Psychological stress and type D personality have been associated with adverse cardiac prognosis, but little is known about their relative effect on the pathogenesis of coronary heart disease (CHD). "Type D" refers to the tendency to experience negative emotions and to inhibit the expression of these emotions in social interactions. We investigated the relative effect of stress and type D personality on prognosis at 5-year follow-up. At baseline, 337 patients with CHD who participated in cardiac rehabilitation filled in the General Health Questionnaire (psychological stress) and the Type D personality scale. Patients were followed for 5 years. The end point was major adverse cardiac events, which were defined as a composite of cardiac death, myocardial infarction, and cardiac revascularization (coronary artery bypass grafting/percutaneous coronary intervention). There were 46 major adverse cardiac events at follow-up, including 4 deaths and 8 myocardial infarctions. Type D patients had an increased risk of death/infarction (odds ratio 4.84, 95% confidence interval 1.42 to 16.52, p = 0.01) compared with non-type D patients, independent of disease severity. Stress (p = 0.011) and type D (p = 0.001) were related to an increased risk of developing a major adverse cardiac event after adjusting for gender, age, and biomedical risk factors. Multivariate analysis yielded left ventricular ejection fraction < or =40%, no treatment with coronary artery bypass grafting, and type D personality (odds ratio 2.90, 95% confidence interval 1.42 to 5.92, p = 0.003) as independent predictors of major adverse cardiac events, whereas psychological stress was marginally significant (odds ratio 2.01, 95% confidence interval 0.99 to 4.11, p = 0.054). In conclusion, type D personality is a psychological factor that may optimize risk stratification in patients with CHD. Type D reflects more than temporary changes in general stress level because it predicted cardiac events after controlling for concurrent symptoms of stress.