The distressed (Type D) personality

Schwerpunkt Herzschr Elektrophys 2011 DOI 10.1007/s00399-011-0139-9 © Springer-Verlag 2011

S.S. Pedersen1, 2 · A.A. Schiffer3 1 CoRPS – Center of Research on Psychology in Somatic diseases, Department of Medical Psychology, Tilburg University, LE Tilburg 2 Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam 3 Department of Medical Psychology, TweeSteden Hospital, Tilburg

The distressed (Type D) personality A risk marker for poor health outcomes in ICD patients

Implantable cardioverter–defibrillator (ICD) treatment is generally well accepted, but 25–33% of patients experience psychological difficulties and report poor quality of life (QoL) [15, 22]. In turn, psychological morbidity and poor QoL in ICD patients may influence clinical events, including mortality [25]. As such, a vicious cycle may ensue with ICD shocks on its own or in combination with heart disease leading to distress, and the manifestation of such distress enhancing the risk of clinical events ([2], . Fig. 1). Identification of this subset of patients at risk is important in order to enhance secondary prevention in these patients.

derlying heart disease (e.g., symptomatic heart failure) [6, 26] and the psychological profile of the patient, including catastrophic cognitions and concerns about the ICD giving a shock (not the shock itself) [9, 19], optimism [23], and the patient’s personality [10, 19, 28], may be equally important contributors as shocks to poor patient-reported outcomes and morbidity and mortality. Hence, in order to capture all patients at risk of emotional distress and poor QoL, it is worthwhile to focus on other factors in addition to shocks. Irrespectively, this does not negate that an ICD shock to individual patients

Structural heart disease

How does personality fit in? One could potentially rely on the occurrence of ICD shock only to identify the subset of patients at risk of clinical events, such as tachyarrhythmias and mortality, but the underlying assumption of such a choice would be that only shocked patients experience distress. As indicated in a recent viewpoint on the influence of ICD shock on patient-reported outcomes, such as QoL and anxiety and depression, the evidence on the role of shock as the primary culprit of poor patient-reported outcomes is inconsistent [18]. Moreover, studies examining the effect of ICD shocks on these outcomes show that un-

comprises a critical event that should be taken seriously and be dealt with professionally [2, 24]. In the general cardiovascular literature and also in the arrhythmia literature, there has been a tendency to avoid the inclusion of personality factors, since the publication of conflicting results with respect to the Type A Behavior Pattern (TABP). However, given that personality refers to the organization of traits, which reflect consistencies in affect and behavior of persons over time, personality factors are less prone to be influenced by acute events, such as mood states (e.g., anxiety

Autonomic imbalance HR ↑ HRV ↓ Inflammation ↑

Distress (Anxiety / Depression)

Fig. 1 7 Supposed vicious cycle of shocks and distress [2] (with permission from Oxford University Press). HR heart rate, HRV heart rate variability

Tachyarrhythmia / shock

Increased perception, dysfunctional appraisal, maladaptive coping Personality Pre-existing distress Social support

Herzschrittmachertherapie + Elektrophysiologie 2011

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Schwerpunkt Tab. 1 The German Type D Scale (DS14)a: Nachstehend finden Sie einige Aussagen, die Menschen häufig verwenden, um sich selbst zu beschreiben. Bitte lesen Sie jede Aussage und umkringeln Sie daneben die für Sie passende Antwort! Es gibt keine richtigen oder falschen Antworten: Nur Ihr eigener Eindruck zählt!

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Es fällt mir leicht, Kontakt mit anderen Menschen zu knüpfen Ich rege mich oft über unwichtige Dinge auf Ich unterhalte mich oft mit Fremden Ich fühle mich oft unglücklich Ich bin oft gereizt Ich fühle mich oft im Umgang mit anderen gehemmt Ich sehe die Dinge pessimistisch Es fällt mir schwer, mit anderen ein Gespräch zu beginnen Ich bin oft schlechter Laune Ich bin vom Wesen her verschlossen Ich neige dazu, andere Leute auf Abstand zu halten Ich mache mir oft Sorgen Ich bin oft schlecht drauf Ich weiß nicht, worüber ich mit anderen reden soll

0 = Trifft überhaupt nicht zu 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 = Trifft eher nicht zu 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 = Unentschieden 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 = Trifft eher zu 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 = Trifft voll und ganz zu 4 4 4 4 4 4 4 4 4 4 4 4 4 4

aReprinted with permission from Herrmann-Lingen, Grande & Denollet, J. Denollet, and the American Psychosomatic SocietyReproduction of this questionnaire or any por-

tion thereof by any process without written permission is prohibited.

and depression). Thus, due to the inherent characteristics of personality factors, they are likely to be trustworthy predictors of individual differences in not only psychological distress and QoL but also health outcomes, and may help to identify subsets of ICD patients at risk for these outcomes.

The epidemiology of Type D personality The distressed (Type D) personality construct was originally developed in the 1990s in Belgian patients with coronary artery disease (CAD) undergoing cardiac rehabilitation, using a combination of theory, empirical evidence, and clinical observations [5]. This personality type reflects a general propensity to psychological distress, although it has also been shown to be a vulnerability factor for a range of adverse health outcomes, including psychological morbidity, poor QoL and health status, and poor survival in several different populations with cardiovascular disease [5]. A recent meta-analysis showed that Type D personality incurs a 3-fold risk of poor prognosis independent of indicators of disease severity and traditional biomedical risk factors [5]. Type D personality is prevalent in 21– 45% of patients across diagnostic catego-

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ries, including acute coronary syndrome, chronic heart failure, peripheral arterial disease, heart transplantation recipients, and patients treated with ICD therapy [5].

Nature of Type D personality Type D personality is a normal, nonpathological construct that is defined by the two stable traits social inhibition and negative affectivity [3]. Social inhibition is the general tendency to inhibit the expression of emotions and behaviors in interpersonal contact, because of fear of disapproval or rejection by others, while negative affectivity is typified by the general tendency to experience a broad range of negative emotions and to have a negative view of self, others, and the world. Hence, patients with this personality profile are inclined to experience negative emotions, such as irritability and worry, and to inhibit the expression of those feelings in social interactions [3, 5]. Although there is some misconception that the Type D personality construct is nothing more than depression, there are several differences between the two constructs. While Type D is a normal, chronic disposition encompassing not only negative affectivity but also how patients deal with these negative emotions due to the inclusion of the social inhibition component, depression is an epi-


sodic, psychopathologic marker that says nothing about how patients deal with depressive symptomatology [5]. Hence, it is not surprising that most patients with a Type D personality do not have a clinical diagnosis of depression, with the overlap being only around 25% [3, 4]. In addition, despite Type D patients displaying some depressive symptoms, they tend to experience a wider range of negative emotions than patients with depression [3, 4].

Assessment of Type D personality Type D personality can be assessed with the brief 14-item Type D Scale (DS14), with 7 items contributing to the negative affectivity (e.g., ’I often feel unhappy’) and social inhibition (e.g. ’I am a closed kind of person’) subscales, respectively [3]. Respondents rate the 14 items on a 5-point Likert scale ranging from 0 (false) to 4 (true), with a score range from 0–28 for both subscales [3]. Those with a score of ≥10 on both subscales are classified as Type D, with this cut-off being demonstrated as the most optimal using item response theory [3]. The German Type D scale is represented in . Tab. 1. The psychometric properties of the Type D Scale are good, with Cronbach’s α of 0.86 and 0.88, and test–retest reliability of 0.72 and 0.82 for the social inhibition and negative

Abstract · Zusammenfassung affectivity subscales, respectively [3]. The cross-cultural validity of the Type D Scale has been demonstrated in several European and non-European countries, including Germany, Italy, Denmark, and China. The Type D Scale has been shown to be a stable measure during an 18-month period in postmyocardial patients [7] and to be unconfounded by indicators of somatic disease, such as left ventricular dysfunction and New York Heart Association (NYHA) functional class and symptoms of anxiety and depression [7].

Type D personality in arrhythmia research Since 2004, 13 studies on the role of Type D personality in ICD patients have been published. An overview of these studies are presented in . Tab. 2. The studies originate from four different study cohorts: (1) a cross-sectional cohort from the Netherlands [8], (2) a cross-sectional cohort from Denmark [12, 13], (3) a prospective cohort from the Netherlands [23, 28], and (4) the prospective MIDAS cohort (Mood and personality as precipitants of arrhythmia in patients with an Implantable cardioverter Defibrillator: A prospective Study) also from the Netherlands [10, 11, 17, 19, 29, 30]. One of the studies was based on merged data from the two prospective Dutch cohorts [14].

Patient-reported outcomes Type D ICD patients were more likely to be anxious and depressed and to report poor device acceptance compared to nonType D ICD patients, also when adjusting for potential demographic and clinical confounders, including ICD shocks [8, 10, 12, 27]. In the 2004 study [8], personality was shown to have a considerable influence on symptoms of anxiety and depression, with Type D patients without a shock compared to non-Type D patients with a shock having a higher prevalence of both anxiety (61% versus 32%) and depression (57% versus 19%) (.  Fig. 2). Type D patients were also more likely to display symptoms of posttraumatic stress at 3 months after device implantation [30] and to suffer from chronic anxiety [15]. Type D has been shown to cluster togeth-

er with other psychological risk markers, such as poor device acceptance and high levels of ICD concerns, increasing the risk of anxiety and depression compared to the presence of one of the psychological risk markers [11, 13]. There is also evidence to suggest that the personality of patients and their partners may interact to influence levels of psychological distress in patients. In a study of 281 ICD patients and their partners, patients reported more depression if the partner also had a Type D personality [29].

Clinical outcomes To date, two studies have linked Type D personality to adverse clinical outcomes in ICD patients [19, 28]. In a cohort of 391 patients examining the influence of Type D, symptoms of anxiety and depression, and their interaction, in relation to the onset of ventricular arrhythmias, there was no statistically significant main effect for any of the psychological factors [28]. However, patients with a Type D personality in combination with increased levels of anxiety (thus, the anxious Type Ds) were shown to have a higher risk (hazard ratio 1.7) for ventricular arrhythmias, adjusting for potential demographic and clinical confounders ([28], .  Fig. 3). In the other study, in a separate and independent cohort of ICD patients, Type D personality and high levels of pre-implantation ICD concerns predicted mortality, also in adjusted analyses with either psychological risk marker incurring a more than 2-fold risk of premature death [19]. ICD concerns tap into patient concerns about the ICD giving a shock and not whether patients have received an actual shock, and can be evaluated with the brief, standardized, and validated 8-item Patient ICD Concerns (ICDC) questionnaire [9]. If patients had both a Type D personality and experienced high levels of ICD concerns, the risk of premature death increased from 2-fold (the presence of only one of these psychological risk markers) to close to 4-fold (. Fig. 4).

Herzschr Elektrophys 2011 · [jvn]:[afp]–[alp] DOI 10.1007/s00399-011-0139-9 © Springer-Verlag 2011 S.S. Pedersen · A.A. Schiffer

The distressed (Type D) personality. A risk marker for poor health outcomes in ICD patients Abstract The distressed (Type D) personality is an emerging risk marker for poor health outcomes in patients with cardiovascular disease. Patients with this personality disposition are typified by a general propensity to experience psychological distress. The contribution focuses on the impact of Type D personality on psychological distress, quality of life, ventricular tachyarrhythmias, and mortality in implantable cardioverter–defibrillator (ICD) patients and examines the relative influence of this vulnerability factor compared to ICD shocks and markers of disease severity in relation to these outcomes. Keywords Type D personality · Health outcomes ·   Implantable cardioverter–defibrillator ·   Psychological distress

Type D Persönlichkeit. Ein Risikofaktor für schlechtere Gesundheitsergebnisse bei ICD-Patienten Zusammenfassung Eine Typ-D-Persönlichkeit („distressed personality“) ist für Patienten mit Herz- und Kreislauferkrankungen ein Risikofaktor für schlechtere therapeutische Ergebnise. Patienten mit dieser Persönlichkeitsdisposition haben die Neigung, verstärkt auf psychische Belastungen zu reagieren. Der Beitrag untersucht, welche Auswirkungen diese Disposition auf die Merkmale „psychologischer Stress“, „Lebensqualität“, „ventrikulare Arrhythmien“ und „Prognose/Lebenserwartung“ hat. Es wird verglichen, in welcher Relation diese Merkmale zur Schockabgabe und zum Krankheitsverlauf stehen. Schlüsselwörter Typ-D-Persönlichkeit · Gesundheitsergebnisse · ICD · Psychologischer Stress


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Schwerpunkt Tab. 2 Overview of studies on Type D personality in ICD patients Reference

PaParttients ners n n Patient-reported outcomes Pedersen et 182 144 al. (2004) [8]

Country of origin

Study design

FU

Endpoints

Main results

The Netherlands

Crosssectional

–

Anxiety Depression

Pedersen et al. (2007) [10]

154

–

The Netherlands

Prospective

3 months

Quality of life

van den Broek et al. (2008) [27]

308

–

The Netherlands

Prospective

2 months

Anxiety (interviewerrated and selfreport)


566

–

The Netherlands

–

Poor device acceptance


176

–

The Netherlands

Crosssectional Prospective

- Type D personality was an independent associate of anxiety and depression in both patients and partners - Type D patients without shocks had a higher prevalence of anxiety and depression than non-Type D patients with shocks - Type D personality but not ICD indication was associated with poorer quality of life - Type D patients with a primary prophylaxis had the poorest quality of life - Type D personality was an independent predictor of both interviewer-rated and self-reported anxiety - Anxiety scores of patients experiencing a shock during FU increased, while scores of non-shocked patients decreased - Type D personality was an independent predictor of poor device acceptance

6 months

Anxiety Depression


557

–

Denmark

–

Anxiety Depression


284

–

The Netherlands

Crosssectional Prospective

12 months

Chronic anxiety2


196

196

The Netherlands

Prospective

6 months

Anxiety Depression


348

–

The Netherlands

Prospective

10 days, and 3, 6, and 12 months

281

The Netherlands

Prospective

6 months

Course of anxiety (state and trait) and ICD concerns Anxiety Depression

–

The Netherlands

Prospective

3 and 6 months

Posttraumatic stress disorder

–

The Netherlands

Prospective

12 months

Ventricular arrhythmias1

–

The Netherlands

Prospective

1.7±0.5 years

Mortality

van den Broek 281 et al. (2011) [29] Versteeg et al. 300 (2011) [30] Clinical outcomes van den Broek 391 et al. (2009) [28] Pedersen et 371 al. (2010) [19]

- Anxiety but not depression scores were higher in patients with clustering of Type D/high levels of ICD concerns - Anxiety and depression were more prevalent in patients with clustering of Type D/poor device acceptance compared to one or none of these psychological risk markers - Of 284 patients anxious at baseline, 53.9% remained anxious at 12 months - Type D personality [OR: 1.87; 95%CI: 1.09–3.19], diabetes [OR: 2.49; 95%CI: 1.16–5.36], and cardiac resynchronization therapy [OR: 2.03; 95%CI: 1.02–4.05] were independent predictors of chronic anxiety - More anxiety in partners - Partners and patients did not differ on depression - Secondary prophylaxis, ICD shock and partner (Type D) personality predicted partner distress - Type D personality was an independent predictor of the higher trajectories of anxiety (both state and trait) and ICD concerns - Patients with a Type D personality reported more depression, but not anxiety, if the partner also had a Type D personality - Type D personality was an independent predictor of PTSD at 3 months but not 6 months - Increased risk of ventricular arrhythmias in anxious Type D patients [HR: 1.72; 95%CI: 1.03–2.89] independent of demographic and clinical variables - Type D personality [HR: 2.79; 95%CI: 1.25–6.21] and high levels of ICD concerns [HR: 2.38; 95%CI: 1.06–5.34] were independent predictors of mortality - Patients with both psychological risk markers [HR: 3.86; 95%CI: 1.64–9.10] had a higher risk of mortality

FU follow-up, HR hazard ratio, OR odds ratio, PTSD posttraumatic stress disorder, 95%CI 95% confidence interval1 Appropriate therapies; 2 Chronic anxiety = defined as anxiety at the time of ICD implantation and 12-month follow-up.

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70

%

P < .001

72

1.0

P < .001 67

61

57

60

0.9

50 40

32

30 19

20

14

13

10 0 Anxiety Type D -shocks Type D -no shocks

Ventricular arrhythmia (%)

80

0.8

0.7

0.6

Depression Non Type D -shocks Non Type D -no shocks

0.5

Fig. 2 8 Prevalence of anxiety and depression in ICD patients stratified by Type D personality and shocks (no shocks versus ≥1 shock) [8] (with permission from Wolters Kluwer/Lippincott, Williams & Wilkins)

0

100

200

300

400

Number of days to first appropriate therapy Blue line 320 Green line 71

294 60

286 57

277 55

265 49

Fig. 3 8 Kaplan–Meier curve for time to first ventricular arrhythmia in Type D patients with increased anxiety [28] (with permission from the American College of Cardiology Foundation). Other groups (blue line); anxious Type D patients (green line)

Psychological and behavioral interventions

20

8/44

18 16 14 2-year mortality (%)

In order to facilitate psychological adaptation and to preserve QoL, adjunctive behavioral and psychological intervention may be warranted. At this point in time, we do not have sufficient knowledge to conclude whether we should single out shocked or highly distressed patients only for adjunctive behavioral and psychological intervention or offer it to all patients. The disadvantage of only including patients with an ICD shock is that one excludes ICD patients with high levels of distress due to other causes, such as underlying heart disease, with symptomatic heart failure having an equal or larger impact than shocks on distress and QoL [6, 26]. Cognitive behavioral therapy (CBT) has been the mainstay of treatment in studies on psychological interventions in ICD patients. Some studies include ICDspecific education, sometimes also incorporating the suggestion to patients to develop a shock plan with the rationale that ICD-specific education may serve as a preventive measure against the develop-

HR: 3.65 [95% CI: 1.57-8.45; p = .003]

Fig. 4 7 Mortality stratified by the clustering of psychological risk markers (i.e., Type D personality and high levels of ICD concerns) [18] (with permission from Oxford University Press). HR hazards ratio

12 10 8 17/327

6 4 2 0 Clustering of both psychological risk markers

ment of distress and, thus, may be particularly important in first-implant patients at the time of implantation [16, 21]. The question is whether intervention that is successful in the general ICD patient may also show benefits in ICD patients with a

One psychological risk marker or none

Type D personality. It is a common misconception that intervening in the context of Type D is meaningless, because personality traits are stable over time. In fact, behavioral and psychological interventions might show even greater benefits in pa-


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Schwerpunkt tients with a Type D personality, because this subset of patients reports the highest levels of distress and poorer QoL compared to patients without this psychological profile. Thus, there is more room for improvement and gains in these patients. To date, no intervention trials are available in cardiac patients that have specifically targeted the Type D personality profile. However, results from three cardiac rehabilitation studies show that Type D patients benefit from rehabilitation in terms of improved health status, although they still report lower health status than their non-Type D counterparts post rehabilitation. The cardiac rehabilitation program did not have an effect on the personality construct itself. Importantly, however, the interventions in these studies were not designed to specifically target Type D personality nor were patients randomized. Currently, there are three randomized controlled trials in patients with heart disease ongoing which incorporates Type D patients: (1) WEBCARE (WEBbased distress management program for implantable CARdioverter dEfibrillator patients) [16]; (2) STEP-IN-AMI (Short TErm Psychotherapy in Acute Myocardial Infarction) [20]; and (3) SPIRR-CAD (Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease) in depressed patients with CAD [1]. None of these trials specifically target Type D personality either, but patients are randomized and, thus, they are likely to provide us with more insight into what works for Type D patients at a behavioral and psychological level, e.g., which mode of intervention might be most beneficial for this subset of high-risk patients. It is possible that Type D patients may feel more comfortable with a web-based approach due to their high level of social inhibition and, hence, may benefit more from such an approach than from face-to-face psychotherapy. In our opinion, interventions targeted at the Type D personality profile should not be aimed at changing the underlying personality itself, but rather the behavioral underpinnings that place Type D individuals at higher risk for worse health outcomes. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are two forms of therapy that could be

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successfully applied to Type D patients, also those with an ICD. In brief, CBT— primarily based on Beck’s Cognitive Model—focuses on the negative thoughts patients may have about themselves, others (the world), and the future, which lead to (more intense) negative emotions. The goal of CBT is to teach the individual to recognize negative and unrealistic thoughts and to use several different techniques to restructure them to more adaptive and realistic cognitions. CBT has proven to be effective in reducing emotional distress and improving social support compared with care as usual in patients with CAD, but there is no study on its effectiveness in cardiac patients with a Type D personality. However, given that Type D patients tend to have a gloomy view of self, the world and others (cognitive triad), and to inhibit these negative thoughts and feelings, because they think that will be negatively evaluated by others, CBT may be effective in targeting exactly these unrealistic thoughts. IPT is a manualized, present-oriented, and time-limited form of psychotherapy, originally developed for the treatment of depression in the 1970s, but nowadays used to treat various forms of psychological distress. IPT focuses on interpersonal distress, social factors, and interpersonal problems and is based on the idea that psychosocial stressors affect mood and that mood itself has negative effects on interpersonal functioning. We think that IPT might be effective in Type D patients, because these patients are very much in need of supportive and stimulating interpersonal contacts due to difficulties with establishing valuable interpersonal relationships. They feel a need to share their negative emotions and thoughts with others, but refrain from doing so, because they fear disapproval or rejection. Furthermore, the ICD itself and the patient’s underlying heart disease may have adverse effects on interpersonal contacts due to changes in social roles because of physical limitations. In particular, for Type D patients this may be very difficult to manage. Taken together, there are multiple options available for Type D patients with an ICD to prevent the development of chronic distress and to preserve QoL. A multi-


factorial rather than a monofactorial approach, comprised of a combination of CBT/IPT, stress management, psycho-education about the ICD, and physical exercise as part of a cardiac rehabilitation program, is likely to be the most beneficial approach to Type D patients, although this needs to be confirmed in randomized controlled trials. In addition to emphasizing possible treatment options, the importance of screening for Type D personality, and also for depression and anxiety, in ICD patients has to be stressed. Knowing which ICD patients are at risk for the negative patient-reported and clinical outcomes provides an opportunity to intervene at an early stage in order to prevent worsening of physical and mental health. Generally, we would recommend the presence of a mental health professional as part of the multidisciplinary team that manages ICD patients in order to ensure that a professional trained in mental health issues and knowledgeable of both heart disease and device therapy is easily accessible and can provide the appropriate diagnostics and care. With a mental health professional as part of the team, the implicit message to patients is that seeing a psychologist or other mental health professional is considered as important and as normal as monitoring blood pressure and health failure symptoms, taking medication, and following up on lifestyle advice, thereby hopefully minimizing the stigma associated with seeing such a professional.

Conclusion F The distressed (Type D) personality comprises a vulnerability factor for distress, poor QoL, and morbidity and mortality in ICD patients and their partners. F ICD patients with a Type D personality are also at risk of ventricular tachyarrhythmias and premature death. F To identify these high-risk patients in clinical practice, the DS14 (Type D Scale) can be used, which is also available in the German language. F Knowing which of your ICD patients are at increased risk for negative health outcomes provides a window of opportunity to intervene at an early stage.

F Despite lack of intervention trials in ICD patients specifically targeting Type D personality, it would seem unethical to withhold adjunctive treatment from this subset of patients until results of such trials are available. F Having a mental health professional on the multidisciplinary treatment team ensures that a professional trained in mental health issues and knowledgeable of both heart disease and device therapy is easily accessible and can provide the appropriate diagnostics and care.

Corresponding address S.S. Pedersen CoRPS – Center of Research on Psychology in Somatic diseases, Department of Medical   Psychology, Tilburg University 90153 Warandelaan 2, 5000 LE Tilburg The Netherlands [email protected] Acknowledgments. This research was in part supported with a VENI (451-05-001) from the Netherlands Organization for Scientific Research (NWO) and a VIDI grant (91710393) from the Netherlands Organization for Health Research and Development (ZonMw), The Hague, The Netherlands, to Dr. Susanne S. Pedersen. Conflict of interest. Prof. Dr. S.S. Pedersen has received speaker fees from Medtronic and St. Jude Medical, and is currently serving as a consultant for St. Jude Medical, Cameron Health, and Sanofi-Aventis. Dr. A.A. Schiffer has in the past received an independent research grant from Medtronic and St. Jude Medical.

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