Type D Personality and Anatomical Complexity as Predictors of Long-Term Mortality in Coronary Artery Disease: Beyond the Clinical Paradigm and the "Anxiety Paradox"

Background: Traditional cardiovascular risk models often overlook "residual risk" driven by psychopathological factors. This study investigates the independent and in-cremental predictive value of Type D personality (TDP) and specific symptomatic di-mensions on long-term all-cause mortality in patients with coronary artery disease (CAD). Methods: We prospectively evaluated 221 patients with confirmed CAD. An-atomical complexity was quantified via the SYNTAX Score (SS). Psychological profil-ing utilized the DS14 scale for TDP and the SCL-90 for granular symptoms (depression, anxiety, and hostility). Mortality was analyzed over a mean follow-up of 1,026 days using multivariate Cox proportional hazards models. Results: TDP prevalence was 33.0% and significantly correlated with higher anatomical complexity (SS: 26.21 vs. 15.49; p < 0.001). In the integrated psychological model, Anxiety emerged as a signifi-cant independent predictor of survival (HR = 0.941; p = 0.049). This suggests an "Anxi-ety Paradox," where heightened vigilance may improve outcomes. The psychological model demonstrated superior predictive accuracy (C-index = 0.624) compared to the clinical model (C-index = 0.527). Significant correlations were confirmed between SS and psychological distress (e.g., depression: r = 0.493). Conclusions: TDP and granular psychological symptoms are robust, independent determinants of mortality that transcend anatomical severity. TDP acts as a marker of biological vulnerability and accelerated vascular aging, while manageable anxiety may enhance treatment adher-ence. Integrating systematic psychological screening into routine CAD care is essential for refined risk stratification and improved long-term survival.