Quality of life and Psychopathology in Essential Hypertension with Dyslipidaemia

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1 Διεπιστημονική Φροντίδα Υγείας(2014) Τόμος 6,Τεύχος 3, ISSN Quality of life and Psychopathology in Essential Hypertension with Dyslipidaemia Tsartsalis D. 1, 2, Dragioti E. 3, Kontoangelos K. 4,5, Gouva M. 3, Pitsavos C. 2, Sakkas P. 4, Papageorgiou C. 4, Stefanadis C. 2, Kallikazaros I. 1 1,2 MD, MSc, Cardiologist Department of Cardiology, Hippokration Hospital, Athens, Greece, and 1st Department of Cardiology, University of Athens, Medical School, Hippokration Hospital, Athens, Greece. 3 Psychologist, MSc, PhD,Research Laboratory Psychology of Patients, Families and Health Professionals - Higher Technological Educational Institution of Epirus, Ioannina, Greece. 4,5 MD, PhD, Psychiatrist 1st Department of Psychiatry, University of Athens, Medical School, Eginition University Hospital, Athens, Greece, and University Mental Health Research Institute, Athens, Greece. 3 Associate Professor of Psychology -Research Laboratory Psychology of Patients, Families and Health Professionals - Higher Technological Educational Institution of Epirus, Ioannina, Greece. 2 Professor of Cardiology - 1st Department of Cardiology, University of Athens, Medical School, Hippokration Hospital, Athens, Greece. 4 Associate Professor of Psychiatry - 1st Department of Psychiatry, University of Athens, Medical School, Eginition University Hospital, Athens, Greece. 4 Professor of Psychiatry,Department of Psychiatry, University of Athens, Medical School, Eginition University Hospital, Athens, Greece 2 Professor of Cardiology, Head of 1st Department of Cardiology, University of Athens, Medical School, Hippokration Hospital, Athens, Greece. 1 MD, PhD, Cardiologist, Head of Department of Cardiology, Hippokration Hospital, Athens, Greece. ABSTRACT Background:Patients with chronic conditions like hypertension may experience many negative emotions which increase their risk for poor quality of lifeas well as the development of anxiety and depression symptomatology. However little is known about hypertension accompanied by dyslipidaemia. Aim: This study aimed to investigate the possible differences between hypertensive patients with dyslipidaemia and hypertensive patients without dyslipidaemia on quality of life and mental health. Methods:One hundred and nineteen-seven patients with essential hypertension participated and classified into two groups dyslipidemic and non dyslipidaemic based on the levels of hypertension and cholesterol after medical examination. Along with a questionnaire regarding demographics and clinical features the SF-36 Health Survey, the Symptom Checklist-90-R, and the Cardiac Anxiety Questionnaire were administered. Results: Lower levels of Physical Functioning (p=.001), Role Physical (p=.046), Vitality (p=.000), Bodily Pain (p=.004), General Health (p=.000) and Physical Component Summary (p=.000)betweendyslipidemic and non dyslipidaemichypertensive patients were found. Significant differences between groups were also observed in all dimensions of psychopathology with exception to Hostility (p=.097), and Phobic Anxiety (p=.472). Apart from the avoidance subscale (p=.018), no difference onheart focused anxiety between the two groups was found. Logistic regression model found that dyslipidaemic hypertensive patients had in general a higher risk of impairment regarding quality of life and psychopathology. Conclusions: There is a significant association between presence of dyslipidaemia and deteriorated quality of life as well as mental symptomatology inhypertensive patients. The need for a more target therapeutic schema is outlined. Key-words: essential hypertension quality of life psychopathology dyslipidaemia heart focused anxiety Cor. Author: Gouva M. Tei of Epirus gouva@ioa.teiep.gr 128

2 Interscientific Health Care (2014) Vol 6, Issue 3, ISSN Ποιότητα ζωής και Ψυχοπαθολογία σε Ιδιοπαθή Υπέρταση με Δυσλιπιδαιμία Τσαρτσάλης Δ. 1, 2, Δραγκιώτη Ε. 3,Kοντοάγγελος Κ. 4,5, Γκούβα Μ. 3, Πίτσαβος Χ. 2, Σακκάς Π. 4, Παπαγεωργίου Χ. 4, Στεφανάδης Χ. 2, Καλλικάζαρος Ι. 1 1,2 MD, MSc, Καρδιολόγος ΚαρδιολογικόΤμήμα, ΙπποκράτειοΝοσοκομείοΑθηνώνκαι 1ηΚαρδιολογική Κλινική, Πανεπιστήμιο Αθηνών, Ιατρική Σχολή, Ιπποκράτειο Νοσοκομείο Αθηνών 3 Ψυχολόγος, MSc, PhD,Ερευνητικό Εργαστήριο Ψυχολογίας Ασθενών Οικογενειών και Επαγγελματιών Υγείας, Ανώτατο Τεχνολογικό Εκπαιδευτικό Ίδρυμα Ηπείρου. 4,5 Ψυχίατρος,MD, PhD, 1ηΨυχιατρικήΚλινική, Πανεπιστήμιο Αθηνών, Ιατρική Σχολή, Αιγινήτειο Νοσοκομείο Αθηνών και Ερευνητικό Πανεπιστημιακό Ινστιτούτο Ψυχικής Υγιεινής, Αθήνα. 3 ΑναπληρώτριαΚαθηγήτριαΨυχολογίας, Ερευνητικό Εργαστήριο Ψυχολογίας Ασθενών Οικογενειών και Επαγγελματιών Υγείας, Ανώτατο Τεχνολογικό Εκπαιδευτικό Ίδρυμα Ηπείρου. 2 ΚαθηγητήςΚαρδιολογίας, 1η Καρδιολογική Κλινική, Πανεπιστήμιο Αθηνών, Ιατρική Σχολή, Ιπποκράτειο Νοσοκομείο Αθηνών. 4 ΑναπληρωτήςΚαθηγητήςΨυχιατρικής1η Ψυχιατρική Κλινική, Πανεπιστήμιο Αθηνών, Ιατρική Σχολή, Αιγινήτειο Νοσοκομείο Αθηνών 4 Καθηγητής Ψυχιατρικής, 1η Ψυχιατρική Κλινική, Πανεπιστήμιο Αθηνών, Ιατρική Σχολή, Αιγινήτειο Νοσοκομείο Αθηνών 2 Καθηγητής Καρδιολογίας, 1η Καρδιολογική Κλινική, Πανεπιστήμιο Αθηνών, Ιατρική Σχολή, Ιπποκράτειο Νοσοκομείο Αθηνών 1 MD, PhD, Καρδιολόγος, ΣυντονιστήςΔιευθυντής Καρδιολογικό Τμήμα, Ιπποκράτειο Νοσοκομείο Αθηνών. ΠΕΡΙΛΗΨΗ Εισαγωγή: Ασθενείς με χρόνιες παθήσεις σαν την υπέρταση είναι δυνατό να βιώνουν αρκετά αρνητικά συναισθήματα, τα οποία αυξάνουν τον κίνδυνο για φτωχή ποιότητα ζωής καθώς και την ανάπτυξη άγχους και καταθλιπτικής συμπτωματολογίας.παρόλα αυτά λίγα μας είναι γνωστά για την υπέρταση συνοδευόμενη με δυσλιπιδαιμία. Σκοπός:Σκοπός της παρούσας μελέτης είναι η διερεύνηση των πιθανών διαφορών μεταξύ των υπερτασικών ασθενών με ή χωρίς δυσλιπιδαιμία αναφορικά με την ποιότητα ζωής και την ψυχική υγεία. Μέθοδος:Εκατόν ενενήντα επτά ασθενείς με ιδιοπαθή υπέρταση συμμετείχαν στην παρούσα μελέτη και ταξινομήθηκαν σε δύο ομάδες δυσλιπιδαιμικοί και μη δυσλιπιδαιμικοί με βάση τα επίπεδα της αρτηριακής πίεσης και της χοληστερίνης μετά από ιατρική εξέταση. Οι ασθενέις συμπλήρωσαν μαζί με ένα ερωτηματολόγιο δημογραφικών και κλινικών παραμέτρων το ερωτηματολόγιο Επισκόπησης τη Υγείας SF-36, την Kλίμακα Ψυχοπαθολογίας SCL-90-R, και την Κλίμακα μέτρησης άγχους για την καρδιακή λειτουργίαcaq. Αποτελέσματα:Χαμηλότερα επίπεδα σωματικής λειτουργικότητας (p=.001), σωματικού ρόλου (p=.046), ζωτικότητας (p=.000), σωματικού πόνου (p=.004), γενικής υγείας (p=.000) και συνοπτικού δείκτη σωματικής υγείας (p=.000) διαπιστώθηκαν μεταξύ υπερτασικών ασθενών με δυσλιπιδαιμία και υπερτασικών ασθενών χωρίς δυσλιπιδαιμία. Επίσης, παρατηρήθηκαν στατιστικά σημαντικές διαφορές ανάμεσα στις δύο ομάδες όσον αφορά όλες τις διαστάσεις της ψυχοπαθολογίας με εξαίρεση την επιθετικότητα (p=.097) και το φοβικό άγχος (p=.472). Εκτός από την διάστασης της αποφυγής των δραστηριοτήτων που συνδέονται με την καρδιακή λειτουργία (p=.018), δεν διαπιστώθηκαν διαφορές σε σχέση με το άγχος για την καρδιακή λειτουργία. Το μοντέλο της λογαριθμικής παλινδρόμησης ανέδειξε ότι εν γένει, οι δυσλιπιδαιμικοί υπερτασικού ασθενείς έχουν αυξημένο κίνδυνο για επιβαρυμένη ποιότητα ζωής και ψυχική υγεία. Συμπεράσματα: Τα αποτελέσματα υποστηρίζουν μια στατιστικά σημαντική διασύνδεση μεταξύ δυσλιπιδαιμίας και ποιότητας ζωής, καθώς και με την ψυχοπαθολογία στο ευρύτερο πλαίσιο της ιδιοπαθούς υπέρτασης. Είναι πρόδηλη η ανάγκη στοχευμένων θεραπευτικών παρεμβάσεων. Λέξεις κλειδιά:ιδιοπαθής υπέρταση ποιότητα ζωής ψυχοπαθολογία δυσλιπιδαιμία άγχος για την καρδιακή λειτουργία. INTRODUCTION Essential hypertension is a well-established major risk factor contributing significantly to morbidity by causing stroke, as well as cardiovascular and kidney disease (He et al. 2005). It is estimated that at least 30% of overall mortality worldwide is somehow associated with hypertensive disease. The prevalence of hypertension is already elevated and is expected to rise further in the forthcoming years (Kearney et al. 2004), magnifying proportionally the burden in health systems (Mancia et al. 2013; WHO 2012). Several studies have highlighted the significant impact on the quality of life of patients with hypertension (Barger et al. 2006; Gil et al. 2001). Both disease s complications and medication adverse reactions are considered as the factors responsible to Cor. Author: Gouva M. Tei of Epirus gouva@ioa.teiep.gr 129

3 this effect (Reibis et al. 2012; Krijnen et al. 2005). Hypertensive patients tend to demonstrate declined performance in various dimensions of HRQOL as in general well-being, functional capacity and symptoms of psychological distress (Trevisol et al. 2012; Khaw et al. 2011; Ayalon et al. 2006; Erikson et al. 2001). Thus, evidence support that deteriorated levels of healthrelated quality of life (HRQOL) implicate the cardiovascular outcome in this group of patients (Bardage&Isacson 2001). There is also a great consideration regarding the role of psychological factors in the cardiovascular spectrum (Frasure-Smith et al. 1993; Rosengren et al 2004). As in other chronic medical conditions, hypertensives experience many profound emotions which attenuate their risk for the development of psychological distress in terms of anxiety and depression (Krijnen et al. 2005;Bardage&Isacson 2001). Evidence underline especially the close reciprocal link between hypertension and depression. Depressive mood and anxiety have been associated with increased rates of hypertension whereas clinical diagnosis of depression represents a potential risk factor leading to elevated arterial blood pressure (Patten et al. 2009;Hildrum et al. 2008). Therefore the modern therapeutics should focus not only on symptom management, but also on quality-of-life and mental health improvement (Kokkinos et al. 2009). Nevertheless, dyslipidaemia is also becoming a common medical condition with increasing incidence. As many as half of the adult population in the USA have total cholesterol levels 200 mg/dl, while 2 out of 3 patients with cardiovascular disease (CVD) in Europe have total cholesterol levels 190 mg/dl(ford et al. 2003).In this point of view,the evaluation of both HRQL and psychopathology are provided to be intriguing tasks in hypertensives patients with dyslipidaemia, as these conditions often clash together increasing the total cardiovascular risk and moreover implicating negatively the physical, social and mental domains that determine the patients overall well-being and status (Perk et al. 2012; Catapano et al. 2011).As a result, a therapeutic strategy focusing in improvement of quality of life, could also offer substantial improvement in the management of patients suffering from hypertension anddyslipidaemia. However less attention to the combination of these factors has been devoted so far. Therefore the aim of the present study was to measure HRQL and psychopathology in patients suffering from hypertension with and without dyslipidaemia, as well as to compare them in order to explore possible differences in their symptomatology. METHODS Subjects and procedures We prospectively included 197 newly diagnosed patients with essential hypertension. The patients were recruited from an outpatient hypertension clinic at Athens Hippokration University Hospital. Further inclusion criteria were: age between 18 and 80 years. Patients had not to be under optimized medical therapy for hypertension before entering the study. All patients underwent a detailed clinical work up including a careful medical history further asking for mental disorders, and additional laboratory testing including blood and urine samples in order to evaluate the presence of dyslipidaemia and identify other accompanying cardiovascular risk factors and primitive implications of hypertension. Cardiac and carotid ultrasounds were implemented in all participants. Diagnosis of hypertension was established combining office and 24-hour ambulatory blood pressure measurements according to 2007 ESC/ESH guidelines. Dyslipidaemia was defined in terms of total cholesterol (TL) >190 mg/dl (5.0 mmol/l) and/or low density lipoprotein (LDL) cholesterol >115 mg/dl (3.0 mmol/l), and/or high density lipoprotein (HDL) cholesterol <40 mg/dl (1.0 mmol/l) and/or high fasting triglycerides >150 (1.7 mmol/l) at first examination ((Perk et al. 2012; Catapano et al. 2011). In a next step, those 197 patients were assigned into two groups on the basis of their measurements on dyslipidaemiascores.the first group (dyslipidaemic hypertensive patients) consisted of 121 patients and the second group (non dyslipidaemic hypertensive patients) consisted of 76 patients. Exclusion criteria were as follows: having a psychiatrist disorder or being under relevant treatment for such disorder, secondary hypertension, cognitive impairment, and/or being older than 80 years. All patients gave written informed consent for this study, which was approved by the Ethics Committee of the University of Athens. Psychological measures were scored by an expertise psychologist (E.D). INSTRUMENTS Quality of life Quality of life was measured by using the multipurpose health survey Short Form-36 (SF-36) questionnaire. The SF-36 is a self reported instrument consisting of only 36 questions (Ware et al. 1993). It yields an 8-scale profile of functional health and well-being scores as well as psychometricallybased physical and mental health summary measures and a preference-based health utility index. The score of each dimension is the addition of the item scores of the related dimension further transformed to a score of The higher values representing better perceived health-related quality of life (Mc Horney, 1994). It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. It has been standardized for the Greek population and has been demonstrated to possess satisfactory psychometric features for clinical and non-clinical samples (Pappa et al. 2005). Psychopathology The Symptom Checklist-90 R (SCL-90 R; Derogatis, 1977) was selected to evaluate the convergent validity ofthe Cardiac Anxiety Questionnaire. The SCL-90 R was designed to assessa wide range of psychological factors and symptoms of psychopathology.it consists of 90 items that measure nine primary symptom dimensions (somatisation, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism).it is rated on a 5-point scale (0: Not at all to 4: Extremely), indicating the frequency of experiencing the symptoms described at a specific point in time. The SCL-90 R is constructed to provide Υπεύθ. Αλ/φίας: Γκούβα Μ. ΤΕΙ Ηπείρου gouva@ioa.teiep.gr 130

4 an overview of a patient s symptoms and their intensity by providing three global indices (Derogatis, 1993). It has been standardized for the Greek population and has satisfactory psychometric properties (Donias, Karastergiou, & Manos,1991). Cardiac anxiety Heart focused anxiety (commonly referred to as cardiophobia) was measured using the Greek version of Cardiac Anxiety Questionnaire (CAQ) consists of 10 items (Dragioti et al. 2011). The initial instrument (Eifert et al. 2000) consists of 18 items and 3 subscales: (a) Fear (8 items; e.g, Even if tests come out normal, I will still worry about my heart ); (b) Avoidance (5 items; e.g, I avoid physical exertion ); and (c) Attention (5 items; e.g, I pay attention to my heartbeat ). A 5-point Likert-type scale, with anchors of 0: Never and 4: Always, was used to rate the responses on each item. The CAQ -10 yields a total score and scores for each above subscale. Values close to 4 are representing more anxiety and cardiac functioning concern (i.e. cardiophobia) (Eifert et al. 2000]. It has been standardized for the Greek population and found to possess satisfactory psychometric features. The stability of the questionnaire was verified by a high test-retest reliability over a 3-mo. period (r =.86). The test also has high internal consistency (α=.80) (Dragioti et al. 2011). Demographic characteristics and clinical features Along with the measures described above the participants completed a questionnaire regarding socio-demographic information (e.g., age, gender, marital status). Substantial clinical features werealso recorded and evaluated by a specialist cardiologist doctor (D.T) during a medical interview at hypertensive unit. Data Analyses Distribution frequencies, means and standard deviations were applied for the description of sample s social, demographic and psychological characteristics. The parametric independent student T test was adopted to compare dyslipidaemic hypertensive patients,and non dyslipidaemic hypertensive patients scores on the quantitative variables, since their distribution was symmetric. The criteria for testing normality was: ± 2,00 for the Skewness and ± 5,00 for the Kyrtosis (Skordilis&Stavrou, 2005). Pearson x2 (chi-square) tests was performed for the comparison of categorical variables. As a final steplogistic regression model was performed to investigate whether dimensions of quality of life, psychopathology and cardiac anxiety were independently associated with dyslipidaemic hypertensive patients, regardless of other possible covariate effects. RESULTS Demographic characteristics of the sample Of the 1307 patients approached during a period of six months, 314 were eligible for inclusion and invited to participate in the study. One hundred and nineteenseven ( %; mean age) completed and returned the questionnaires. The rest of them did not complete fully the instruments or did not provide the consent to participate in the study. Therefore the final sample was consisted of 197 with a mean age of 53 years (SD = 12) at baseline. One hundred -eight (55.1%) patients were females and the rest eighty-nine (44.9%) males. The vast majority of the participants were married (71.1%). The duration of essential hypertension was 27.5 months (SD = 40). Ninety-forty of the (47.7%) participants suffered from essential grade I hypertension; 68 (34.5%) were grade II; 16 (8.1%) were categorized as grade III, while only 10 (5.1%) patients were recorded as high normal (normotensives). Fullness mean standard deviations and distribution frequencies of demographic characteristics of the sample are represented in Table 1. Complete data were available also for the two groups (dyslipidaemic vs non dyslipidaemichypertensive patients). Age (p=.004), marital status (p=.008) and smoking (p=.012)werediffer significantly between dyslipidaemic hypertensive patients, and non dyslipidaemic hypertensive patients. Comparisons between groups The next step to our analysis was to compare the two groups on the quantitative variables by means of t tests. As shown in Table 2 the dyslipidaemia group reported marginally lower levels of Physical Functioning (p=.001), Role Physical (p=.046), Vitality (p=.000), Bodily Pain (p=.004), General Health (p=.000) and Physical Component Summary (p=.000) as measured by Short Form-36 (SF-36) questionnaire. Significant differences between groups were also observed on all dimensions of psychopathology as measured by SCL-90-R with exception to Hostility (p=.097), and Phobic Anxiety (p=.472). The groups were not significantly different on the dimensions of cardiac anxiety, except the Avoidance scale (p=.017). Regression models for dyslipidaemic hypertensive patients To justify further investigation, models of logistic regression, examining the associations among dyslipidaemia, quality of life, psychopathology and family environment, was performed. As shown in table 3, after controlling for socio-demographic and clinical variables, dyslipidaemic hypertensive patients had a higher risk of Role -Physical (OR=1.07, 95% CI= ), Vitality (OR=.94, 95% CI= ), Physical Component Summary (OR=1.01, 95% CI= ), Somatization (OR=1.60, 95% CI= ),Interpersonal Sensitivity (OR=1.37, 95% CI= ), Anxiety (OR=.72, 95% CI= ), Paranoid Ideation (OR=.72, 95% CI= ) and Avoidance (OR=8.71, 95% CI= ). DISCUSSION We explored the differences in terms of dyslipidaemia among hypertensive patients and we showed that there is a significant association between dyslipidaemia and quality of life as well as mental symptomatology in the context of hypertension. Specifically, we found significantly lower levels in dimensions of quality of life and higher levels almost in all dimensions of psychopathology when hypertension is accompanied by dyslipidaemia compared to patients without dyslipidaemia. Large effect of avoidance of activities believed to reproduce cardiac symptoms in dyslipidaemic hypertensive patients was further observed. Cor. Author: Gouva M. Tei of Epirus gouva@ioa.teiep.gr 131

5 Several studies have outlined the impact of uncontrolled hypertension on health-related quality of life, expressed as deteriorated functional capacity, affected vitality and impaired mental health. There is less evidence to support the negative effect of high levels of blood cholesterol with dimensions of quality of life, especially in the setting of essential hypertension (Katsi et al. 2010). In our study, hypertensive patients with coexisting dyslipidaemia reported marginally lower levels in different aspects of HRQoL as physical functioning, physical role, vitality, bodily pain, and general health, whereas we didn t find significant differences in terms of mental health, social functioning and emotional role. This could imply that dyslipidaemia are prone to affect specific dimensions related with more biological factors. It is possible that patients with combined morbidity with hypertension and dyslipidaemia, as they represent a group in higher risk, are characterized with more extended cardiovascular complications (Catapano et al. 2011). However, it seems to exist something like a paradox phenomenon in our results. Albeit the association between the dyslipidaemia and quality of life is limited to the physical components, when we compared the psychopathology between the two groups, statistical significant differences were found. More analytically, we observed higher levels of somatization, obsessivecompulsive, interpersonal sensitivity, depression, anxiety, paranoid ideation and psychoticism. An explanation to this paradox could be that the chronic burden of the disease create an emotional response accompanied by negative thoughts, self-criticism and psychological distress. This is consistent with published evidence (Spruill et al. 2013; Mena-Martin et al. 2003). In order to further investigate this association we performed logistic regression analysis. We found that only physical role, vitality and physical component summary remain significant after adjustments. Especially lowering levels of blood cholesterol tend to raise vitality and reduce levels of anxiety and paranoid ideation. On the other hand, higher levels of dyslipidaemia produce higher levels of somatization and interpersonal sensitivity. A remarkable finding is that dyslipidaemia is strongly associated with avoidance behavior. Specifically hypertensives with high levels of cholesterol demonstrate 8-fold higher rates of avoidance compared with normolipidaemichypertensive patients. This is in accordance with the work of Lalonde et al, where diagnosis of dyslipidaemia in asymptomatic patients is accompanied with reduction in HRQoL. Presumably this phenomenon could be produced because they adopt the perception of illness (Lalonde et al. 2001). 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7 Tables Table 1 Demographic characteristics and clinical parameters of the two groups and the whole sample Variables Dyslipidaemic hypertensive patients Non- Dyslipidaemic hypertensive patients (n=76) Total (n=197) Dyslipidaemicvs. Non- Dyslipidaemic (n=121) Mean age in years(±sd) 54.8± ± ±12 p=.004 Gender p=.062 Men 48 (39.7%) 40 (53.3%) 88 (44.6%) Women 73 (60.3%) 36 (46.7%) 109 (55.4%) Marital Status p=.008 Single 24 (19.8%) 24 (32.0%) 48 (24.4%) Married 88 (72.7%) 52 (68.0%) 140 (71.1%) Divorced 8 (6.6%) 0 (0.0%) 8 (4.1%) Widowed 1 (0.8%) 0 (0.0%) 1 (.5%) COPD p=.184 Yes 6 (5.0%) 1(1.3%) 7 (3.6%) No 115 (95.0%) 75 (98.7%) 190 (96.4%) Smoking p=.012 Yes 64 (52.9%) 25 (33.3%) 89 (45.2%) No 57 (47.1%) 51 (66.7%) 108 (54.8%) Impaired glucose tolerance p=.643 Yes 15 (12.4%) 7 (9.3%) 22 (11.2%) No 106 (87.6%) 69 (90.7%) 175 (88.8%) Duration in mo. (mean ± SD) 29.2± ± ±40 p=.532 Dipping Status (n=189) p=.430 Dippers 84 (69.4%) 42 (56.0%) 126 (64%) No Dippers 31 (25.6%) 20 (26.7%) 51 (29.9%) Reverse Dippers 6 (5.0%) 6 (8.0%) 12 (6.1%) LV Hypertrophy (n=189) p=.630 Yes 49 (40.5%) 23 (30.7%) 72 (36.5%) No 72 (59.5%) 45 (60.5%) 117(59.4%) Renal Failure (n=189) p=.969 Yes 6 (5.0%) 3 (1.9%) 9 (4.6%) No 115 (95.0%) 65 (86.7%) 180 (92.9%) Stroke (n=189) p=.891 Yes 4(3.3%) 2 (2.7%) 6 (3.0%) No 117 (96.7%) 66 (88.0%) 183 (92.9%) Intima Media Thickness p=.414 (n=188) Yes 41 (33.9%) 17 (22.7%) 58 (29.4%) No 80 (66.1%) 50 (66.7%) 130 (66.0%) COPD= Chronic Obstructive Pulmonary Disease 134

8 Table 2 Means and standard deviations for psychometric variables Variables Groups N Mean SD Dyslipidaemic vs. Non- Dyslipidaemic PhysicalFunctioning (PF) Dyslipidaemic p=.001 Non- Dyslipidaemic Role -Physical (RP) Dyslipidaemic p=.046 Non- Dyslipidaemic Role-Emotional (RE) Dyslipidaemic p=.973 Non- Dyslipidaemic Vitality (VT) Dyslipidaemic p=.000 Non- Dyslipidaemic Mental Health (MH) Dyslipidaemic p=.473 Non- Dyslipidaemic Social Functioning (SF) Dyslipidaemic p=.051 Non- Dyslipidaemic BodilyPain (BP) Dyslipidaemic p=.004 Non- Dyslipidaemic General Health (GH) Dyslipidaemic p=.000 Non- Dyslipidaemic PhysicalComponentSumm ary (PCS) Dyslipidaemic p=.000 Non- Dyslipidaemic MentalComponentSumm Dyslipidaemic p=.084 ary (MCS) Non- Dyslipidaemic Somatization Dyslipidaemic p=.000 Non- Dyslipidaemic Obsessive-compulsive Dyslipidaemic p=.000 Non- Dyslipidaemic Interpersonalsensitivity Dyslipidaemic p=.001 Non- Dyslipidaemic Depression Dyslipidaemic p=.000 Non- Dyslipidaemic Anxiety Dyslipidaemic p=.004 Non- Dyslipidaemic Hostility Dyslipidaemic p=.097 Non- Dyslipidaemic Phobicanxiety Dyslipidaemic p=.472 Non- Dyslipidaemic Paranoidideation Dyslipidaemic p=.025 Non- Dyslipidaemic Psychoticism Dyslipidaemic p=.010 Non- Dyslipidaemic Fear Dyslipidaemic p=.059 Non- Dyslipidaemic Avoidance Dyslipidaemic p=.017 Non- Dyslipidaemic Heart Focused Attention Dyslipidaemic p=.196 Non- Dyslipidaemic Total CAQ Dyslipidaemic p=.848 Non- Dyslipidaemic CAQ= Cardiac Anxiety Questionnaire 135

9 Table 3Logistic Regression analysis of demographic and psychometric variables Variables Wald P value Odds ratio (95% Confidence Interval) Age.016 p> ( ) Marital status.120 p> ( ) Smoking.063 p> ( ) Physical Functioning.003 p> ( ) (PF) Role -Physical (RP) p < ( ) Vitality (VT) p < ( ) BodilyPain (BP).215 p> ( ) General Health (GH).263 p> ( ) PhysicalComponentSum mary (PCS) p < ( ) Somatization p < ( ) Obsessive-compulsive.448 p> ( ) Interpersonalsensitivity p < ( ) Depression.114 p> ( ) Anxiety p < ( ) Paranoidideation p < ( ) Psychoticism.003 p> ( ) Avoidance p < ( ) Methods=Enter 136