Type D Personality, Unhealthy Behaviors, and 2-Year Outcomes after Acute Coronary Syndrome: A Cohort Study

Abstract Aims This study aims to examine the impact of Type D personality and health behaviors on long-term major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). Methods We included 10,003 patients with ACS who underwent PCI between May 2017 and September 2023. Type D personality was measured using the Type D Scale-14; scores ≥ 10 on both subscales (negative affectivity and social inhibition) defined Type D. Cardiovascular health (CVH) was assessed using Life's Essential 8 across eight components: smoking status, physical activity, average sleep duration, diet, body mass index, blood lipids, blood glucose, and blood pressure. CVH scores (0–100) were categorized as poor (0–49), intermediate (50–79), and ideal (80–100). The joint effect of Type D status and CVH category on two-year MACE, defined as stroke, non-fatal myocardial infarction, revascularization, cardiac death, or cardiac hospitalization, was evaluated using Cox regression analyses. Results A total of 2117 individuals developed MACE during the follow-up. Cox regression results revealed that, compared with the Type D (-) ideal CVH group, the Type D (+) poor CVH group [hazard ratio (HR) 2.960, 95% confidence interval (CI): 2.238–3.914, p < 0.001], the Type D (+) intermediate CVH group (HR 2.270, 95% CI: 1.739–2.962, p < 0.001), and the Type D (-) poor CVH group (HR 1.953, 95% CI: 1.501–2.541, p < 0.001) exhibited a higher risk of experiencing 2-year MACE. When the Type D (+) ideal CVH group served as the reference group, both the Type D (+) intermediate CVH group (HR 1.895, 95% CI: 1.274–2.820, p = 0.002) and the Type D (+) poor CVH group (HR 2.471, 95% CI: 1.645–3.713, p < 0.001), as well as the Type D (-) poor CVH group (HR 1.631, 95% CI: 1.092–2.436, p = 0.017), remained significant predictors of MACE risk. Furthermore, among individuals with Type D personality, intermediate to poor levels of health behavioral dimensions (HR 1.864, 95% CI: 1.348–2.578, p < 0.001; and HR 2.452, 95% CI: 1.776–3.387, p < 0.001) conferred a higher risk of MACE than equivalent levels of health factor dimensions (HR 1.640, 95% CI: 1.280–2.101, p < 0.001; HR 2.131, 95% CI: 1.629–2.787, p < 0.001). Among individuals with Type D personality, intermediate or poor levels of physical activity, blood glucose, and sleep were significantly associated with a higher MACE risk, whereas in individuals with non-Type D, a significant increase in MACE risk was observed only at poor levels of these behaviors (all p < 0.05). Conclusion Individuals with Type D personality and intermediate or poor CVH exhibited an elevated risk of MACE. Individuals without Type D personality but with poor CVH also exhibited an elevated risk. Across personality strata, the risk attributable to health behaviors exceeded that attributable to health factors. The most pronounced differences were observed in physical activity, blood glucose, and sleep. These observations supported early assessment of Type D personality and CVH following PCI in patients with ACS, with the aim of reducing the incidence of MACE.