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
stimuli and perceived mental distress, including type D person-
ality, anxiety, and depression, are still under debate. The aim of
this study was to examine associations between cardiovascular
reactivity to social stress and mental distress in patients after
acute coronary syndrome.
Methods:  Patients (n = 116, 86% males, 52 ± 8 yr) with cor-
onary artery disease 2 wk after acute coronary syndrome were
evaluated for sociodemographic, clinical characteristics and cor-
onary artery disease risk factors. The Trier Social Stress Test was
employed to measure cardiovascular reactions to social stress
(systolic and diastolic blood pressure and heart rate). Mental
distress assessment included type D personality (Type D Scale),
anxiety and depressive symptoms (Hospital Anxiety and De-
pression Scale), and state and trait anxiety (State-Trait Anxiety
Inventory).
Results: Multiple linear regression analysis showed associa-
tions between type D personality and lower heart rate during
Trier Social Stress Test periods of task instruction (β = −.196,
P < .04), preparation time (β = −.232, P < .01), and recovery
time (β = −.209, P < .029). Higher trait anxiety was linked
with lower heart rate during baseline rest (β = −.287, P < .01),
task instruction (β = −.286, P < .01), preparation time (β =
−.241, P < .01), and recovery period (β = −.209, P < .05).
Depressive symptoms were associated with higher systolic blood
pressure during baseline rest (β =.187, P < .05), task instruction
(β = .306 P < .01), and free speech (β = .264, P < .05).
Conclusions: Mental distress was associated with cardiovas-
cular stress reactions independent from possible covariates,
suggesting dysregulated psychophysiological reactions to acute
stress.
Key Words:  acute coronary syndrome • cardiovascular reac-
tivity to stress • depressive symptoms • trait anxiety • type D
personality
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
and physiological mechanisms underlying emotional trigger-
Author Affiliation: Laboratory of Behavioral Medicine, Neuroscience
Institute, Lithuanian University of Health Sciences, Palanga, Lithuania.
Julija Gecaite works as a consultant at Facit, LLC, and Julius Burkauskas
has served as consultant to Cogstate, Ltd. The other authors declare no
conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.jcrpjournal.com).
Correspondence: Julija Gecaite, MA, Laboratory of Behavioral Medicine,
Neuroscience Institute, Lithuanian University of Health Sciences, Vyduno al
4, LT-00135 Palanga, Lithuania (julija.gecaite@lsmuni.lt).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/HCR.0000000000000457
E12    Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39:E12-E18
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ing of acute coronary syndrome (ACS), as defined by acute
myocardial infarction and/or unstable angina pectoris, is
not well understood.4 Although there is a growing body of
studies examining relationships between CV stress reactions
and psychological factors, which might modulate CV stress
response,1 there is still very little known about these associa-
tions in patients with coronary artery disease (CAD).
The psychophysiological studies, explaining how type
D personality, characterized as a tendency to experience
negative emotions and inhibit self-expression,5 influenc-
es health-related outcomes in CAD patients, are relatively
sparse. Previous research has shown that the presence of
Distressed or type D personality, which itself is an indepen-
dent predictor of adverse events,6 is associated with reduced
heart rate (HR) reactions to a mental stress challenge in
patients with heart failure.7 Similar results were found by
Howard et al,8 in which individuals with type D personality
showed a weaker myocardial profile. There is a growing
body of research9,10 suggesting that autonomic dysfunction
may be manifested by not only exaggerated but also dimin-
ished CV stress response. The long-term emotional distress
may disrupt the biological regulatory system, including
diminishing of the autonomic nervous system, which may
result in poor health-related outcomes.11-14
Nonetheless, the results regarding individuals with type
D personality and their CV stress reactivity are inconsis-
tent15,16 with some studies finding higher cardiac output
during psychological stress for individuals with type D per-
sonality in comparison with individuals without type D per-
sonality. The inconsistencies in the results might be caused
by methodological differences, distinct characteristics of
study participants, or relatively small sample sizes. Hence,
further research is warranted.
Depression is also an essential risk factor in heart-related
diseases,17,18 and together with anxiety symptoms may lead
to worse self-care, health-related quality of life,19-22 and
mortality.23-27 There is substantial evidence in the literature
underlining the impact of depression and anxiety on CV
reactions to laboratory-induced stress. However, the results
differ in various populations.
Past studies have suggested depressive blunting, mean-
ing that patients with depressive symptoms demonstrated
diminished CV reactivity when faced with social stress. Par-
ticularly, in the study by York et al,28 depressive patients
with CAD showed reduced HR and diastolic blood pressure
(DBP) reactivity during psychological stress challenge. Sev-
eral other studies in different clinical and healthy popula-
tions reported a similar pattern suggesting significant links
between decreased CV reactivity to mental stress and higher
depressive as well as anxiety symptoms.29-37
Other research has reported no differences in sympa-
thetic activity between depressed and nondepressed partici-
pants. Brydon et al38 and Wang et al39 found no significant
associations between depression, anxiety, and CV reactivity
www.jcrpjournal.com
in ACS patients. In contrast, exaggerated CV reactivity in re-
lationship to higher depressive symptoms was meta-analyzed
by Kibler and Ma.40
In terms of state and trait anxiety, another study by
Pointer et al41 reported no significant links between CV re-
activity and trait anxiety. However, Jezova et al42 suggested
that subjects with higher trait anxiety had increased HR in
comparison with participants with low trait anxiety. Thus,
further studies are warranted in order to clarify the links
between mental distress and CV reactivity to stress.
Understanding associations between mental distress
characteristics and CV reactions during stress-inducing
tasks in CAD patients after ACS may help further investi-
gate the underlying mechanism of stress-related pathologies
in this particular population.
Therefore, in this study, we aimed to examine associations
between CV reactions to psychosocial stress, type D personality,
anxiety and depression symptoms, and state and trait anxiety in
CAD patients after ACS. Taking into account results from pre-
vious research7 in patients with heart failure, we hypothesized
that in patients the presence of type D personality would be
associated with diminished CV reactivity to social stress, partic-
ularly the HR response. The exploratory aim was to investigate
the relationship between CV reactivity to mental stress, anxiety,
and depression symptoms as well as state and trait anxiety.
METHODS
PARTICIPANTS
One hundred forty-three consecutive CAD patients 2 wk
after ACS were recruited to participate in the study. Inclu-
sion criteria are provided as Supplemental Digital Content
1, available at: http://links.lww.com/JCRP/A129. All study
participants had been receiving standard treatment for
secondary prevention of CAD based on established guide-
lines.1,43,44 The Lithuanian Biomedical Research Ethics
Committee approved the study protocol, which conforms
to the ethical guidelines of the Helsinki Declaration. All pa-
tients were also approved by their cardiologist for partic-
ipation. Each participant signed written informed consent
before inclusion in the study and was debriefed afterward.
The study cardiologist evaluated patient left ventricular
ejection fraction, using cardiac echocardiography. Objec-
tive evidence of ACS was obtained from clinical records.
Exclusion criteria (Supplemental Digital Content 1, avail-
able at: http://links.lww.com/JCRP/A129) were evaluated
on the basis of case history and evaluation of clinical char-
acteristics by the study cardiologist. The final study sample
comprised 116 participants (86% males).
Sociodemographic (age, sex, and education), clinical
characteristics, and major CAD risk factors of eligible par-
ticipants were measured 2 d after admission to rehabili-
tation by the study cardiologist or health psychologists.
Clinical characteristics consisted of diagnosis, current medi-
cation use, and the presence of heart failure (left ventricular
ejection fraction of ≤40%). Subject history of ACS, angina
pectoris, and hypertension was retrieved from the medical
records. Cardiovascular risk factors were evaluated by mea-
suring obesity (body mass index), history of smoking, and
presence of arterial hypertension.
In addition to a mental stress challenge, performed with
Trier Social Stress Test (TSST), patients were also evaluated
for type D personality (Type D Scale-14 [DS14]), mental
distress (Hospital Anxiety and Depression Scale [HADS],
State-Trait Anxiety Inventory [STAI]), which is in line with
established guidelines for measuring psychosocial risk fac-
tors in CAD prevention in clinical practice.3
www.jcrpjournal.com Cardiovascular Reactivity to Stress and Mental Distress in Patients After ACS     E13
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
MEASURES
Trier Social Stress Test
The TSST, a standardized psychosocial laboratory stress
test, was conducted to measure CV reactions to psychoso-
cial stress: systolic blood pressure (SBP), DBP, and HR.45
The TSST was performed on the basis of standard proto-
col,45-47 with previously established modification of arithmetic
tasks that included serial addition (described later) as opposed
to serial substraction.48-50 All patients participated in the TSST
between 2 and 4 pm. They took a baseline rest (10 min), fol-
lowed by upcoming task instruction (5 min), during which
participants were told that they would assume the role of a
job applicant invited for individual interview with the se-
lection committee. Subsequently, subjects were given 5-min
preparation time, during which they had to prepare a speech
to convince the panel that they were the best candidates for
the specified job. The fourth stage of TSST was a simulated
job interview (5 min). Participants were encouraged to uti-
lize the entire time for the speech and were asked standard
job interview questions. A second stress-evoking task during
the fifth stage of TSST was an 8-min Arithmetic task, using
the Paced Auditory Serial Addition Test.51 The Paced Audi-
tory Serial Addition Test involved the tape-recorded presen-
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
Addition Test comprises 4 series of numbers, with progres-
sively shorter interdigit time intervals.
The TSST was led by a trained psychologist, accompa-
nied by 2 laboratory technicians. The TSST was completed
with a recovery period of 10 min, where participants rested
quietly alone. After the TSST was over, subjects were de-
briefed about the aim of the tasks and any questions that
had arisen were answered.
Cardiovascular measures were assessed continuously
over 6 periods of TSST using Oscar2 24-HR ABP (SunTech
Medical Inc).52 The monitor was mounted on the left arm.
Heart rate, SBP and DBP were obtained at 1, 3, 6, 8, and
10 min and raw scores averaged during the baseline rest (1)
and the recovery period (6). The same CV characteristics
were evaluated at 1, 3, and 5 min during task instruction
(2), preparation time (3), job interview (4), 1, 3, 6, and 8
min during arithmetic task (5), and averaged as well.45
Type D Scale-14
The type D personality was assessed using the Lithuanian
version of DS14.53-55 The DS14 has two 7-item subscales,
which assess negative affectivity and social inhibition.
Statements on both 7-item scales are based on a 5-point
Likert scale (“false” [0] to “true” [4]). Scores range from
0 to 28 on each subscale, where >10 on both DS14 sub-
scales of negative affectivity and social inhibition indicate
the presence of type D personality.
State-Trait Anxiety Inventory
The STAI was used to measure trait (STAI-T) and situa-
tional (STAI-S) anxiety.54,56 Each questionnaire contains 20
statements that are based on 4-point Likert scale. The total
scores of subscales range from 0 to 60. Higher scores on
both scales indicate more anxiety symptoms. Scores that are
≥30 points indicate moderate, while scores ≥45 determine
severe anxiety.56
Hospital Anxiety and Depression Scale
Mental distress was evaluated with a self-report HADS,
which consists of 14 items.57,58 Each statement is rated
on a scale from 0 to 3 according to the experiences of the
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
The results of this study suggest that the presence of type D
personality and high trait anxiety is associated with blunt-
ed HR reactivity to acute social stressors, independently
from sociodemographic, clinical characteristics, and CAD
risk factors in patients after ACS, which may suggest an
of depression were associated with increased levels of SBP
during TSST. These results further underscore the impor-
tance of subjectively experienced mental distress symptoms
in stress-induced somatic reaction in patients with CAD.
As hypothesized, the findings of lower HR reactivity in
subjects with type D personality were consistent with the

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Figure. Heart rate reactivity during Trier Social Stress Test in patients
with and without type D personality (N = 116).
study of patients with chronic heart failure.7 Studies per-
formed in otherwise healthy subjects with type D person-
ality15,16 report exaggerated HR response to mental stress.
However, our findings and the findings by Kupper et al7
suggest that type D personality correlates with diminished
HR in patients with vascular disorders.
The current study also extended previous investigation
with healthy subjects42 by specifically examining associa-
tions between trait anxiety and CV reactions to TSST in
patients after ACS. Yet, our study showed distinctive results
in terms of HR response during mental stress. Specifically,
Jezova et al42 found that higher trait anxiety correlated with
higher HR reactivity, while in our study we observed in-
verse associations between these 2 variables. The difference
in results might be caused due to differing population with
regard to age and the presence of somatic illness.
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.
Previous literature suggests that significant deviations in
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
associated with various health-related parameters including
obesity,11 increased smoking behavior,13 poorer self-report-
ed health,12 and higher physical disability.14 Meta-analysis
by Chida and Hamer60 reports that long-term, personali-
ty-related stress, such as neuroticism, negative affect, or
anxiety, is linked with dampened CV stress response as well.
While depressive symptoms might be temporal, personali-
ty-related stress usually causes long-term chronic stress. As
a consequence, this daily pattern may tend to activate the
sympathetic nervous system more often causing the “wear
off” effect and loss of adaptive capacity to react in stressful
situations.61 Therefore, personality-related stress, including
trait anxiety and type D personality, might dysregulate the
psychophysiology of stress reactions by diminishing, rather
than increasing CV reactivity and prevent the autonomous
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
may be due to difference in coping strategies of individu-
als with type D personality versus of those with depres-
sive tendencies. Type D individuals engage in maladaptive
withdrawal, specifically passive coping strategy,62 while
depressive individuals tend to use emotion-oriented style63
focusing on the need to relieve stress.64 Therefore, patients
with type D personality who use a passive coping strategy
to distract themselves from negative stimuli may respond
with less anxiety and stress,65 while depressive patients,
due to focus on negative emotions, demonstrate elevat-
ed CV response to stress. Nevertheless, further studies
exploring coping strategies in individuals after ACS are
necessary to support possible explanations.
It is worth noting that there has been a discussion that type
D personality and depression have substantial phenomeno-
logical overlap.66 Previous study by Bunevicius et al55 report-
ed type D personality as a possible independent risk factor
for developing clinically significant depressive and anxiety
symptoms in CAD patients. In this particular study,55 those
with type D personality had 9-fold increased chances of de-
veloping depression and 5-fold increased odds of significant
anxiety symptoms.
However, Denollet et al67 propose that type D personali-
ty and depression manifest different forms of distress due to
distinctive core characteristic of social inhibition in type D
personality.67 This may partly explain why CV reactivity of
stress differed in type D personality and depressive patients
in our study in terms of reactions during all TSST periods
and the directions of associations.
The strengths of this study include a novel approach to
measuring social stress using TSST in CAD patients after
ACS. The findings may also contribute to further experi-
mental research in the area of psychophysiological stress
reactions in order to improve secondary prevention during
cardiac rehabilitation programs for ACS patients.
However, the major limitation of this study is the
cross-sectional design precluding implications with regard
to causal effects of personality traits on psychosocial stress
reactions. Our data are also limited to the group of patients
after ACS; thus, the study results should be considered
with caution in the overall CAD population. Elevated rest-
ing HR has been demonstrated to have prognostic value
in ACS patients for further increased risk of adverse out-
comes68-70; thus, reducing the limit <70 bpm has become
one of the important goals in cardiac rehabilitation treat-
ment programs.71 Although the current study has evaluated
medication use as one of the possible confounders, which
was not significant in univariate models, the medication use
that was targeted toward lowering HR might be seen as a
limitation in this study. Finally, since the study was mainly
exploratory in design aiming to pinpoint factors associated
with CV stress reactivity, studies with a larger sample size
and corrections for multiple comparisons are warranted.
CONCLUSIONS
In this study, personality-related stress and trait anxiety were
linked to blunted HR response during social stress in patients
with CAD after ACS. Symptoms of depression were associ-
ated with higher SBP during a mental stress challenge. Type
D personality, trait anxiety, and depressive symptoms might
present as useful markers for social stress assessment. Howev-
er, due to limited sample size and inconsistencies of previous
research results, further studies should attempt to replicate
our findings with patients after ACS. Future work should also
concentrate on HR variability and neuroendocrinological re-
sponse to mental stress in CAD patients after ACS.
E16    Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39:E12-E18
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ACKNOWLEDGMENTS
The authors thank the staff of the Laboratory of Behavioral
Medicine for their great help in conducting this research,
including medical doctor Audrius Alonderis for ensuring
patient safety during TSST, junior researcher and registered
nurse Nijole Kazukauskiene for monitoring patient health
during the TSST and great contribution in coordination of
the research program, and Dr Alicja Juskiene and Dr Laima
Sapezinskiene for conducting the psychological testing and
TSST.
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