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MONA SCHLYTER

MYOCARDIAL INFARCTION

PERSONALITY FACTORS, COPING

STRATEGIES, DEPRESSION AND

SECONDARY PREVENTION

MALMÖ UNIVERSIT Y HEAL TH AND SOCIET Y DOCT OR AL DISSERT A TION 20 1 6:1 MON A SC HL YTER MALMÖ UNIVERSIT MY OC ARDIAL INF AR CTION PERSON ALIT Y F A CT ORS, C OPIN G S TR A TEGIES, DEPRESSION AND SEC OND AR Y PREVENTION

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M Y O C A R D I A L I N F A R C T I O N P E R S O N A L I T Y F A C T O R S , C O P I N G S T R A T E G I E S , D E P R E S S I O N A N D S E C O N D A R Y P R E V E N T I O N

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Malmö University,

Health and Society Doctoral Dissertations 2016:1

© Mona Schlyter 2016

ISBN: 978-91-7104-666-6 (print) ISBN: 978 -91-7104-667-3 (pdf) ISSN: 1653-5383

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MONA SCHLYTER

MYOCARDIAL INFARCTION

PERSONALITY FACTORS,

COPING STRATEGIES, DEPRESSION

AND SECONDARY PREVENTION

Malmö University, 2016

Faculty of Health and Society

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To my wonderful and fantastic Family “Ab imo pectere”

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CONTENTS

ABSTRACT ... 9

LIST OF PUBLICATIONS ... 11

ABBREVIATIONS ... 12

INTRODUCTION ... 13

CONTEXT OF THE STUDY ... 14

BACKGROUND ... 15

Coronary heart disease and myocardial infarction ... 15

Pathophysiology ... 15

Incidence and mortality ... 16

Risk factors ... 17

Symptoms ... 18

Diagnosis and treatment during the acute phase ... 18

Prognosis ... 19

After discharge ... 19

Prevention ... 19

Cardiac Rehabilitation / Secondary Prevention ... 19

Secondary prevention programs ... 20

Personality ... 21 Neuroticism ... 22 Extraversion ... 22 Openness ... 22 Agreeableness ... 23 Conscientiousness ... 23

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Psychosocial factors ... 23

Coping ... 23

Stress ... 24

Depression ... 24

Social support and network ... 25

Rationale ... 25

AIMS OF THIS THESIS ... 26

MATERIAL AND METHODS ... 27

Setting ... 27

Design ... 27

Data collection process ... 28

Inclusion and exclusion criteria ... 28

Drop-outs ... 28

Enrolment ... 29

Data collection ... 29

Medical measurements clinical characteristic and laboratory testing ... 30

Instruments ... 30

Psychosocial characteristics measurement ... 30

Personality factors ... 30

Coping ... 31

Adaptive behavior - The serial Color Word Test (CWT) ... 31

The Beck Depression Inventory ... 32

Social support and network ... 33

Statistical analysis ... 33 Paper I ... 33 Paper II ... 34 Paper III ... 34 Paper IV ... 35 ETHICAL CONSIDERATION ... 36 Information ... 36 Confidentiality ... 36 RESULTS ... 37

Baseline characteristics papers I-IV ... 37

Paper I ... 37

Paper II ... 43

Paper III ... 43

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DISCUSSION ... 48

Personality factor and disease severity after an acute MI in a stressful situation ... 48

Influences of personality factors, coping strategies, or depression when there is a time lag in seeking acute care for a suspect MI ... 49

Association between personality factors, coping strategies, depression and smoking cessation after MI ... 50

Impact of personality and depression on seeking health care following acute MI ... 51

METHODOLOGICAL CONSIDERATIONS ... 53

Design and research perspective ... 53

Data collection and procedures ... 53

Interviews ... 54

Measures ... 54

Strengths and limitations ... 55

CONCLUSION ... 57 FUTURE IMPLICATIONS ... 58 CONTINUING RESEARCH ... 59 SVENSK SAMMANFATTNING ... 60 ACKNOWLEDGEMENTS ... 65 REFERENCES ... 68

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ABSTRACT

A longitudinal study with 400 patients diagnosed with myocardial infarction (MI) was conducted at the Cardiology department at Malmö University hospital in Sweden, between 2002 and 2005. The aim of the project was to identify personality and psychosocial factors, influencing patients’ actions and the prognoses after MI. The five factor model of personality, (measures on Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness), coping strategies, depressive symptoms, the impact on delay seeking emergency care, smoking habits and cardiac health care utilization were studied. This thesis reports the result from four papers. In paper I the aim was to investigate whether maladaptive behaviour in the serial Color Word Test (CWT) alone or in combination with any specific personality dimensions were associated with severity of the MI. The indicators of severity of disease were maximum levels above median of the cardiac biomarkers troponin I and creatine-kinase-MB (CKMB), Q-wave infarctions, and a left ventricular ejection fraction (LVEF). The findings showed that maladaptive behaviour in combination with low scores on extraversion was associated with higher levels in cardiac biomarkers, following an MI. Another crucial factor for the prognoses and survival after a MI is early arrival to the emergency department and rapid intervention. In paper II we analysed the correlation of personality and psychosocial factors, with the time lag between the onset of coronary symptoms and seeking emergency hospital care. There was no significant conjunction in time delay and personality factors, coping strategies and depression. In paper III we examined whether personality traits, coping strategies and symptoms of depression were related to smoking cessation after an MI. Out of the 149 patients who smoked at baseline, 2 years follow-up data was available on 133 individuals, of these 44% (n=59) still smoked and 56% (n=74) had stopped smoking during the 2 years. Those who still smoked had lower score in the personality factor agreeableness, more lived alone and were unemployed in contrast to those

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who had stopped smoking. They also had significantly higher coping scores as confrontational behaviour. Finally, in paper IV we examined whether personality factors and depressive symptoms predicted cardiac health care utilization over the first two years after the MI event. Those MI patients showing traits of Neuroticism at baseline had significantly higher utilization at the out-patient cardiac clinic than those without. Individuals with a high score of depressive symptoms at baseline had instead a higher utilization of social workers and telephone contacts over the two year follow-up.

In conclusion, we found that the personality factors extraversion, agreeableness and neuroticism were factors that had impact on MI severity, smoking cessation and out-patient clinic contacts, while delay in seeking acute care was not affected by personality factors, depression or coping strategies. Maladaptive behaviour and a confronting coping strategy influenced MI severity and smoking cessation 2 years after an MI. Taking personality factors and coping strategies more into consideration when caring for patients in cardiac rehabilitation might be indicated.

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LIST OF PUBLICATIONS

This thesis is based on the following papers referred to in text in Roman numerals I-IV. The papers have been reprinted with permission from the publishers. I. Behavior in a stressful situation, personality factors, and disease severity in

patients with acute myocardial infarction: baseline findings from the prospective cohort study SECAMI (the Secondary Prevention and Compliance following Acute Myocardial Infarction). André-Petersson L, Schlyter M, Engström G, Tydén P, Hedblad B. BMC Cardiovasc Disord. 2011 Jul 21; 11:45.

II. The impact of personality on delay in seeking treatment of acute myocardial infarction. Schlyter M, André-Petersson L, Engström G, Tydén P, Östman M. BMC Cardvasc Disord. 2011 May 19; 11:21.

III. Smoking cessation after acute myocardial infarction in relation to depression and personality factors. Schlyter M, Leosdottir M, Engström G, André- Petersson L, Tydén P, Östman M. Int J Behav Med. 2015 Oct 16.

IV. Personality factors and depression as predictors of health care consumption during the first two years following a myocardial infarction. Schlyter M, Östman M, Engström G, André-Petersson L, Tydén P, Leosdottir M. Submitted to the European Journal of Cardiovascular Nursing.

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ABBREVIATIONS

ACS Acute coronary syndrome

AMI Acute myocardial infarction

BDI Beck Depression Inventory

BMI Body mass index

CABG Coronary artery by-pass grafting

CI Confidence interval

CDT Carbohydrate-Deficient Transferrin

CHD Coronary heart disease

CKMB Creatine-kinase, isoenzyme MB (M=muscle, B=brain)

CVD Cardiovascular disease

CWT Color Word Test

ECG Electrocardiogram

ED Emergency department

IHD Ischemic heart disease

HbA1C Glycosylated haemoglobin A1C

HDL High density lipoprotein

LDL Low density lipoprotein

LVEF Left ventricular ejection fraction

MADRS Montgomery Åsberg Depression Rate Scale

MI Myocardial infarction

NSTEMI Non-ST segment elevation myocardial Infarction

OR Odds ratio

PCI Percutaneous Coronary Intervention

SECAMI Secondary Prevention and Compliance following Acute Myocardial Infarction

SPSS Statistical Package for the Social Sciences

STEMI ST- segment elevation myocardial infarction

Troponin-I Protein complex released during myocardial injury

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INTRODUCTION

Without the heart there is no life. The heart starts beating during the fetal period and continues to do so for the rest of a person’s life. At 80 years of age a healthy heart has pumped more than 200 million liters of blood. During the course of a lifetime the heart is subjected to various forms of stress, depending on the life one lives, including the way one experiences stress, psychosocial factors, and personality. All these factors in combination with age, heredity, and different illnesses such as diabetes and high blood pressure impact the health of the heart, and coronary heart disease(CHD) being the most common form. CHD is defined as all atherosclerotic processes in the coronaries, i.e. both the stable form (stable angina pectoris) as well as the acute form that includes Unstable Angina Pectoris (UAP), Non-ST Elevation Myocardial Infarction (NSTEMI) and ST Elevation Myocardial Infarction (STEMI). The acute form of the disease has a much worse prognosis and is collectively named Acute Coronary Syndrome (ACS). Furthermore NSTEMI and STEMI are referred to as Myocardial Infarction (MI), i.e. myocardial damage due to an acute thrombotic obstruction of a coronary artery. When an ACS occurs, this can in the setting of modern health care facilities, usually be treated quickly with Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG).

However, when it comes to prevention of MI – the most important aspect of diminishing the burden of cardiovascular morbidity and mortality - there is no such quick fix. Since modifiable risk factors account for more than 80% of the risk for developing the disease, society and the health care system must have good knowledge of the risk factors contributing to the development of CHD. Furthermore, when an MI has occurred health professionals should be able to assess individual patients´ risk factor profiles to be able to individualize and plan future treatment. The treatment of MI after the acute event, referred to as secondary prevention, involves coaching patients on how they can modify their lifestyle, prescribing suitable physical training, and stressing adherence to medication.

The way in which a patient’s personality impacts the acute phase of the disease and aspects of secondary prevention needs to be further studied.

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CONTEXT OF THE STUDY

If I had been able to look into a crystal ball in 1965 and see what was going to happen in my future, I still would have chosen the same professional field: to be a nurse working with cardiology patients.

I have often wondered about the effect of my work as a cardiac nurse for MI patients, first for many years in acute cardiac care, and later on with secondary prevention. Especially considering makers for a successful follow-up of patients, do we only try to educate patients, or do we also listen to their needs?

Looking back, it hardly seems possible that such tremendous medical advances have been made over the past four decades. At the beginning of the 1960s, the most important thing for a nurse was to learn about new medical techniques and pharmacology. Nurse caring was put aside. But soon after, nurses began taking courses about caring for patients, and although it took some years, nurses were on track again, doing what they were trained for and have always wanted to do: providing patient care, and doing this with a holistic view in focus. Today many goals have been reached in this area, but far from all. Most hospitals in Sweden have cardiac rehabilitation and nurse-led secondary prevention programs as two of the most important rehabilitation services. However, there are still many challenges in cardiac rehabilitation that can be enhanced, with possibilities of developing a better understanding for the people we are caring for. In order to improve the instruments used today in cardiac rehabilitation and secondary prevention it might be useful to increase aspects concerning personality, stress, coping, and depression and by doing so, to further individualise secondary preventive programs.

When I was asked to participate in the Secondary Prevention and Compliance

Following Acute Myocardial Infarction (SECAMI) study, in Malmö an

investigation of MI in relation to personality factors and secondary prevention, it gave me the opportunity to get new answers to some of the questions raised in my clinical work. This thesis is an extension of that quest.

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BACKGROUND

Coronary heart disease and myocardial infarction

History

ACS covers unstable angina and acute MI. The term MI was introduced in 1896 by the French physician René Marie. However, the Swedish physician J.P. Malmsten was the one who presented a paper entitled ”Fall av ruptura cordis” in 1859. His paper and one by the pathologist von Düben´s were the first known reports on MI. Since Malmsten’s paper was written in Swedish, it took many years and the research of others until the diagnosis was accepted, first in the United States in 1912, and in England by 1915 [1]. Not until William Einthoven developed the electrocardiograph in 1903, and the electrocardiogram (ECG) was invented [2], was it possible to objectively diagnose an MI. Since then the term MI has been used widely, both in research and in clinical practice.

Pathophysiology

CHD is caused by atherosclerosis in the coronary arteries. It is believed that an inflammatory process precedes the onset of plaques in the vessels [3]. Plaques form because of fat, especially cholesterol, forming streaks in the arterial walls, along with other substances (i.e., calcification) (Figure 1). The process is slow and it can take a long time before symptoms occur. Angina pectoris can be an early symptom of this process.

The inflammatory markers found in patients with CHD represent only a small part of the evidence of the disease’s presence. It is expected that we will learn more about the part inflammation plays in CHD and ACS in the coming years [4].

In earlier studies it was assumed that an acute MI arose from a blood clot, however this was not finally proven until 1980 [5]. A rupture forms in the atherosclerotic plaque, a clot is formed, and the clot subsequently creates a complete or partial occlusion of the artery. This limits coronary flow, which reduces the oxygen supply, subsequently leading to an acute MI [6-8].

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Figure 1. Atherosclerosis causes narrowing of the coronary arteries, which can lead to angina and eventually a myocordial infarction.

Incidence and mortality

In a worldwide perspective, age-standardized MI incidence has decreased from 1990 to 2010. However, with an aging population the burden of CHD is predicted to increase in the future [9]. There are also regional differences. In 2010 CHD death rates had risen in Eastern Europe and Asia while declining in Western and Northern Europe [9].

Even if the MI mortality risk has dropped about 40% over the last 20 years [10], 6,000 patients still suffered a fatal MI in Sweden in 2012 [11]. According to the World Health Organization (WHO) 7.4 million people died from CHD

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in 2012, representing 13.2% of all global deaths [12]. In the last three decades incidence and mortality from various heart diseases has declined steadily, both in Sweden and in the Western world [11, 13].

In total the gap between the incidence of acute MI and survival has decreased in Sweden, even if there are difference in various parts of the country [11]. Despite advances in medicine, cardiovascular disease (CVD) remains the primary cause of death in Europe and the greatest national disease in Sweden [14].

In 2013 the incidence of MI in Sweden differed for men (522/100000) and women (344/100000). Age and gender have a great impact on the incidence, but there are also environmental factors [11]. For example, for men in Sweden aged 45 to 74 with 9 or less years of education, the incidence was 40% higher than for those with 10 or more years of education. For women the incidence was 60% higher for those with less education [11].

A suggested explanation for the decline in the incidence and mortality of acute MI, points not only to treatment procedures, but also prevention efforts [15]. A study by Björk et al.[16] showed that the decline in MI mortality in Sweden between 1985 and 2002 was mostly attributable to changes in major risk factor such as cholesterol, smoking, and blood pressure, as well as secondary preventive treatment, findings that have been confirmed by others [17-20].

According to the WHO, mortality from CHD could be reduced by more than 75% through appropriate lifestyle changes [12].

Risk factors

The Framingham investigators were the first to mention the term “risk factors” in connection with CHD. Epidemiological studies such as Framingham [21] and the Seven Countries Study identified several risk factors that contribute to the development of CHD [22]. These include family history, age, gender (collectively called non-modifiable); smoking, high blood pressure, cholesterol, diabetes; and socioeconomic factors including marital status and stressful workload (referred to as modifiable risk factors) [23-25].

In the INTERHEART study of 52 countries, the major factors accounting for 90% of the risk of MI were smoking, diabetes, hypertension, high level of lipids, abdominal obesity, physical inactivity, alcohol, low levels of fruit intake, and psychological factors [26, 27]. They also found stress, depression, and locus of control to be risk factors for MI [28, 29]. Other studies have shown an association between the risk of CHD and less control over one’s job [30].

Smoking causes vascular dysfunction and the increased adhesion of platelets and macrophages, thus inducing a pro-coagulant and inflammatory environment [31]. It is one of the most important risk factors for arteriosclerosis [31]. CHD is

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significantly higher in smokers than non-smokers [32]. Women who smoke seem to have an even greater increased risk for CHD than male smokers; and the same is true for diabetes [33]. In a prospective study, Willi et al. showed that smoking was associated with increased risk for type II diabetes, both in women and men [34]. It is also known that individuals with diabetes have an increased risk for developing CHD than those without diabetes. People with obesity and diabetes are at even higher risk [33, 35].

Hypertension is strongly related to mortality from CHD, and several pathophysiological mechanisms link hypertension to development of atherosclerosis [36]. In both middle- and old age, total cholesterol is positively associated with mortality from CHD.

As such, modifiable risk factors account for a large part of CHD risk, and these are highly interrelated [37]. Nevertheless, despite extensive research, the factors behind the emergence of CHD are not fully understood.

Symptoms

The most common symptom of CHD is chest pain due to myocardial ischemia [38]. Its location is usually close to the sternum, but can also be located between the shoulders, in the neck, arms, jaw, or abdomen and extend as far as the throat. There can also be more atypical diffuse symptoms like shortness of breath, anxiety, nausea, sweating and palpitations. Sometimes it is difficult to recognize the symptoms of CHD, which leads to some individuals self-medicating. This can cause a delay in seeking hospital care. More atypical symptoms [39] tend to appear in women [40], the elderly, and people with diabetes.

Diagnosis and treatment during the acute phase

When a person arrives at a hospital with acute chest pain a diagnosis is determined by ECG and cardiac biomarkers [41]. When a patient suspected of having an acute MI arrives at the emergency room, it is vital that the person be treated immediately. The most important thing is to restore blood flow in the occluded coronary artery [42]. Nowadays the diagnosis is often clear already in the ambulance due to early ECG and direct telecommunication with the Coronary Care Unit (CCU), thereby bypassing the emergency ward. The choice of treatment methods depends on what

an angiogram shows and the patient’s general condition. Major breakthroughs

in the treatment ofMI have been made since the early 1980s [43]. CHD can be

approached invasively either with percutaneous coronary intervention (PCI) or coronary artery by-pass graft surgery (CABG). The vast majority of all patients with MI are treated with PCI.

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Prognosis

After an acute MI there is a higher risk for recurrent cardiac events, especially during the first year [44] and risk for mortality increases [45, 46]. Thereafter, the risk declines, but readmissions to a hospital over a five year period is very common [47, 35, 48]. According to registry data, the one-year mortality after an MI in Sweden 2006-2011 was 12.3%. Cardiovascular deaths accounted for 66.1%. Additionally, 10.0% of MI patients during this period had a new MI and 2.4% had a stroke during the first year after the index event [44].

After discharge

When they return home, most of the patients will have some or all of these feelings: existential dread, guilt, denial, and loss of their former way of life. They have been informed about the need for life-long medication and lifestyle changes. For patients with MI the hospitalization and revascularisation process can be a scary experience and hence make them unsure. Others who have experienced an MI and hospitalisation can be fearful and insecure [49]. The hospital stay is short (3 to 5 days) if there are no complications, and patients have little time for reflection as there are many tests to be done during their hospital stay. Taken together, this makes the discharge procedure important, as it informs the patients about long-term treatment and cardiac rehabilitation programs needed.

Prevention

Prevention has traditionally been categorised as primary, secondary, and tertiary. Primary prevention aims at delaying the onset of a disease, while secondary prevention seeks to arrest the progression of disease and recurrent events. Tertiary prevention goals are to reduce the negative impact of established disease by restoring function and reducing disease-related complications. Nowadays cardiologists preferably use risk scores [50]. Four levels are used, with those who have had an MI belonging to the highest risk score group. In this thesis only aspects related to individuals with the highest risk and to secondary prevention will be considered.

Cardiac Rehabilitation / Secondary Prevention

History

In the middle of the 1960s, patients had to stay in bed for 6 weeks following an acute coronary event. There was some progress after 1940 with the “chair therapy” [51], followed by advanced exercises which was advocated by Saltin et al. [52]. In cardiac rehabilitation programs (CR) exercise was originally the

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primary component. To ensure safety, the programs were highly structured and supervised by physicians. Programs for secondary prevention were not used in Sweden until the late seventies, when both Gothenburg and Oskarshamn started secondary prevention clinics. Joep Perk was a pioneer in this area [53]. The Swedish National Board recommended CR by the beginning of the eighties. Since the late eighties, the Nordic Congress for Cardiac Rehabilitation has emerged and has played an important role.

Secondary prevention programs

Secondary prevention programs are essential for patients recuperating from an MI because modifying risk factors has a favourable impact on their health. After the acute phase, this secondary prevention – the long-term treatment of CHD

through cardiac rehabilitation – commences. CHD is not curable; it is a chronic

illness whose medical treatment is life-long. Those who have been treated with revascularisation either by PCI or CABG might think they are cured [54, 55]. It is, therefore, necessary to make patients aware of the fact that the disease is chronic

and may recur. However, the risk of a new MI is greatly influencedbyeffective

secondary preventive treatment, as has been shown in several studies [56-58].

To have experienced an MI is life-challenging. It makes cardiac rehabilitation long-time essential [59]. Prevention and cardiac rehabilitation necessitate skilled nursing intervention [60, 61]. There have been certain lacks of knowledge among

professionals in this area [62, 57]. Nowadays most hospitals in Sweden and

elsewhere in the Western world have structured secondary programs coordinated

by specialist nurses [63]. Several studies have demonstrated a significant positive

effect on CHD death with cost-effective nurse-led prevention programs [16, 64, 65]. Populations at high risk (i.e., those who already have CHD) should be given priority in secondary prevention, which includes lifestyle modification of risk factors and pharmacological treatment [50].

While secondary prevention is offered to all patients after an acute event, the participation rate varies for a number of reasons. It can be low because of financial issues, the absence of guidelines to implement rehabilitation [66], and the failure to refer patients to the program. Those who have minimal education, language difficulties, depression, or low motivation have been shown to have a decreased level of participation in secondary prevention programs [67].

The most common form of CR in Sweden is provided by a multidisciplinary team in which physicians, nurses, physiotherapists, dieticians and sometimes psychologists participate. These programs are usually delivered to out-patient groups and last three months.

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CR and secondary prevention programs are made by an assessment of the patient immediately following a hospital stay. Outpatient programs begin soon after hospital discharge and include multiple components, such as training in physical exercise, dietary management, managing hypertension and high cholesterol, smoking, diabetes, and weight control. This is done individually and in groups in “heart school”, that is personalised patient education programs, at the end of which secondary prevention is maintained by long-term follow-up.

In Sweden acute care has had good results, as shown in the Swedish Heart Intensive care Admission Register (RIKS-HIA). This register includes individual information on medication, risk factors, previous heart disease, treatment, laboratory findings, testing, (i.e., echocardiography, angiography etc.), and diagnosis at discharge [68]. Recommendations are not always adhered to by the patients, even though there are great benefits to be had though optimal use of secondary prevention programs by those recovering from an acute MI [69]. Many patients fail to reach the goals for lipid lowering, reduction of hypertension, and smoking cessation according to the Swedeheart Annual report for 2014 from the national register [70]. The reason for this is unclear. It may be that the wrong instrument was used. Another possibility is that some patients may be difficult to reach soon after their MI because they are depressed [71] or tired. It is not unusual that patients experience considerable fatigue [72, 73] after an MI, or use coping strategies as such denial or other reasons not to participate.

Personality

It is not common procedure to use personality inventories in medical context. By introducing personality factors in medical settings it is assumed that it makes a patient’s problem easier to understand and facilitates to choose the appropriate treatment [74, 75]. However, a recent study shows that personality traits should also be taken in account to predict health outcomes in other services than psychological clinics [76].

The main focus of this thesis is MI patients’ behaviour in relation to their personality. Every person is unique up to a point, while in some ways we are like all others [77]. Individuals differ in personality, which involves behaviors, thinking, and feeling [78, 79]. Of the many personality theories that are available, one that is often used is the NEO Personality Inventory. It measures on five basic personality traits: neuroticism, extraversion, openness, agreeableness, and conscientiousness [80, 81]. They are known as the five broad, personality traits, and are assumed to be generally stable over time [79]. Genetic impact and influences from the environment both increase in stability with age and after with

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increases in phenotypic stability[82]. In the literature, personality traits are seen as an important predictor of health [76, 83]. They have been commonly applied within psychiatry and have not been used to any great extent in cardiac care, although it might be a helpful tool in secondary prevention after an MI. Some personality traits might deter a patient from participating in the rehabilitation. For example, people who have low levels of agreeableness tend to demonstrate poor self-care [84], and such individuals may be less willing to listen and to follow lifestyle advice.

Neuroticism

Individuals scoring high on neuroticism tend to be characteristic by emotional instability [78]. Those who score high on this trait may be people who worry more and have problems controlling desires and stressful situations [85]. They may also have less healthy behaviors, such as smoking or tendencies towards antisocial or poorly adaptive behavior caused by either fear or as a defence against anxiety [86]. People high in neuroticism with no signs of illness may perceive themselves to be in poor health [87]. Such individuals may have a number of psychiatric symptoms, complain frequently of somatic disease, and recurrently seek medical care [88]. Those with low score on neuroticism are often characterised as calm

and relaxed people who will be more able to deal with stressful situations, while

those scoring high on neuroticism have a significantly higher risk of death from cardiovascular diseases [89].

Extraversion

People with high scores on this trait show excitability, sociability, talkativeness, assertiveness, and optimism [85]. They also have high amounts of emotional expressiveness and perceive themselves to be in good health, even when they may be having medical problems [87]. Highly extraverted people are more likely to smoke [90] and to seek other forms of stimulation [91] ,anyhow they tend to exercise and have healthy diets [92]. Their motivation comes from other people and so they like to work with others. People with low scores on extraversion are the opposite; they prefer to work alone and often seek quietness for concentration. They need very little external stimulation and can easily be over-stimulated.

Openness

Those high in openness tend to have a broad range of interests, a lively imagination, and considerable insight. They are open to new experiences and seek enjoyment [78]. Such individuals may have a tendency to take risks e.g., women who may

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be heavy smokers and have other less healthy behaviors. Other characteristics associated with openness are flexibility, receptiveness to new ideas, and the willingness to show one’s feelings. Low scoring people are more conservative, have few interests, and are less likely to act out their feelings [85].

Agreeableness

The quality of interpersonal interaction is involved in the trait agreeableness [78]. Those with high levels of this trait exhibit trust, altruism, and kindness, and are likely to cooperate with others. A high level of agreeableness is typical of a person who is harmonious in relation to others. Those who score low on this trait tend to be more negative and self-centred; they may also be more hostile and intolerant and less interested listening to advice i.e. to stop smoking [86, 93].

Conscientiousness

The degree of goal-directed motivation a person possesses is a measure of conscientiousness [78]. High scores on this trait are connected to thoughtfulness, impulse control, good health, ambition, and foresight. People who score low in conscientiousness tend to be lazy, unrealistic, indirect, and lack self-discipline [85]. Low conscientiousness is related to such negative health outcomes as hypertension, stroke, mental illness, and premature mortality [94], as well as harmful behaviors such as drinking and smoking [95, 96].

Psychosocial factors

Coping

There is a distinction between coping as a trait and coping as a process. Lazarus &

Folkman have defined coping as “constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (p. 141) [97]. Coping can be described as actions or thoughts that individuals employ when dealing with stressful circumstances [97].

Coping strategies are used to modify the physiological and psychological reaction of stress, and thus are thought to have a buffering effect on stress [98]. Problem- and emotion-focused responses are two major ways of coping [97, 99, 100]. In order to reconceptualise a problem, an individual uses problem-focused coping to either solve it or minimize its effect. When using emotion-focused coping is meant the manner in which an individual managed the emotions that stressful situation has caused. Using these coping strategies might help feeling better but does not solve the origin of the distress.

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Coping has not been effective if a stress reaction takes place, or if it has been

maladaptive. Maladaptive behaviors are never good because they prevent people

from adapting to the demands of life. Maladaptive behaviors actually often result in dysfunctional and non-productive outcomes. The premise is that it is not a single stressful incident that is handled in a maladaptive way that leads to disease, but that long term experiences of maladaptive coping might lead to increased morbidity and mortality. It is well know that both acute and long term problem- and emotion-focused coping strategies are correlated with overall health outcomes [101].There have been suggestions that problem-focused coping strategies are more positively and emotion-focused coping more negatively associated with health. However, this could not be found in a meta-analysis by Penley et al. [100]. Both coping strategies address problems encountered in a stressful situation.

Stress

Adaptation to stress can be measured by using the serial Color Word Test (CWT) [102], a semi-experimental way to measure how individuals adapt in a stressful situation. This test was originally designed for the study of interference.

Interference is the conflict that occurs between reading what is printed instead of naming the color in which the word is printed. It is a version of the Stroop test [103] and has been used in several studies [102, 36, 104]. Stress reflects a dynamic relationship between the environment and an individual. It occurs when an individual experiences circumstances that exceed their ability to manage the situation. It is reasonable to hypothesize that after an MI emotional maladaptive behaviour can have negative effect on the recovery.

Depression

Depression or depressive symptoms imply that a person is experiencing a decreased state of that individual’s general mood [105]. Depression can be triggered by difficult events or stress [106]. It can even occur without a trigger and be disproportionate to the factors that brought it about. Both women and men with CHD and depressive symptoms are reported to have an increased risk for mortality and morbidity [107]. Depression and smoking are interrelated, and also independently linked to CHD [108]. Studies have shown that depressed patients are more likely to smoke [109-111] and that depressive symptoms may influence the ability to quit smoking [109, 112]. Depression in itself has been found to be a risk factor for the development of CHD [113, 114]. Research has found that within two weeks after an MI, between 16% and 27% were depressed [71], and more than half of MI patients continued to be depressed three months later [115]. Patients who are depressed attend secondary prevention programs after their MI

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Social support and network

Functional support includes instrumental support (e.g, available if needed, help in getting tasks done) and emotional support: marriage satisfaction, whether the individual has someone who will listen when there is need to talk about problems, and whether the individual feels loved and appreciated. There is also network support, referring to how many individuals there are in a person’s network, as well as the quality of the network [117, 118].

Several earlier studies show, that social support is an important predictor of prognosis after an MI [119, 120]. Those patients with low perceived social support have more cardiac events [121, 122] and higher mortality [123, 124]. It has been shown that patients who received support from their family and closest friends following their MI functioned better and had a better health-related quality of life [125]. They also had increased ability to handle problems, as well as less anxiety and depressive symptoms [126, 127]. However, there is a lack of consensus on how to measure social support [128].

Rationale

Nursing as a caring science has shifted its focus from biological aspects of disease to a holistic approach that encompasses the entire context of disease, health, and illness that surrounds an individual [129]. Many factors, such as personality, coping and psychosocial circumstances, could interact with the individual and increase or reduce the risk of disease [130]. The concept of health is a variable, multi-dimensional concept [131]. Disease is a biomedical term that depends on a diagnosis established by measurements and information on symptoms and signs [132]. Illness is the individual’s experience of symptoms of the disease [133].

With regard to secondary prevention after an MI, research on personality factors might help understand a patient’s incentive to stop smoking. Furthermore, it might also be easier to communicate with those who delay seeking care when suffering an acute MI if one knew more about their personality.

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AIMS OF THIS THESIS

The overall aim of this thesis was to investigate whether there is a relationship between personality factors, stress adaptation, coping strategies, and depression on the one hand, and acute myocardial infarction and aspects of cardiac rehabilitation on the other.

The aim of Paper I was to investigate whether maladaptive behaviour in the serial Color Word Test alone or in combination with any specific personality factor was associated with the severity of the myocardial infarction.

The aim of Paper II was to analyse the correlation of personality and psychosocial factors with the time lag between the onset of coronary symptoms and seeking emergency hospital care.

The aim of Paper III was to examine whether personality traits, coping strategies, and symptoms of depression were related to smoking cessation after a myocardial infarction.

The aim of Paper IV was to examine whether personality factors or depressive symptoms predicted health care utilization during the first two years following a myocardial infarction.

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MATERIAL AND METHODS

Setting

This study was conducted at Malmö University Hospital in the third largest city in Sweden. This hospital was the single referral unit for patients with acute MI in the area. The catchment area for the Coronary Care Unit (CCU) at the Cardiology Department contained about 285,000 inhabitants in 2002. Within the catchment area the time needed for an ambulance to reach the hospital was 20 minutes maximum. During the study period (2002-2005) an average of 630 patients suspected of having an acute MI were admitted annually to the Cardiology Department, approximately 38% of whom were below the age of 71.

Design

The data used in this thesis is part of a research project entitled the Secondary Prevention and Compliance Following Acute Myocardial Infarction,

(SECAMI)-study. It was designed to explore the effect of personality and psychological factors in patients with MI on prognosis, adherence to secondary prevention measures, and treatment plan. The Recruitment for the SECAMI longitudinal cohort study went from July 2002 to January 2005.

Papers I to IV had a longitudinal cohort descriptive design: patients were followed-up after 6, 12, and 24 months. A clinical psychologist administered the Serial Color Word Test used in Papers I and II; the questionnaires on personality factors used in Studies I to IV; coping strategies used in Paper II and III; depression screening used in Papers I to IV.

Papers III and IV also included data form the 2-year follow-up. Paper III followed smoking cessation, and Paper IV followed hospital readmissions as well as cardiac health care utilization for 2 years after the MI. Data about deaths during the

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2-year follow-up was obtained from the patient journals and controlled by The National Board of Health and Welfare, Cause of Death Register. Living patients were followed for 6, 12, and 24 months. Data were collected within the Cardiology Department, between July 2002 and January 2005.

For paper IV, data from 2002 to 2007 was collected between January 2015 and May 2015 to gather all hospital readmissions, visits, and telephone calls to the Cardiology Department. All medical records for hospital readmissions were read to control the diagnoses.

Data collection process

Missed n = 208, no research staff was avaiable

n = 101, excluded due to residence outside Malmö

n = 72, excluded due to not understanding Swedish

n = 21, excluded due to being too ill Agreed to participate n = 400

n = 45, excluded; wanted not to participate Eligible n = 847

Figure 2.

Inclusion and exclusion criteria

Patients were recruited within 24 to 36 hours of admission to the CCU. Criteria

for inclusion were a diagnosis of acute MI, age under 71 years, residence within

the hospital service area, no communication barriers, ability to read Swedish language, and judged by the staff to have adequate mental and physical capability.

Drop-outs

In all, 847 patients with an acute MI (ICD-code121) were identified. One hundred and one patients were excluded because they lived outside the hospital catchment area; 72 did not understand Swedish; and 21 were either severely ill or judged to have insufficient physical or mental capacity to participate. Since only the research

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nurse and a psychologist did the screening, 208 patients were missed because they were at the care unit when the research staff was on leave, and 45 patients who fulfilled the inclusion criteria declined to take part in the study.

Enrolment

Participants were informed about the study, and told that they would be followed up after 6, 12, and 24 months. They were given information verbally and in writing and were given the opportunity to discuss this with a relative or think it over before they decided to join the study. Those who agreed to participate signed an informed consent. They were told that they could end their participation at any time.

Data collection

The initial data was collected within 24 hours of admission. Questionnaires for measuring personality factors, coping strategies, adaption to stress, depression, and social support were used (Table 1). Also a semi-structured questionnaire covering socioeconomic circumstances, cultural background area of residence, and onset of symptoms was compiled by the research nurse. Clinical data, such as information on diagnoses, comorbid conditions, family history, medication, as well as ECG, biomedical markers, and previous interventions (such as PCI and CABG) were gathered from patient charts.

The diagnosis of diabetes mellitus was retrieved from patient charts and also through patient self-reporting (responses to yes/no questions on taking anti-diabetic medication). Angina pectoris was self-reported or noted from physician diagnoses or use of nitrates. Data on the severity and type of MI (ST-elevation vs. non- ST-elevation) and left ventricular ejection fraction were obtained.

Drinking and smoking habits were also recorded, and whether participants were daily or occasional smokers. The duration, years of smoking, number of cigarettes smoked daily, and time since cessation was entered at baseline and at each follow-up as “current”, “former”, or “never”.

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Table 1. Overview of sample, time, and instruments used.

Paper 1 Paper 2 Paper 3 Paper 4

Time baseline baseline 24 Months 24 Months

Population 400 400 366 * 366* Sample n = 180 n = 323 n = 298** n = 366 NEO Personality Inventory 147 323 323 363 Beck Depression Inventory 147 323 323 339 Coping 147 323 323 323 Color Word 147 323 --

--* 34 dead or lost to follow-up ** 77 with missing data

Medical measurements clinical characteristic and laboratory testing

All measurements were performed when the study began and at each visit by the research nurse. Blood pressure was measured three times using a sphygmomanometer after 10 minutes of rest. ECG was taken. BMI was calculated as weight/heigth² (kg/m²) by measuring height (m) and weight (kg) when subjects were wearing light clothing and no shoes. Blood samples were drawn after an overnight fast. Levels of total serum cholesterol, LDL, HDL, triglycerides, carbohydrate deficient transferrin (CDT, for alcohol consumption level), and blood glucose were determined using the Malmö University laboratory standard methods. Diabetes was defined by diagnosis (see above) or as fasting whole blood glucose > 6.1 mmol/l. Cholesterol levels > 5mmol/l according to the guidelines at that time was set as hypercholesterolemia. The same regime was done at 6, 12, and 24 months follow-up visits.

Instruments

Psychosocial characteristics measurement

A questionnaire was developed and used in Paper I to IV to measure psychosocial characteristics and medical history. The same questionnaire also obtained information about risk factors for CHD.

Personality factors

The abbreviated 60 items version of the NEO Personality Inventory was used to measure personality traits. This inventory assesses the five basic dimensions of personality: neuroticism, extraversion, agreeableness, openness, and

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conscien-tiousness. Each one of the five is represented by 12 items that must be scored on a scale of 1 to 5 representing “strongly disagree” to “strongly agree” [85, 80]. Patients completed the questionnaire in the presence of the psychologist. This inventory has been widely used and has shown good psychometric properties [86, 134].

Coping

A structured interview asking about coping strategies when faced with critical life events was included in the psychological examination. A real situation that the patient remembered as critical or difficult was sought out in order to learn how the individual experienced and coped with it [135]. The psychologist asked the patient to think through the year before the heart attack and recall a critical event that was difficult to manage. The patient was then encouraged to describe in what way the event was perceived as critical or difficult and then tell what strategies she or he used to manage the situation.

Answers were sorted into ten different categories, as suggested by Folkman & Lazarus [136].

The categories were: confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal. The categories altruism and “failure to find a coping strategy” were also added depending on the answers received [99] and [137-141]. This was done when answers could not be considered ways to address one’s own problems, but reflected a willingness to help others. Individuals who could not identify any coping strategy were classified separately.

Adaptive behavior - The serial Color Word Test (CWT)

A semi-experimental design, the serial CWT [102, 103] was chosen to assess how individuals cognitively manage and adapt in a conflict situation. Its origin is the Stroop test [103]. The design is very simple. On a sheet of paper the words ‘yellow’, ‘blue’, ‘green’, and ‘red’ are printed in an incongruent color, in a design of 10 words x 10 rows. The object of the test is to name the color in which the word is printed while ignoring the written word. The challenge is to handle the interference, which in this case is the conflict between reading what is printed, and naming the color in which the word is printed.

Administration and scoring

Individuals are presented with the test and asked to name the color of the print as quickly as possible. The serial version of the CWT is a construction in which

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five identical tests are repeated, each repetition being labeled as a subtest. Scoring of each sub-test is done by the test administrator after 20, 40, 60, 80, and 100 responses, and is expressed as time consumption in seconds. The scoring was straightforward as every two rows in the test were allotted a certain amount of time. Before the actual test started, an opportunity to practice was given.

When classifying behavior in a testing session it is possible to either regard it as dependent on the particular context, or on the individual’s personal history and development [142]. The former type of behavior can be called situational and is categorized according to the pattern that occurs most frequently during the test session. Manners dependent on a person are called habitual because it is assumed they reflect the way an individual generally behaves in dealing with challenging cognitive tasks. Different patterns of habitual behavior can be categorized by analyzing the temporal aspects of these manners, which also allows us to regard cognitive adaptation as a process. This process is two-dimensional, consisting of both linear change in time consumption, regression, and nonlinear change variability. All test scores were compared with the reference medians of the entire cohort [143], whereby four patterns of adaptation in each dimension were categorized. The four patterns were equally named in both dimensions. Detailed information on the administration and analyses of the test is found in a manual [102, 103] which has been revised and translated into English [144].

The patterns may be described in the following manner: Stabilized patterns show even, uniform time consumption during all the subtests. Cumulative patterns show increasing time consumption within subtests and from one subtest to the next. Dissociative patterns show recurrent increases and decreases in time consumption in all five subtests. Finally, the Cumulative-dissociative pattern shows increasing time consumption from the first subtest until the last, combined with intermittently increasing and decreasing time consumption in each sub-test. Graphic illustrations of the adaptive patterns may be found in the literature [102, 103, 36, 104]. The instrument has been used in several studies [104, 36 ].

The Beck Depression Inventory

Depressive symptoms was measured by using the 21 item BDI [145], a self-reporting inventory that consists of a series of four statements scored from 0 to 3, with higher scores indicating greater symptom severity. The inventory, which takes approximately 10 minutes to complete, was filled out by the patient with the psychologist beside. This inventory has been used in many studies and has been shown to have good psychometric properties [146, 147]. In Paper I a cut off of > 17 was used in order to catch those with more severe depression symptoms.

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In the other papers, a cut off > 10 was used, as this is the most common cut-off in studies of depression following an MI [147, 148].

Social support and network

A questionnaire measuring social support and social network was designed for the SECAMI study. The questions measured how many people were in an individual’s network and the quality of those associations [117, 118]. The questionnaire consisted of questions regarding marital satisfaction; support that would be available; whether the patient had someone who would listen when there was need to talk about problems; and whether or not the patient felt loved and appreciated.

Statistical analysis

Data analysis was performed using Statistical Package Software (SPSS versions 17, 19, and 22 [SPSS Inc., Chicago, IL, USA

])

. All significance tests were two sided and p-values < 0.05 were considered statistically significant. Background variables in all four studies were described using percentages and means (standard deviations).

Paper I

Logistic regression analysis was used to calculate unadjusted odds ratios for background and clinical variables and their association with the severity indicators of MI (maximum troponin I level above median, maximum Creatininkinase isoenzyme, M= muscle, B= brain (CKMB) level above median, Q-wave infarction and a left ventricular ejection fraction (LVEF ≤ 50%). Differences in mean levels of maximum troponin I and CKMB were compared between patients with adaptive and maladaptive behavior and between patients with different levels in the five personality dimensions (scores divided into tertiles) by using the one-way ANOVA test. To analyse differences in distribution of maladaptive and adaptive behavior in the serial Color Word Test (CWT) the Pearson chi-square test was used. It was also used in low versus high tertiles of the five personality factors dimensions between patients with and without an LVEF ≤ 50%, and between patients with and without Q-wave infarctions. For the final analyses personality dimensions with p ≤ 0.10 were included.

The multivariate analyses of whether behavior in the CWT together with a specific personality dimension was associated with the severity of an MI were performed by means of logistic regression. In these analyses the odds ratios for a severe infarction were calculated for four strata of patients defined in terms of

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adaptive or maladaptive behavior in the CWT, low respectively high level in the chosen personality dimension.

The following parameters were included in the multivariate analyses: age, sex, current smoking status, living alone, educational level less than 9 years, employed or unemployed, born outside Sweden, treatment for hypertension, angina pectoris, diabetes mellitus, level of BMI and hyperlipidaemia, moderate to severe level of depression, history of MI, and previous revascularization.

We had four indicators of severity. Four different analyses were performed and only those variables associated with a severity indicator in each analysis with p < 0.20 were included.

Paper II

Background factors and clinical variables were compared in men and women, using Pearson’s chi-square test for dichotomous and logistic regression analysis for ordinal variables with sex and employed as dependent factor. Based on the time interval from initial symptoms to arrival at hospital, patients were categorized into three groups. The time was 0 to 119 minutes for Group 1, 120 minutes to 6 hours for Group 2, and 6 to 72 hours for Group 3. Time delay groups were compared by using dichotomous variables in a logistic regression. Time delay was then fitted as an ordinal variable in the logistic regression model and p-values for the trend among the groups was used. To adjust the p-values for age and sex, a logistic regression model was also used. For continuous variables, a general linear model was used. The groups of time delay were used as a fixed factor and the p-value for the linear association among the factor levels was used. Finally, a stepwise multiple logistic regressions with time delays above or below 6 hours was applied as a dependent variable to assess factors independently associated with long time delays. The p-value for removal from the stepwise model was 0.10 in this analysis.

Paper III

The patient cohort was divided into three groups according to smoking status (current, former, or never). Background factors between these groups were compared. Pearson’s chi-square test for comparing frequencies, and analysis of variance for comparing means were employed.

Pairwise comparisons between the categories of smoking were performed only for risk factors with significant differences in the overall ANOVA test. A general linear model was used to compare personality factors and depression between groups with adjustment for age and sex. Logistic regression was used to adjust

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dichotomous variables for age and sex. A stepwise multiple logistic regression was performed (dependent variable: current smoker at the baseline examination) to assess factors that were independently associated with smoking at baseline.

A backward stepwise logistic regression model was used to explore baseline variables that independently predicted smoking cessation after two years of follow-up. Personality factors at baseline that were associated with smoking cessation with p < 0.10 in the univariate analysis were entered together with age and sex in the first step of a stepwise model. The least significant variable was removed in each step. P > 0.10 was used as criterion for removal from the model.

Paper IV

Personality factor index scores for neuroticism, extraversion, openness, agreeableness, and conscientiousness were divided into low, intermediate, and high score. Depression scores (measured by BDI) were dichotomized according to recommended cut-off values for detecting depressive symptoms. Whether any of these personality factors or depression were related to health care consumption were examined using negative binominal regression analysis. The lowest tertile was used as a reference group for the personality factors. We also investigated whether any of the above personality factors were related to age, gender, current smoking status, alcohol consumption (measured by CDT levels), size of the MI (measured as max level on troponin-I and LVEF), and health care utilization. For the personality traits we also adjusted for symptoms of depression by BDI score. Depression score by BDI was dichotomized into low (0 to 9) and high (≥ 10) scores. Correlations with health care consumption were analysed in the same way as personality factors.

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ETHICAL CONSIDERATION

Information

All participants were informed verbally and in writing about the aims of the study. They were judged capable of understanding the information and were told they may discontinue their participation at any time without fear of reprisal. A written informed consent form was signed by the participant before each interview was conducted.

All four studies were approved by the ethical vetting board at the Ethics Research Committee, Faculty of Medicine, Lund University, Sweden: Papers I to III (LU 230-02) Paper IV (Dnr 2015/279).

The idea of enrolling the patients shortly after their arrival at the CCU was motivated by the short time that MI patients are often hospitalized if no complications occurs. A second reason was the importance of interviewing patients while they still clearly remember everything that happened in connection with the onset of chest pain.

In accordance with the Helsinki Declaration of 1975, we made allowance for the vulnerable situation of patients with a newly-diagnosed MI and tried to respect their integrity, privacy, and the autonomy of each person [149, 150].

Attempting to chart the personality, stress handling patterns, and social interactions of people who have recently been informed that they have had an acute MI could easily be perceived as an invasion of privacy. Furthermore, psychological tests may provoke thoughts and concerns that would otherwise not have come to the surface. In order to give participants the opportunity to adjust, they were told that a specialized nurse could be brought in to assist them.

Confidentiality

Participants were assured that the researcher would not communicate anything a patient said to the health care staff. All data was computerized, analysed, and the results presented on group level, so that no individual could be identified.

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RESULTS

Baseline characteristics papers I-IV

Baseline characteristics for the SECAMI participants are shown in Table 2. The mean age of the SECAMI study sample was 58 years (range 26 to 70, median age 60). The average age of Swedish men was 59 years; it was 55 years for those men not born in Sweden (p = 0.0001);for Swedish women it was 61 years, and for women not born in Sweden it was 57 years, (p = 0.026)

Of the 400 patients contacted, 323 patients answered the questionnaires regarding depression, personality factors, and coping strategies. Of the 323, 77 patients had missing data on one or more personality inventories. The proportion of men who completed all inventories was higher (73% vs. 58%, p = 0.01) and the mean age was somewhat lower (58.4 ± 8.3 vs. 59.4 ± 8.3, p = 0.34) than women. One hundred forty-seven patients completed all three assessments (CWT, BDI, and NEO-PI). They had a mean age of 58 ± 9 years, i.e, the same as the total population.

Paper I

Low scores in the dimension of Extraversion together with a maladaptive behavior in the serial CWT was related to severity of MI when severity was defined as maximum levels above median of the cardiac biomarkers troponin I and CKMB. No association was found when severity was defined as a Q-wave infarction or a decreased LVEF. Background data showed that 10.2 % of the 147 patients had moderate to severe levels of depression, and less than half (44.2%) had been prescribed treatment for hypertension. In the univariate analyses, BDI, female gender, treatment for angina pectoris, presently not employed or professionally active were associated with a decreased LVEF. Extraversion was the only personality factor related to any severity indicator, namely maximum troponin I (Table 3). Extra version was thus selected as the personality dimension to be analysed for the investigation of a possible association of severity of MI (troponin I, CKMB, Q-wave and LVEF) in connection with behaviour in the serial CWT. Four seperate analyses were carried out. The results can be seen in Table 4.

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Table 2. Background factors and clinical characteristic of the Secondary Prevention and Compliance following Acute Myocardial Infarction (SECAMI) study participants.

Men Women n=283 70.8% n=117 29.2% p-value1 Age 0.018 26 - 50 56 19.8 14 12.0 – 51 - 60 107 37.8 35 29.9 – 61 - 70 120 42.4 68 58.1 – Living alone 72 25.4 49 41.9 0.001 Employed 140 49.5 39 33.3 0.003

Not born in Sweden 72 25.4 21 17.9 0.107

Current smoker 128 45.2 57 48.7 0.524 Education 0.086 Low (< 9 years) 87 30.7 38 32.5 – Intermediate 160 56.5 66 56.4 – High (University) 36 12.7 13 11.1 – Previous MI 54 19.1 17 14.5 0.728 Hypertension* 115 40.6 58 49.6 0.101 Hyperlipidemia* 72 25.4 24 20.5 0.294 Diabetes mellitus 49 17.3 23 19.7 0.579 BMI ≥ 30 74 26.1 42 35.9 0.051 Previous CABG 14 4.9 6 5.1 0.940 Previous PTCA 24 8.5 8 6.8 0.582 LVEF ≤ 50 162 58.1 76 65.0 0.201 Q-wave infarction 103 36.4 33 28.2 0.116 1 Pearson chi-square

CABG = coronary artery by-pass grafting PTCA = percutaneous transluminal coronary LVEF = left ventricular ejection fraction, * medical treatment

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Table 3.

Stress-management and personality-factors in relation to four indicators of severity of myocardial infarction (n=147; Paper I).

Maximum tr oponin I-le vel; abo ve median Maximum cr eatine kinase-MB; abo ve median Q-w av e inf ar ction Lef t v entricular ejection fr action (L VEF) ≤50% OR 1 (95% CI 2) p OR 1 (95% CI 2) p OR 1 (95% CI 2) p OR 1 (95% CI 2) p

Maladaptive behavior in the CWT

1.15 (0.60-2.19) 0.68 1.15 (0.60-2.19) 0.68 0.96 (0.49-1.90) 0.91 1.21 (0.63-2.32) 0.56

High level of neuroticism

1.18 (0.59-2.37) 0.64 1.04 (0.52-2.09) 0.90 0.83 (0.40-1.74) 0.63 0.85 (0.43-1.71) 0.66

Low level of extraversion

2.01 (0.98-4.11) 0.06 2.01 (0.98-4.11) 0.06 1.83 (0.89-3.78) 0.10 1.27 (0.62-2.57) 0.52

Low level of openness

1.04 (0.52-2.09) 0.90 0.63 (0.31-1.27) 0.20 0.54 (0.25-1.16) 0.11 0.85 (0.43-1.71) 0.66

Low level of agreeableness

1.11 (0.56-2.21) 0.77 1.11 (0.56-2.21) 0.77 1.05 (0.51-2.16) 0.90 0.91 (0.45-1.81) 0.78

Low level of conscientiousness

1.58 (0.80-3.13) 0.19 1.24 (0.63-2.45) 0.53 1.00 (0.49-2.02) 0.99 0.70 (0.36-1.39) 0.31

1 Odds Ratio 2 Confidence Inter

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Table 4.

Background, clinical, and psychosocial factors and associations with different indicators of severity of myocardial infarction.

Results from multivariate logistic regression analyses (n=147; Paper

I). Indicat or of se verity Fact or OR 1 95% C I 2 p Maximum tr oponin I-le vel; abo ve median Str ess-manag ement and le vel of extr av er sion

Adaptive behavior and high level of extraversion

Reference

Adaptive behavior and low level of extraversion

1.88

0.60-5.90

0.283

Maladaptive behavior and high level of extraversion

1.23

0.34-2.83

0.633

Maladaptive behavior and low level of extraversion

2.97

1.08-8.20

0.043

For

mal education of <9 years

0.48 0.21-1.08 0.08 Immigrant 2.18 0.70-6.79 0.18

Treatment for angina pectoris

0.52 0.17-1.62 0.26 Previous revascularization3 0.63 0.15-2.72 0.54 Maximum cr eatine kinase-MB; abo ve median Str ess-manag ement and le vel of extr av er sion

Adaptive behavior and high level of extraversion

Reference

Adaptive behavior and low level of extraversion

1.26

0.39-4.02

0.693

Maladaptive behavior and high level of extraversion

1.09

0.46-2.59

0.853

Maladaptive behavior and low level of extraversion

3.31 1.11-9.85 0.033 Current smoking 2.30 1.08-4.90 0.03 Previous revascularization3 0.19 0.04-0.99 <0.05 For

mal education of <9 years

0.51 0.21-1.24 0.14 Immigrant 2.28 0.96-7.55 0.18

Treatment for angina pectoris

0.72 0.22-2.34 0.58 Age 1.00 0.95-1.04 0.81 (T

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Indicat or of se verity Fact or OR 1 95% C I 2 p Q-w av e inf ar ction Str ess-manag ement and le vel of extr av er sion

Adaptive behavior and high level of extraversion

Reference

Adaptive behavior and low level of extraversion

1.31

0.43-4.05

0.643

Maladaptive behavior and high level of extraversion

0.77

0.32-1.86

0.563

Maladaptive behavior and low level of extraversion

1.65 0.63-4.30 0.313 Current smoking 1.74 0.86-3.53 0.13 Previous MI 0.48 0.10-2.30 0.36 Previous revascularization4 0.53 0.11-2.61 0.44 Lef t v entricular ejection fr action (L VEF) ≤50% Str ess-manag ement and le vel of extr av er sion

Adaptive behavior and high level of extraversion

Reference

Adaptive behavior and low level of extraversion

1.26

0.39-4.04

0.693

Maladaptive behavior and high level of extraversion

1.12

0.48-2.60

0.793

Maladaptive behavior and low level of extraversion

1.06 0.39-2.92 0.913 Female sex 2.38 1.04-5.44 0.04

Moderate to severe level of depression (BDI

19)

7.09

0.80-62.95

0.08

Presently not employed or professionally active

1.61 0.80-3.25 0.18 Previous MI 2.19 0.59-8.16 0.24

Treatment for angina pectoris

1.43 0.48-4.36 0.53 1 O dds Ratio 2 Confidence Inter val

3 In comparison with reference stratum 4 PCI (Percutaneous Coronar

y Inter

vention) or CABG (Coronar

y Ar

ter

y Bypass Graft)

(T

Figure

Figure 1.  Atherosclerosis causes narrowing of the coronary arteries, which can lead to angina  and eventually a myocordial infarction.
Table 1.  Overview of sample, time, and instruments used.
Table 2. Background factors and clinical characteristic of the Secondary Prevention and  Compliance following Acute Myocardial Infarction (SECAMI) study participants.
Table 3. Stress-management and personality-factors in relation to four indicators of severity of myocardial infarction (n=147; Paper I)
+7

References

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