Cardiac Rehabilitation

Cardiovascular Reactivity to Acute Mental Stress

THE IMPORTANCE OF TYPE D PERSONALITY, TRAIT ANXIETY, AND
DEPRESSION SYMPTOMS IN PATIENTS AFTER ACUTE CORONARY SYNDROMES
Julija Gecaite, MA; Julius Burkauskas, PhD; Julija Brozaitiene, PhD; Narseta Mickuviene, PhD

Purpose:  Links between psychophysiological reactions to stress ing of acute coronary syndrome (ACS), as defined by acute
stimuli and perceived mental distress, including type D person- myocardial infarction and/or unstable angina pectoris, is
ality, anxiety, and depression, are still under debate. The aim of not well understood.4 Although there is a growing body of
this study was to examine associations between cardiovascular studies examining relationships between CV stress reactions
reactivity to social stress and mental distress in patients after and psychological factors, which might modulate CV stress
acute coronary syndrome. response,1 there is still very little known about these associa-
Methods:  Patients (n = 116, 86% males, 52 ± 8 yr) with cor- tions in patients with coronary artery disease (CAD).
onary artery disease 2 wk after acute coronary syndrome were The psychophysiological studies, explaining how type
evaluated for sociodemographic, clinical characteristics and cor- D personality, characterized as a tendency to experience
onary artery disease risk factors. The Trier Social Stress Test was negative emotions and inhibit self-expression,5 influenc-
employed to measure cardiovascular reactions to social stress es health-related outcomes in CAD patients, are relatively
(systolic and diastolic blood pressure and heart rate). Mental sparse. Previous research has shown that the presence of
distress assessment included type D personality (Type D Scale), Distressed or type D personality, which itself is an indepen-
anxiety and depressive symptoms (Hospital Anxiety and De- dent predictor of adverse events,6 is associated with reduced
pression Scale), and state and trait anxiety (State-Trait Anxiety heart rate (HR) reactions to a mental stress challenge in
Inventory). patients with heart failure.7 Similar results were found by
Results: Multiple linear regression analysis showed associa- Howard et al,8 in which individuals with type D personality
tions between type D personality and lower heart rate during showed a weaker myocardial profile. There is a growing
Trier Social Stress Test periods of task instruction (β = −.196, body of research9,10 suggesting that autonomic dysfunction
P < .04), preparation time (β = −.232, P < .01), and recovery may be manifested by not only exaggerated but also dimin-
time (β = −.209, P < .029). Higher trait anxiety was linked ished CV stress response. The long-term emotional distress
with lower heart rate during baseline rest (β = −.287, P < .01), may disrupt the biological regulatory system, including
task instruction (β = −.286, P < .01), preparation time (β = diminishing of the autonomic nervous system, which may
−.241, P < .01), and recovery period (β = −.209, P < .05). result in poor health-related outcomes.11-14
Depressive symptoms were associated with higher systolic blood Nonetheless, the results regarding individuals with type
pressure during baseline rest (β =.187, P < .05), task instruction D personality and their CV stress reactivity are inconsis-
(β = .306 P < .01), and free speech (β = .264, P < .05). tent15,16 with some studies finding higher cardiac output
Conclusions: Mental distress was associated with cardiovas- during psychological stress for individuals with type D per-
cular stress reactions independent from possible covariates, sonality in comparison with individuals without type D per-
suggesting dysregulated psychophysiological reactions to acute sonality. The inconsistencies in the results might be caused
stress. by methodological differences, distinct characteristics of
study participants, or relatively small sample sizes. Hence,
Key Words:  acute coronary syndrome • cardiovascular reac-
further research is warranted.
tivity to stress • depressive symptoms • trait anxiety • type D
Depression is also an essential risk factor in heart-related
personality
diseases,17,18 and together with anxiety symptoms may lead
to worse self-care, health-related quality of life,19-22 and
T he importance of psychological stress in the develop-
ment and course of cardiovascular (CV) diseases is well
established.1-3 However, the interplay between psychological
mortality.23-27 There is substantial evidence in the literature
underlining the impact of depression and anxiety on CV
and physiological mechanisms underlying emotional trigger- reactions to laboratory-induced stress. However, the results
differ in various populations.
Past studies have suggested depressive blunting, mean-
Author Affiliation: Laboratory of Behavioral Medicine, Neuroscience ing that patients with depressive symptoms demonstrated
Institute, Lithuanian University of Health Sciences, Palanga, Lithuania.
diminished CV reactivity when faced with social stress. Par-
Julija Gecaite works as a consultant at Facit, LLC, and Julius Burkauskas ticularly, in the study by York et al,28 depressive patients
has served as consultant to Cogstate, Ltd. The other authors declare no with CAD showed reduced HR and diastolic blood pressure
conflicts of interest.
(DBP) reactivity during psychological stress challenge. Sev-
Supplemental digital content is available for this article. Direct URL citations eral other studies in different clinical and healthy popula-
appear in the printed text and are provided in the HTML and PDF versions tions reported a similar pattern suggesting significant links
of this article on the journal’s Web site (www.jcrpjournal.com).
between decreased CV reactivity to mental stress and higher
Correspondence: Julija Gecaite, MA, Laboratory of Behavioral Medicine, depressive as well as anxiety symptoms.29-37
Neuroscience Institute, Lithuanian University of Health Sciences, Vyduno al Other research has reported no differences in sympa-
4, LT-00135 Palanga, Lithuania (julija.gecaite@lsmuni.lt).
thetic activity between depressed and nondepressed partici-
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. pants. Brydon et al38 and Wang et al39 found no significant
DOI: 10.1097/HCR.0000000000000457 associations between depression, anxiety, and CV reactivity

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Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
in ACS patients. In contrast, exaggerated CV reactivity in re- MEASURES
lationship to higher depressive symptoms was meta-analyzed
by Kibler and Ma.40 Trier Social Stress Test
In terms of state and trait anxiety, another study by The TSST, a standardized psychosocial laboratory stress
Pointer et al41 reported no significant links between CV re- test, was conducted to measure CV reactions to psychoso-
activity and trait anxiety. However, Jezova et al42 suggested cial stress: systolic blood pressure (SBP), DBP, and HR.45
that subjects with higher trait anxiety had increased HR in The TSST was performed on the basis of standard proto-
comparison with participants with low trait anxiety. Thus, col,45-47 with previously established modification of arithmetic
further studies are warranted in order to clarify the links tasks that included serial addition (described later) as opposed
between mental distress and CV reactivity to stress. to serial substraction.48-50 All patients participated in the TSST
Understanding associations between mental distress between 2 and 4 pm. They took a baseline rest (10 min), fol-
characteristics and CV reactions during stress-inducing lowed by upcoming task instruction (5 min), during which
tasks in CAD patients after ACS may help further investi- participants were told that they would assume the role of a
gate the underlying mechanism of stress-related pathologies job applicant invited for individual interview with the se-
in this particular population. lection committee. Subsequently, subjects were given 5-min
Therefore, in this study, we aimed to examine associations preparation time, during which they had to prepare a speech
between CV reactions to psychosocial stress, type D personality, to convince the panel that they were the best candidates for
anxiety and depression symptoms, and state and trait anxiety in the specified job. The fourth stage of TSST was a simulated
CAD patients after ACS. Taking into account results from pre- job interview (5 min). Participants were encouraged to uti-
vious research7 in patients with heart failure, we hypothesized lize the entire time for the speech and were asked standard
that in patients the presence of type D personality would be job interview questions. A second stress-evoking task during
associated with diminished CV reactivity to social stress, partic- the fifth stage of TSST was an 8-min Arithmetic task, using
ularly the HR response. The exploratory aim was to investigate the Paced Auditory Serial Addition Test.51 The Paced Audi-
the relationship between CV reactivity to mental stress, anxiety, tory Serial Addition Test involved the tape-recorded presen-
and depression symptoms as well as state and trait anxiety. tation of numbers from 1 to 9. Participants had to add each
number presented on the tape to the immediately preceding
number and to say the answer aloud. Paced Auditory Serial
METHODS Addition Test comprises 4 series of numbers, with progres-
sively shorter interdigit time intervals.
PARTICIPANTS The TSST was led by a trained psychologist, accompa-
One hundred forty-three consecutive CAD patients 2 wk nied by 2 laboratory technicians. The TSST was completed
after ACS were recruited to participate in the study. Inclu- with a recovery period of 10 min, where participants rested
sion criteria are provided as Supplemental Digital Content quietly alone. After the TSST was over, subjects were de-
1, available at: http://links.lww.com/JCRP/A129. All study briefed about the aim of the tasks and any questions that
participants had been receiving standard treatment for had arisen were answered.
secondary prevention of CAD based on established guide- Cardiovascular measures were assessed continuously
lines.1,43,44 The Lithuanian Biomedical Research Ethics over 6 periods of TSST using Oscar2 24-HR ABP (SunTech
Committee approved the study protocol, which conforms Medical Inc).52 The monitor was mounted on the left arm.
to the ethical guidelines of the Helsinki Declaration. All pa- Heart rate, SBP and DBP were obtained at 1, 3, 6, 8, and
tients were also approved by their cardiologist for partic- 10 min and raw scores averaged during the baseline rest (1)
ipation. Each participant signed written informed consent and the recovery period (6). The same CV characteristics
before inclusion in the study and was debriefed afterward. were evaluated at 1, 3, and 5 min during task instruction
The study cardiologist evaluated patient left ventricular (2), preparation time (3), job interview (4), 1, 3, 6, and 8
ejection fraction, using cardiac echocardiography. Objec- min during arithmetic task (5), and averaged as well.45
tive evidence of ACS was obtained from clinical records.
Exclusion criteria (Supplemental Digital Content 1, avail- Type D Scale-14
able at: http://links.lww.com/JCRP/A129) were evaluated The type D personality was assessed using the Lithuanian
on the basis of case history and evaluation of clinical char- version of DS14.53-55 The DS14 has two 7-item subscales,
acteristics by the study cardiologist. The final study sample which assess negative affectivity and social inhibition.
comprised 116 participants (86% males). Statements on both 7-item scales are based on a 5-point
Sociodemographic (age, sex, and education), clinical Likert scale (“false” [0] to “true” [4]). Scores range from
characteristics, and major CAD risk factors of eligible par- 0 to 28 on each subscale, where >10 on both DS14 sub-
ticipants were measured 2 d after admission to rehabili- scales of negative affectivity and social inhibition indicate
tation by the study cardiologist or health psychologists. the presence of type D personality.
Clinical characteristics consisted of diagnosis, current medi-
cation use, and the presence of heart failure (left ventricular State-Trait Anxiety Inventory
ejection fraction of ≤40%). Subject history of ACS, angina The STAI was used to measure trait (STAI-T) and situa-
pectoris, and hypertension was retrieved from the medical tional (STAI-S) anxiety.54,56 Each questionnaire contains 20
records. Cardiovascular risk factors were evaluated by mea- statements that are based on 4-point Likert scale. The total
suring obesity (body mass index), history of smoking, and scores of subscales range from 0 to 60. Higher scores on
presence of arterial hypertension. both scales indicate more anxiety symptoms. Scores that are
In addition to a mental stress challenge, performed with ≥30 points indicate moderate, while scores ≥45 determine
Trier Social Stress Test (TSST), patients were also evaluated severe anxiety.56
for type D personality (Type D Scale-14 [DS14]), mental
distress (Hospital Anxiety and Depression Scale [HADS], Hospital Anxiety and Depression Scale
State-Trait Anxiety Inventory [STAI]), which is in line with Mental distress was evaluated with a self-report HADS,
established guidelines for measuring psychosocial risk fac- which consists of 14 items.57,58 Each statement is rated
tors in CAD prevention in clinical practice.3 on a scale from 0 to 3 according to the experiences of the

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individual in the past 2 wk. The total HADS scores range Table 1
from 0 to 21 for depressive symptoms (HADS-D) and 0 to
Baseline Characteristics of Study Participants (n = 116)a
21 for anxiety symptoms (HADS-A), with higher total score
indicating more severe depressive and anxiety symptoms.59 Age, yr 52 ± 8
Scores ≥ 8 on the HADS-D or HADS-A were considered Education
to be a cutoff point to measure significant respective   High school 53 (45.7)
symptoms.   College/university degree 63 (54.3)
Diagnosis
STATISTICAL ANALYSES   Unstable angina pectoris 27 (23.3)
Statistical analyses were conducted using SPSS for Windows   Acute myocardial infarction 89 (76.7)
version 17.0 (SPSS Inc). The means and frequencies were Body mass index 28.17 ± 1.45
calculated for sociodemographic, cardiac characteristics, Arterial hypertension 94 (81)
mental distress symptoms, and TSST CV reaction measures Medication use
HR and SBP/DBP. Normal distribution in the variables used
 Nitrates 16 (13.8)
in the study was confirmed using the skewness statistic, kur-
  β-blockers 104 (89.7)
tosis statistic, and 1-sample Kolmogorov-Smirnov tests.
 Tranquillizers 7 (6.0)
A univariate regression analysis was used to examine unad-
Nicotine use (smoking currently/in the past) 62 (53.4)
justed associations between CV reaction to TSST and sociode-
mographic and clinical characteristics (including medication Global cognitive function (Mini-Mental State 28.17 ± 1.45
use) as well as mental distress scores. All associations signifi- Examination)
cant (P < .05) in univariate models were included in further Left ventricular ejection fraction >40 % 99 (85.3)
analysis as possible confounding variables. Multivariable lin- Presence of type D personality (DS-14) 33 (28.5)
ear regression analysis was performed to test associations be- State Trait Anxiety Inventory
tween CV reactions to TSST and mental distress scores, while   State Anxiety 37.03 ± 10.0
controlling for sex, age, education, body mass index, arterial   Trait Anxiety 45.07 ± 7.8
hypertension, and left ventricular ejection fraction. Depressive symptoms (Hospital Anxiety and Depression
Scale)
  Total score <8 109 (93.97)
RESULTS   Total score ≥8 7 (6.03)
Demographic, clinical characteristics, CAD risk factors, Anxiety symptoms (Hospital Anxiety and Depression
and TSST and mental distress (type D personality, depres- scale)
sive and anxiety symptoms, and trait and state anxiety) pa-   Total score <8 83 (71.55)
rameters are presented in Table 1. In the current research,   Total score ≥8 33 (28.49)
psychometric analyses reported good internal consistency Baseline rest
of all study questionnaires: DS14 (Cronbach α = 0.75),   Systolic blood pressure, mm Hg 131.27 ± 14.13
STAI (STAI-T Cronbach α = 0.88; STAI-S Cronbach α =   Diastolic blood pressure, mm Hg 79.26 ± 9.06
0.93), and HADS (HADS-D Cronbach α = 0.6; HADS-A   Heart rate, bpm 68.84 ± 7.43
Cronbach α = 0.84). Task introduction
Univariate regression analysis indicated that CV re-   Systolic blood pressure, mm Hg 133.83 ± 16.74
actions to TSST were associated with type D personality   Diastolic blood pressure, mm Hg 81.62 ± 10.79
(Figure), trait anxiety, and depressive symptoms but not   Heart rate, bpm 69.23 ± 9.52
with other sociodemographic and clinical characteristics, Preparation time
listed in Table 1. Multivariable linear regression analysis in-
  Systolic blood pressure, mm Hg 150.5 ± 15.64
dicated that even after controlling for possible confounders,
  Diastolic blood pressure, mm Hg 91.08 ± 9.86
there was still a significant link between type D personality
and lower HR during TSST periods of task instruction (β =   Heart rate, bpm 74.78 ± 11.68
−.196, P < .04), preparation time (β = −.232, P <. 01), Job interview
and recovery time (β = −.209, P < .029). Similarly, higher   Systolic blood pressure, mm Hg 164.54 ± 18.07
trait anxiety was associated with lower HR during baseline   Diastolic blood pressure, mm Hg 99.31 ± 9.34
rest (β = −.287, P < .01), task instruction (β = −.286,   Heart rate, bpm 78.69 ± 12.36
P < .01), preparation time (β = −.241, P < .01), and re- Arithmetic task
covery period (β = −.209, P < .05). No associations were   Systolic blood pressure, mm Hg 153.08 ± 17.24
found between type D personality, trait anxiety, and SBP/   Diastolic blood pressure, mm Hg 92.01 ± 9.09
DBP measures during TSST. While anxiety symptoms (as   Heart rate, bpm 74.29 ± 10.13
measured by STAI-S and HADS-A) were not significantly Recovery time
linked with CV reactions to stress, depression symptoms   Systolic blood pressure, mm Hg 137.65 ± 14.12
were associated with SBP during the periods of baseline rest   Diastolic blood pressure, mm Hg 83.96 ± 9.16
(β = .187, P < .05), task instruction (β = .306 P < .01),   Heart rate, bpm 67.27 ± 8.38
and job interview (β = .264, P < .05) after controlling for a
Data are presented as mean ± SD or n (%).
possible confounders. The findings are presented in Table 2.

adverse dysregulation of cardiac reactivity.7,9 Symptoms

DISCUSSION of depression were associated with increased levels of SBP
The results of this study suggest that the presence of type D during TSST. These results further underscore the impor-
personality and high trait anxiety is associated with blunt- tance of subjectively experienced mental distress symptoms
ed HR reactivity to acute social stressors, independently in stress-induced somatic reaction in patients with CAD.
from sociodemographic, clinical characteristics, and CAD As hypothesized, the findings of lower HR reactivity in
risk factors in patients after ACS, which may suggest an subjects with type D personality were consistent with the

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 Depression is another factor shown to be associated
with adverse CV reaction during stress-inducing tasks.
Our findings suggest that higher depressive symptoms are
linked with higher SBP, which is in line with previous stud-
ies.40 Our research also partly corresponds to the study by
Brydon et al38 in ACS patients, as they have found depres-
sive symptoms to be unrelated to HR and DBP. However,
the current research contrasts with other previous research
in non-CAD patients, suggesting a “blunting effect” of de-
pressive symptoms in CV reactions to stress.29-35 Depressive
symptoms and their effect on CV reactions to stress are still
an important debate in the scientific community, as they
vary across different studies. Therefore, further investiga-
tion exploring these links, especially in patients with CAD,
is recommended.
Figure. Heart rate reactivity during Trier Social Stress Test in patients Previous literature suggests that significant deviations in
with and without type D personality (N = 116). response, whether exaggerated or dampened CV reactivity
during stress, may signal the dysregulation of the autono-
mous nervous system.7,9,10 Blunted HR response has been
study of patients with chronic heart failure.7 Studies per- associated with various health-related parameters including
formed in otherwise healthy subjects with type D person- obesity,11 increased smoking behavior,13 poorer self-report-
ality15,16 report exaggerated HR response to mental stress. ed health,12 and higher physical disability.14 Meta-analysis
However, our findings and the findings by Kupper et al7 by Chida and Hamer60 reports that long-term, personali-
suggest that type D personality correlates with diminished ty-related stress, such as neuroticism, negative affect, or
HR in patients with vascular disorders. anxiety, is linked with dampened CV stress response as well.
The current study also extended previous investigation While depressive symptoms might be temporal, personali-
with healthy subjects42 by specifically examining associa- ty-related stress usually causes long-term chronic stress. As
tions between trait anxiety and CV reactions to TSST in a consequence, this daily pattern may tend to activate the
patients after ACS. Yet, our study showed distinctive results sympathetic nervous system more often causing the “wear
in terms of HR response during mental stress. Specifically, off” effect and loss of adaptive capacity to react in stressful
Jezova et al42 found that higher trait anxiety correlated with situations.61 Therefore, personality-related stress, including
higher HR reactivity, while in our study we observed in- trait anxiety and type D personality, might dysregulate the
verse associations between these 2 variables. The difference psychophysiology of stress reactions by diminishing, rather
in results might be caused due to differing population with than increasing CV reactivity and prevent the autonomous
regard to age and the presence of somatic illness. nervous system from adaptive acute stress response.12

Table 2
Associations Between Type D Personality, Trait Anxiety, Depressive Symptoms, and Cardiovascular Reactions to Trier
Social Stress Test (TSST) in Patients After Acute Coronary Syndromes (n = 116)a
Baseline Task Preparation Job Arithmetic Recovery
TSST Stages Rest Instruction Time Interview Task Time
Heart rate
Type D (DS-14) r P Value r P Value r P Value r P Value r P Value r P Value
Unadjusted −.156 .094 −.201 .031 −.198 .033 −.098 −.351 −.066 −.553 −.195 .037
β P Value β P Value β P Value β P Value β P Value β P Value
Adjustedb – – −.196 .043 −.232 .014 – – – – −.209 .029
Trait Anxiety (STAI-T) r P Value r P Value r P Value r P Value r P Value r P Value
Unadjusted −.307 .001 −.336 .000 .003 .003 −.126 .228 −.131 .236 −.249 .007
β P Value β P Value β P Value β P Value β P Value β P Value
Adjustedb −.287 .003 −.286 .003 −.241 .012 – – – – −.209 .031
Systolic blood pressure
Depressive symptoms r P Value r P Value r P Value r P Value r P Value r P Value
 (HADS-D) Unadjusted .223 .016 .312 .001 .094 .314 .291 .005 0.147 .183 .196 .036
β P Value β P Value β P Value β P Value β P Value β P Value
Adjustedb .187 .042 .306 .001 – – .264 .011 – – .185 .059

Abbreviations: DS-14, Type D personality scale, self-report; HADS-D, Hospital Anxiety and Depression Scale, depression subscale, self-report; STAI-T, State Trait Anxiety Inventory, trait anxiety
subscale, self-report; TSST, Trier Social Stress Test.
a
Only significant (P < .05) univariate models were included in the multivariable regression analysis reported in the table.
b
Multiple regression analysis, adjusted for sex (male [1]; female [2]), education (up to 8 yr/high school [1]; college/university degree [2]), age, left ventricular ejection fraction (≤40% [1];
>40% [2]), arterial hypertension (nonpresent [0], present [1], defined as systolic blood pressure ≥140 mm Hg, and/or diastolic blood pressure ≥90 mm Hg), and obesity, as measured by
body mass index (≤30 kg/m² [1]; >30 kg/m² [2]).

www.jcrpjournal.com Cardiovascular Reactivity to Stress and Mental Distress in Patients After ACS     E15
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 In addition, distinctive cardiovascular response to TSST ACKNOWLEDGMENTS
may be due to difference in coping strategies of individu- The authors thank the staff of the Laboratory of Behavioral
als with type D personality versus of those with depres- Medicine for their great help in conducting this research,
sive tendencies. Type D individuals engage in maladaptive including medical doctor Audrius Alonderis for ensuring
withdrawal, specifically passive coping strategy,62 while patient safety during TSST, junior researcher and registered
depressive individuals tend to use emotion-oriented style63 nurse Nijole Kazukauskiene for monitoring patient health
focusing on the need to relieve stress.64 Therefore, patients during the TSST and great contribution in coordination of
with type D personality who use a passive coping strategy the research program, and Dr Alicja Juskiene and Dr Laima
to distract themselves from negative stimuli may respond Sapezinskiene for conducting the psychological testing and
with less anxiety and stress,65 while depressive patients, TSST.
due to focus on negative emotions, demonstrate elevat-
ed CV response to stress. Nevertheless, further studies
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