence of ventricular arrhythmia, but none of the other
demographic or clinical variables were related to ventricular
Baseline
and Clinical and
Characteristics
of 391 Patients
Included
in the
Analyses
Table 1 Demographic
Baseline Demographic
Clinical Characteristics
of 391
Patients
Included
in the Analyses
Appropriate Therapy for Ventricular Arrhythmia
Characteristics
% (n)
No, %
Yes, %
80.6 (315)
81.0
78.7
Age (yrs), mean ⫾ SD
62.3 ⴞ 10.4
62.7 ⫾ 10.5
60.5 ⴞ 9.8
0.097
Males
p Value*
0.64
Secondary prevention
42.7 (167)
39.2
57.3
0.004
Nonischemic etiology
28.6 (112)
27.8
32.0
0.48
Severely decreased ejection fraction†
81.8 (320)
82.9
77.3
0.26
Prolonged QRS duration‡
58.8 (230)
59.8
54.7
0.42
No prescription of angiotensin-converting enzyme inhibitor
32.0 (125)
31.6
33.3
0.78
No prescription of beta-blocker
16.9 (66)
15.2
24.0
0.067
*p ⱕ 0.10 are presented in bold. †Ejection fraction ⱕ35%. ‡QRS duration ⱖ120 ms.
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van den Broek et al.
Anxiety, Personality, and Ventricular Arrhythmia
JACC Vol. 54, No. 6, 2009
August 4, 2009:531–7
arrhythmia (Table 2). Regarding isolated psychological factors;
increased anxiety (p ⫽ 0.31) and depression (p ⫽ 0.81) did not
predict arrhythmias, but there was a trend for Type D
personality (p ⫽ 0.079), with 29.6% (21 of 71) of Type D
patients and 16.9% (54 of 320) of non-Type D patients having
experienced ventricular arrhythmias.
Finally, Table 2 shows prognostic values of clustering of
psychological factors. Clustering of anxiety and depression (p ⫽ 0.91) and depression and Type D personality
(p ⫽ 0.18) did not significantly relate to arrhythmia. However, the combined presence of anxiety and Type D personality
did significantly predict ventricular arrhythmias (p ⫽ 0.013).
Independent predictors of ventricular arrhythmias. After
controlling for anxiety and personality main effects, the
anxiety ⫻ Type D interaction effect still was significant
(hazard ratio [HR]: 2.09; 95% confidence interval [CI]:
1.01 to 4.39; p ⫽ 0.049), whereas the anxiety (p ⫽ 0.74) and
Type D (p ⫽ 0.56) main effects were not. Hence, anxiety
only had an impact when Type D personality was present.
Stratification of patients in 4 distinct anxiety/Type D
subgroups confirmed that anxious Type D patients (HR:
1.77; 95% CI: 1.02 to 3.06; p ⫽ 0.041) but not anxious
non-Type D (p ⫽ 0.71) or nonanxious Type D (p ⫽ 0.43)
patients had an increased risk of ventricular arrhythmia
compared with the reference group (low anxiety and nonType D). Because it was the clustering of anxiety and Type
D that was associated with an increased arrhythmia risk, this
combination was further examined in a multivariable model
including demographic and clinical characteristics.
The tests for multicollinearity were negative, with all
tolerance values ranging from 0.65 to 0.97 and VIF values
from 1.03 to 1.54, which demonstrates the absence of
Univariable
VentricularofArrhythmias
Table 2 Predictors
UnivariableofPredictors
Ventricular Arrhythmias
Ventricular Arrhythmias
Variables
HR
95% CI
p Value*
Demographic and clinical factors
Male
0.91
0.52⫺1.58
0.74
Age
0.98
0.96ⴚ1.00
0.087
Secondary prevention
1.96
1.24ⴚ3.10
0.004
Nonischemic etiology
1.18
0.73⫺1.92
0.50
Severely decreased ejection fraction†
0.74
0.43⫺1.27
0.27
Prolonged QRS duration‡
0.81
0.52⫺1.28
0.37
No prescription of angiotensin-converting
enzyme inhibitor
1.07
0.67⫺1.74
0.77
No prescription of beta-blocker
1.68
0.99ⴚ2.85
0.056
0.81
Isolated psychological factors
Increased depressive symptoms
1.06
0.66⫺1.70
Increased anxiety
1.26
0.80⫺1.99
0.31
Type D personality
1.55
0.95ⴚ2.54
0.079
Depression ⫻ anxiety
1.03
0.62⫺1.72
0.91
Depression ⫻ Type D personality
1.49
0.83⫺2.66
0.18
Anxiety ⫻ Type D personality
1.89
1.14ⴚ3.13
0.013
Clustering of psychological factors
*p ⱕ 0.10 are presented in bold. †Ejection fraction ⱕ35%. ‡QRS duration ⱖ120 ms.
CI ⫽ confidence interval; HR ⫽ hazard ratio.
Multivariable
Predictors ofPredictors
VentricularofArrhythmias
Table 3
Multivariable
Ventricular Arrhythmias
Ventricular Arrhythmias
HR
95% CI
Male
1.02
0.56⫺1.86
p Value*
Age
0.98
0.96⫺1.01
0.16
Secondary prevention
1.91
1.14ⴚ3.20
0.014
0.94
Nonischemic etiology
1.08
0.61⫺1.92
0.80
Severely decreased ejection fraction†
1.30
0.63⫺2.67
0.47
Prolonged QRS duration‡
0.98
0.59⫺1.61
0.92
No prescription of angiotensin-converting
enzyme inhibitor
1.05
0.62⫺1.76
0.86
No prescription of beta-blocker
1.54
0.89⫺2.66
0.12
Anxious Type D cluster
1.72
1.03ⴚ2.89
0.039
*p ⱕ 0.10 are presented in bold. †Ejection fraction ⱕ35%. ‡QRS duration ⱖ120 ms.
Abbreviations as in Table 2.
multicollinearity. Hence, these variables did not have significant overlap, and they could be entered in the model at
the same time.
In the multivariable Cox regression analysis (enter model),
adjusting for sex, age, secondary prevention, nonischemic
etiology, severely decreased ejection fraction, prolonged QRS
duration, and prescription of ACE inhibitors or beta-blockers,
clustering of anxiety and Type D personality remained significant with a 1.7-fold risk. In addition, secondary prevention
was associated with a 1.9-fold risk to experience ventricular
arrhythmias (Table 3).
Ventricular arrhythmias in anxious Type D patients.
Kaplan-Meier curves for the time to first ventricular arrhythmia for anxious Type D patients versus the other patients are
shown in Figure 1. The log-rank test was significant (chisquare ⫽ 6.33, degrees of freedom ⫽ 1, p ⫽ 0.012), with
anxious Type D patients experiencing earlier and more often
ventricular arrhythmia as compared with other ICD patients.
Discussion
In this prospective study, we examined the extent to which
Type D personality may modulate the association between
anxiety/depression and ventricular arrhythmia in the first
year after ICD implantation. Clustering of increased anxiety
at the time of implantation and having a Type D personality
predicted arrhythmia, with its 1.7-fold independent risk
being comparable with the 1.9-fold risk for secondary
prevention patients.
Previous studies on psychological risk factors or triggers
of ventricular arrhythmia in ICD patients yielded mixed
findings, but none of these studies focused on a clustering of
psychological risk factors. The findings of the present study
support the notion that psychological factors may cluster in
ICD patients which, in turn, increases the risk for adverse
outcomes (24,26,27,42– 46). More specifically, the finding
that clustering of anxiety and Type D personality was a risk
factor for adverse outcomes has also been described previously, including in ICD patients (12,27). Hence, the fact
that the combined presence of negative emotional states and
JACC Vol. 54, No. 6, 2009
August 4, 2009:531–7
Figure 1
Kaplan-Meier Curve for Time to
First Ventricular Arrhythmia in Type D
Patients With Increased Anxiety (p ⴝ 0.012)
Other groups (blue line); anxious Type D patients (green line).
Type D personality incurs the highest adverse risk should be
taken into account in future studies.
Results of the current study suggest that the relationship
between psychological distress and morbidity and mortality
(36 –39,47) may be mediated by occurrence of ventricular
arrhythmias. However, pathways or mechanisms linking
emotions and personality traits in general and anxiety and
Type D personality in particular to arrhythmias are not well
known and should be explored further in future research.
Stress may be associated with increased sympathetic tone
and its detrimental effects on arrhythmia (48,49). Experimental studies have shown that general mental stress may
induce increased T-wave alternans (50), which is associated
with ventricular arrhythmias and death (51). Mental stress
may also shorten the cycle length of ventricular tachycardia
and consequently result in more difficult termination of this
arrhythmia (52).
Secondary prevention was also significantly predictive for
ventricular arrhythmias, whereas sex, age, nonischemic etiology, severely decreased ejection fraction, prolonged QRS
duration, and prescription of ACE inhibitors or betablockers were not. The findings on indication, sex, and age
are in line with results from previous research (8,21,53,54),
although older and male patients may be at increased risk
for ventricular arrhythmias (55). Because ischemic etiology,
severely decreased ejection fraction, and prolonged QRS
van den Broek et al.
Anxiety, Personality, and Ventricular Arrhythmia
535
duration have been identified as precipitants of ventricular
arrhythmias (1,9) whereas ACE inhibitors and betablockers have been found to have antiarrhythmic effects
(56), it is difficult to explain the nonsignificant findings.
Screening for anxiety and Type D personality may be
standardized in clinical practice because both factors have
been associated with adverse outcomes in ICD patients
(14,17,19,57,58). A recent review indicates that cognitivebehavioral therapy paired with exercise training may be
most useful to diminish anxiety symptoms in ICD patients
(59). Interventions for Type D personality may aim at
changing coping styles for dealing with negative emotions.
Because only a few studies have focused on psychological
intervention in ICD patients (59) and because no study has
investigated interventions for Type D patients, more research is needed on this topic, particularly regarding the role
of supportive or medical therapy with respect to occurrence
of ventricular arrhythmias in Type D patients.
Study limitations. First, ventricular arrhythmias without
therapy were not included. Second, because the cause of
death is not known for most of the patients, it is unknown,
although unlikely, whether death was attributable to ventricular arrhythmia. Third, anxiety was only measured at the
time of implantation, which provided no information about
the course of anxiety levels. However, a previous publication
based on this sample suggested that baseline levels of anxiety
did not differ from levels at 2 months after implantation
(13). In addition, other studies suggest stability of anxiety
levels (11,18).
Conclusions
This prospective study suggests that patients with both
anxiety and a Type D personality, and patients with a
secondary prevention are at increased risk to experience
ventricular arrhythmias in the first year after ICD implantation. In clinical practice, anxious Type D patients should
be identified and offered adequate support. Future studies
may focus on the prevalence and prognostic value of
clustering of psychological risk factors, but also on the role
of supportive therapy in these patients. In addition, mechanisms and pathways linking anxiety and personality traits
to ventricular arrhythmias need to be studied.
Acknowledgments
The authors thank Eefje Postelmans and Hidde Weetink
for inclusion of the patients into the study and Martha van
den Berg, MSc, Vivianne Sterk, MSc, Jolien Diekhorst,
MSc, Marjan Traa, MSc, and Marie-Anne Mittelhaeuser
for help with data management.
Reprint requests and correspondence: Dr. Krista C. van den
Broek, CoRPS, Tilburg University, Department of Medical Psychology, Room P612, P.O. Box 90153, 5000 LE Tilburg, the
Netherlands. E-mail: [email protected].
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Key Words: implantable defibrillator y ventricular arrhythmias y
depression y anxiety y Type D personality.