1 in 8 heart patients suffer PTSD

Any life-threatening event can leave a person with symptoms of PTSD. Now a new study finds not only that a heart attack can lead to PTSD but PTSD can double a person's risk of future cardiac events and death. Read on...

One in eight people who suffer a heart attack or other acute coronary event experience clinically significant symptoms of post-traumatic stress disorder (PTSD), according to a meta-analysis of 24 studies led by Columbia University Medical Center researchers. The study also shows that heart patients who suffer PTSD face twice the risk of having another cardiac event or of dying within one to three years, compared with those without PTSD. The findings were published today in the online edition of PLoS ONE: http://dx.plos.org/10.1371/journal.pone.0038915.

"While most people think of PTSD as a disorder of combat veterans and sexual assault survivors, it is also quite common among patients who have had a severe coronary event," said lead author Donald Edmondson, PhD, assistant professor of behavioral medicine at CUMC. "Not only are such events life-threatening, but their psychological impact can be devastating and long lasting."

PTSD is an anxiety disorder initiated by exposure to a traumatic event such as combat, disaster, or sexual assault. Common symptoms include nightmares, avoidance of reminders of the event, and elevated heart rate and blood pressure.

Each year, about 1.4 million people in the United States experience an acute coronary syndrome (ACS), a term used to describe any condition brought about by sudden reduced blood flow to the heart. Numerous small studies have suggested that ACS-induced PTSD is common and can have serious health consequences, but its prevalence is not known.

To get a better idea of the scope of the problem, Dr. Edmondson and his colleagues performed the first combined review, or meta-analysis, of clinical studies of ACS-induced PTSD. The 24 studies in the meta-analysis included a total of 2,383 ACS patients from around the globe.

The study found that overall 12 percent, or one in eight, of the patients developed clinically significant PTSD symptoms, with four percent meeting full diagnostic criteria for the disorder.

"Given that some 1.4 million ACS patients are discharged from U.S. hospitals each year, our results suggest that 168,000 patients will develop clinically significant PTSD symptoms. That is quite substantial. However, there is abundant evidence that psychological disorders in heart patients are underrecognized and undertreated. In fact, underdiagnosis may be even more pronounced in cardiac practices than in other types of medical practices," said Dr. Edmondson.

"This is a serious problem for individual patients, as well as for the healthcare system as a whole," he said. "PTSD appears to double a heart patient's risk for a second cardiac event and for death, which adds hundreds of millions of dollars to annual health expenditures."

"Fortunately, there are good treatments for people with PTSD," Dr. Edmondson said. "But first, physicians and patients have to be aware that this is a problem. Family members can also help. We know that social support is a good protective factor against PTSD due to any type of traumatic event."

"The next step is further research to assess whether treatment can reduce ACS-induced PTSD symptoms and reduce the associated risk for ACS recurrence and mortality," said Dr. Edmondson.

Traumatic Stress Linked to Heightened Inflammation; Possible Link to Heart Disease

Greater lifetime exposure to the stress of traumatic events was linked to higher levels of inflammation in a study of almost 1,000 patients with cardiovascular disease led by researchers at the San Francisco VA Medical Center and the University of California, San Francisco.

In the first study to examine the relationship between cumulative traumatic stress exposure and inflammation, the scientists found that the more traumatic stress a patient was exposed to over the course of a lifetime, the greater the chances the patient would have elevated levels of inflammatory markers in his or her bloodstream.

“This may be significant for people with cardiovascular disease, because we know that heart disease patients with higher levels of inflammation tend to have worse outcomes,” said lead author Aoife O’Donovan, a Society in Science: Branco Weiss Fellow in psychiatry at SFVAMC and UCSF.

The study was published electronically in February in Brain, Behavior and Immunity.

The authors looked at exposures to 18 different types of traumatic events, all of which involved either experiencing or witnessing a direct a threat to life or physical integrity, in 979 patients age 45 to 90 with stable heart disease. They then measured a number of clinical markers of inflammation that circulate in the bloodstream, and found a direct correlation between degree of lifetime stress exposure and levels of inflammation.

Five years later, they measured the surviving patients’ inflammation markers again, and found that the patients who had originally reported the highest levels of trauma at the beginning of the study still had the highest levels of inflammation.

“Even though we lost some study participants because they died, we still observed the same relationship in those who remained,” O’Donovan said. “This suggests that it wasn’t just the people who were the most sick at the outset who were driving this effect.”

Senior investigator Dr. Beth Cohen, a physician at SFVAMC, emphasized that the effect remained even after the researchers adjusted for psychiatric diagnoses such as post-traumatic stress disorder (PTSD), anxiety and depression.

“Not everyone who is exposed to trauma develops PTSD,” said Cohen, who also is an assistant professor of medicine at UCSF. “This study emphasizes that traumatic stress can have a long-term negative impact on your health even if you don’t go on to develop PTSD. It also tells us that, as clinicians, we need to think about not just which diagnostic box someone might fit into, but what their lifetime trauma exposure has been.”

Although the study did not probe the potential causes for the link between lifetime stress and inflammation, O’Donovan offered one possible explanation.

“We know that in the aftermath of traumatic stress, people become more sensitive to threats,” she said. “This is actually pro-survival, because if you’re in a dangerous environment, that alertness can help you avoid future harm.”

However, she explained, people with heightened threat sensitivity may also show increased inflammatory responses. “What we think is happening is that people with a history of multiple traumatic stress exposures have increased inflammatory response more often and for longer periods, and so inflammation becomes chronically high,” she said.

Cohen noted that “this is a study of older people, and the cumulative effects that decades of traumatic experiences have on their bodies. If we could intervene with young people,” she said, “using techniques that we know help fight stress, such as exercise, yoga and other integrative health techniques, it would be interesting to know if we might be able to prevent some of this.”

The study subjects were all participants in the Heart and Soul Study, an ongoing investigation into the link between psychological factors and the risk of heart events and mortality in patients with stable heart disease. The Heart and Soul study is directed by Dr. Mary Whooley, a physician at SFVAMC and a professor of medicine at UCSF.

Co-authors of the study are Dr. Thomas Neylan of SFVAMC and UCSF and Thomas Metzler, M.A., of SFVAMC.

The study was supported by funds from the National Institutes of Health, the U.S. Department of Defense, the Irene Perstein Foundation, the Department of Veterans Affairs and a Society in Science: Branco Weiss Fellowship. Some of the funds were administered by the Northern California Institute for Research and Education.