Background: Improvement in treatment of patients with coronary heart disease (CHD) has caused longer survival but also an increase in the number of patients at risk for subsequent cardiac events and impaired quality of life (QOL). We hypothesized that chronic emotional distress confers an increased risk of poor outcome despite appropriate treatment.

Methods and results: This prospective study examined the 5-year prognosis of 319 patients with CHD. Baseline assessment included symptoms of depression/anxiety and distressed personality type (type D-ie, high negative affectivity and social inhibition). The main end points were cardiac death or nonfatal myocardial infarction and impaired QOL. There were 22 cardiac events (16 nonfatal); they were related to left ventricular ejection fraction (LVEF) </=50%, poor exercise tolerance, age </=55 years, symptoms of depression, and type D personality. Multivariate analysis yielded LVEF </=50% (OR, 3.9; P=0.009), type D personality (OR, 8.9; P=0.0001), and age </=55 years (OR, 2.6; P=0.05) as independent predictors of cardiac events. Convergence of these risk factors predicted the absence of the expected therapeutic response that was observed in 10% of the patients. When 2 or 3 risk factors occurred together, the rate of poor outcome was 4-fold higher (P=0. 0001). Estimates of medical costs increased progressively with an increasing number of risk factors. Smoking, symptoms of depression, and type D personality were independent predictors of impaired QOL.

Conclusions: Decreased LVEF, type D personality, and younger age increase the risk of cardiac events; convergence of these factors predicts nonresponse to treatment. Emotionally stressed and younger patients with CHD represent high-risk groups deserving of special study.