Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review

A framework for automated and objective modification of tubular structures: Application to the internal carotid artery

Patient-specific medical image-based computational fluid dynamics has been widely used to reveal fundamental insight into mechanisms of cardiovascular disease, for instance, correlating morphology to adverse vascular remodeling. However, segmentation of medical images is laborious, error-prone, and a bottleneck in the development of large databases that are needed to capture the natural variability in morphology. Instead, idealized models, where morphological features are parameterized, have been used to investigate the correlation with flow features, but at the cost of limited understanding of the complexity of cardiovascular flows. To combine the advantages of both approaches, we developed a tool that preserves the patient-specificness inherent in medical images while allowing for parametric alteration of the morphology. In our open-source framework morphMan we convert the segmented surface to a Voronoi diagram, modify the diagram to change the morphological features of interest, and then convert back to a new surface. In this paper, we present algorithms for modifying bifurcation angles, location of branches, cross-sectional area, vessel curvature, shape of bends, and surface roughness. We show qualitative and quantitative validation of the algorithms, performing with an accuracy exceeding 97% in general, and proof-of-concept on combining the tool with computational fluid dynamics. By combining morphMan with appropriate clinical measurements, one could explore the morphological parameter space and resulting hemodynamic response using only a handful of segmented surfaces, effectively minimizing the main bottleneck in image-based computational fluid dynamics.

Analysis of Posttraumatic Stress Disorder, Depression, Anxiety, and Resiliency Within the Unique Population of Spontaneous Coronary Artery Dissection Survivors

Background

Mental health after spontaneous coronary artery dissection (SCAD), a cause of myocardial infarction in young women, remains largely unexplored. We assessed the prevalence and severity of psychiatric symptoms after SCAD.

Methods and Results

Individuals with confirmed SCAD who consented to the Mayo Clinic “Virtual” Multicenter SCAD Registry were sent the Posttraumatic Stress Disorder Diagnostic Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Patient Health Questionnaire‐9, Generalized Anxiety Disorder‐7, Anxiety Sensitivity Index, Connor‐Davidson Resilience Scale, 36‐Item Short‐Form Health Survey, and an SCAD‐specific questionnaire. Among 782 patients contacted, 512 surveys were returned. Most respondents were women (97.5%), with median age at time of SCAD and survey completion of 47 and 52 years, respectively. Eighty‐two percent had at least one trauma, with mild or more posttraumatic stress disorder symptoms in 28%. Symptoms of anxiety and depression were observed in 41% and 32%, respectively. On multivariable analysis, those of younger age at first SCAD and low resiliency scored higher on measures of trauma, anxiety, and depression. Those with higher anxiety sensitivity had more severe anxiety and posttraumatic stress disorder symptoms. Emotional and social quality of life was higher in those with high resiliency scores. Time from SCAD event to survey completion was associated with lower Generalized Anxiety Disorder‐7 score severity.

Conclusions

Survivors of SCAD have significant rates of posttraumatic stress disorder, depression, and anxiety, which are associated with lower quality of life specifically among those with lower resiliency. Given the prevalence and potential impact, screening and treatment for the psychological distress is advised. Behavioral interventions targeted toward resiliency training may be beneficial for this patient population.

From Tear to Fear: Posttraumatic Stress Disorder in Patients With Acute Type A Aortic Dissection

Background

Acute type A aortic dissection presents with abrupt onset of pain that requires emergency surgery. However, minimal research exists on posttraumatic stress disorder (PTSD) in survivors. We aimed to quantify the prevalence and describe characteristics of PTSD in patients following dissection.

Methods and Results

A total of 295 adult survivors of surgical dissection with an email on file were administered a cross‐sectional online survey about their dissection experience; 137 returned questionnaires, and 129 (94%) responded to the 4‐item Primary Care PTSD portion of the survey that was part of a larger lifestyle survey designed to study survivors of aortic dissection and surgery. In addition to the PTSD screening, it inquired about current sexual activity, exercise habits, and employment within the preceding 30 days. At a median of 6.8 years (quartile 1=2.6, quartile 3=8.9 years) after dissection, 23% of patients (30/129) screened positive for PTSD, with 44% (57/129) stating that within the past month they felt constantly on guard or watchful or were easily startled. Of those who screened positive and matched to their electronic medical record (n=27), only 2 (7.4%) had been tested and clinically diagnosed with PTSD. Patients who screened positive for PTSD were more likely to report limited current sexual activity than those who did not (odds ratio, 5.3; 95% CI, 1.9–15 [P=0.0006]).

Conclusions

PTSD is an important mental health consideration in aortic dissection survivors. Physicians should screen these patients for PTSD at follow‐up visits to identify those who test positive and refer them for further testing and treatment, such as trauma‐focused psychotherapy or medication.

Association of Posttraumatic Stress Disorder With Mental Stress-Induced Myocardial Ischemia in Adults After Myocardial Infarction

IMPORTANCE

Posttraumatic stress disorder (PTSD) is prevalent among patients who survived an acute coronary syndrome and is associated with adverse outcomes, but the mechanisms underlying these associations are unclear.

OBJECTIVE

To evaluate the association of PTSD with mental stress-induced myocardial ischemia among individuals who survived a myocardial infarction (MI).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 303 patients aged 18 to 60 years enrolled from a university-affiliated network. Participants had a verified history of MI within 8 months. Data were collected from June 2011 to March 2016, and data analysis was conducted from March to June 2019.

EXPOSURES

A clinical diagnosis of PTSD (lifetime and current) was obtained using the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), and PTSD symptom subscales were assessed with the civilian version of the PTSD Symptom Checklist.

MAIN OUTCOMES AND MEASURES

Patients received technetium 99m-labeled sestamibi myocardial perfusion imaging at rest, with mental stress (ie, a speech task) and conventional stress (ie, exercise or pharmacologic). A summed difference score (ie, the difference between stress and rest scores) was used to assess ischemia under both stress conditions.

RESULTS

Among 303 participants (148 [48.8%] women; 198 [65.3%] African American; mean [SD] age, 51 [7] years), the prevalence of PTSD was 14.5% (44 patients). Patients with PTSD had a higher rate of ischemia with mental stress than those without PTSD (12 of 44 [27.3%] vs 38 of 259 [14.7%]; P = .04) and more than twice the mean number of ischemic segments (1.2 [95% CI, 0.5-1.8] vs 0.5 [95% CI, 0.3-0.7]; P < .001), but there was no difference in conventional stress ischemia (10 of 44 [22.7%] vs 60 of 259 [23.2%]; P = .91). Increasing levels of PTSD symptoms were associated with higher odds of ischemia with mental stress (adjusted odds ratio [OR] per 5-point score increase, 1.18; 95% CI 1.04-1.35; P = .01) but not with conventional stress (adjusted OR per 5-point score increase, 1.05; 95% CI, 0.92-1.21; P = .47). Reexperiencing trauma was the symptom cluster most robustly associated with the presence of ischemia with mental stress (adjusted OR per 5-point score increase, 1.87; 95% CI 1.21-2.91; P = .005), followed by avoidance and numbing (adjusted OR per 5-point score increase, 1.51; 95% CI, 1.07-2.14; P = .02).

CONCLUSIONS AND RELEVANCE

In this study of young and middle-aged individuals with MI, with a large representation of women and patients from racial/ethnic minority groups, PTSD was associated with the development of myocardial ischemia with mental stress. A higher ischemic response to mental stress represents a potential pathway associating PTSD with adverse outcomes after MI.

Explanatory factors of post-traumatic distress and burnout among hospital staff 6 months after Hurricane Irma in Saint-Martin and Saint-Barthelemy

Background

In September 2017, the Hurricane Irma devastated the islands of Saint-Martin and Saint-Barthelemy (French West Indies). This was a particularly distressing time for the local healthcare staff in charge of rescuing the population. The aim of this study was to identify the explanatory factors of post-traumatic distress and burnout in hospital staff.

Methods

An anonymous questionnaire was sent to all 509 hospital workers of Saint-Martin and Saint-Barthelemy. Post-traumatic distress and burnout was assessed using the Post-Traumatic Stress Disorder Checklist (PCL-S) and Copenhagen Burnout Inventory (CBI) scales. Bivariate and multivariate analyses were used to determine the explanatory variables for these two psychological disorders.

Results

Two hundred and sixty-two questionnaires were completed (response rate of 51.7%). The explanatory factors of post-traumatic distress were female gender (OR = 12.93, 95% CI: 2.70–232.10), electricity shortages (OR = 2.92, 95% CI: 1.13–8.19) and home damage (OR = 1.16, 95% CI [1.02–1.33]). In parallel, the explanatory factors of burnout were post-traumatic distress (OR: 10.42, 95% CI: 4.72–25.58), female gender (OR = 2,41, 95% CI: 1.24–5.02) and paramedical staff (OR = 2,53, 95% CI: 1.15–6.21). In the multivariate analysis, only burnout was significantly associated with post-traumatic distress (OR = 9.26, 95% CI: 4.11–23.14).

Conclusions

Six months after Irma, post-traumatic distress among hospital staff was strongly linked to burnout. This study revealed the lack of electricity as a new factor related to post-traumatic distress. It also suggested that psychological intervention should be strengthened.

Cardiac Arrest and Subsequent Hospitalization-Induced Posttraumatic Stress Is Associated With 1-Year Risk of Major Adverse Cardiovascular Events and All-Cause Mortality

OBJECTIVES

To compare 1-year all-cause mortality and major adverse cardiovascular events in cardiac arrest survivors with and without posttraumatic stress disorder symptomatology at hospital discharge.

DESIGN

Prospective, observational cohort.

SETTING

ICUs at a tertiary-care center.

PATIENTS

Adults with return of spontaneous circulation after in-hospital or out-of-hospital cardiac arrest between September 2015 and September 2017. A consecutive sample of survivors with sufficient mental status to self-report cardiac arrest and subsequent hospitalization-induced posttraumatic stress disorder symptoms (cardiac arrest-induced posttraumatic stress symptomatology) at hospital discharge were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The combined primary endpoint was all-cause mortality or major adverse cardiovascular event-hospitalization for nonfatal myocardial infarction, unstable angina, congestive heart failure, emergency coronary revascularization, or urgent implantable cardio-defibrillators/permanent pacemaker placements within 12 months of discharge. An in-person posttraumatic stress disorder symptomatology was assessed at hospital discharge via the Posttraumatic Stress Disorder Checklist-Specific scale; a suggested diagnostic cutoff of 36 for specialized medical settings was adopted. Outcomes for patients meeting (vs not meeting) this cutoff were compared using Cox-hazard regression models. Of 114 included patients, 36 (31.6%) screened positive for cardiac arrest-induced posttraumatic stress symptomatology at discharge (median 21 d post cardiac arrest; interquartile range, 11-36). During the follow-up period (median = 12.4 mo; interquartile range, 10.2-13.5 mo), 10 (8.8%) died and 29 (25.4%) experienced a recurrent major adverse cardiovascular event: rehospitalizations due to myocardial infarction (n = 4; 13.8%), unstable angina (n = 8; 27.6%), congestive heart failure exacerbations (n = 4; 13.8%), emergency revascularizations (n = 5, 17.2%), and urgent implantable cardio-defibrillator/permanent pacemaker placements (n = 8; 27.6%). Cardiac arrest-induced posttraumatic stress symptomatology was associated with all-cause mortality/major adverse cardiovascular event in univariate (hazard ratio, 3.19; 95% CI, 1.7-6.0) and in models adjusted for age, sex, comorbidities, preexisting psychiatric condition, and nonshockable initial rhythm (hazard ratio, 3.1; 95% CI, 1.6-6.0).

CONCLUSIONS

Posttraumatic stress disorder symptomatology is common after cardiac arrest, and cardiac arrest-induced posttraumatic stress symptomatology was associated with significantly higher risk of death and cardiovascular events. Further studies are needed to better understand the underlying mechanisms.

Assessing Voice Hearing in Trauma Spectrum Disorders: A Comparison of Two Measures and a Review of the Literature

Voice hearing (VH) can occur in trauma spectrum disorders (TSD) such as posttraumatic stress disorder (PTSD) and dissociative disorders. However, previous estimates of VH among individuals with TSD vary widely. In this study, we sought to better characterize the rate and phenomenology of VH in a sample of 70 women with TSD related to childhood abuse who were receiving care in a specialized trauma program. We compared the rate of VH within our sample using two different measures: 1) the auditory hallucination (AH) item in the Structured Clinical Interview for DSM-IV-TR (SCID), and 2) the thirteen questions involving VH in the Multidimensional Inventory of Dissociation (MID), a self-report questionnaire that comprehensively assesses pathological dissociation. We found that 45.7% of our sample met threshold for SCID AH, while 91.4% met criteria for MID VH. Receiver operating characteristics (ROC) analyses showed that while SCID AH and MID VH items have greater than chance agreement, the strength of agreement is only moderate, suggesting that SCID and MID VH items measure related but not identical constructs. Thirty-two patients met criteria for both SCID AH and at least one MID VH item ("unequivocal VH"), 32 for at least one MID VH item but not SCID AH ("ambiguous VH"), and 6 met criteria for neither ("unequivocal non-VH"). Relative to the ambiguous VH group, the unequivocal VH group had higher dissociation scores for child voices, and higher mean frequencies for child voices and Schneiderian voices. Our findings suggest that VH in women with TSD related to childhood abuse is common, but that the rate of VH depends on how the question is asked. We review prior studies examining AH and/or VH in TSD, focusing on the measures used to ascertain these experiences, and conclude that our two estimates are consistent with previous studies that used comparable instruments and patient samples. Our results add to growing evidence that VH-an experience typically considered psychotic or psychotic-like-is not equivalent to having a psychotic disorder. Instruments that assess VH apart from psychotic disorders and that capture their multidimensional nature may improve identification of VH, especially among patients with non-psychotic disorders.

Early Exposure to Cardiac Treatment and Distress Among Patients and Their Caregiving Partners

Background: The experience of an acute coronary event (ACE), including early care and evaluation, can be a distressing and traumatic experience for patients and their romantic partners, who also act as caregivers. We hypothesized that, among partners who were present during the ACE, those who were also present during (1) transportation to the hospital and (2) initial medical treatment would experience greater (a) anxiety early post-event and (b) posttraumatic stress symptoms (PSS) related to the event 4 months later. The associations between partner presence with patient anxiety and PSS were also explored.

Methods: Participants were ACE patients and their partners recruited between March 2015 and December 2016 from the Intensive Cardiac Care Unit (ICCU) of the Sheba Medical Center in Israel (N = 143; all patients were males and partners were females). Partners self-reported whether or not they were present during the cardiac event, the hospital drive, and initial care. Patients and partners self-reported anxiety in-hospital and PSS, keyed to the ACE, an average of 4 months later. Data were analyzed using General Estimating Equations (GEE) and Multilevel Modeling.

Results: Neither patient anxiety nor PSS differed according to partner presence during the drive to the hospital. In contrast, partners had higher anxiety when they were not present at all (difference = 3.65, p = 0.019) and when present during the event and during the drive (difference = 2.93, p = 0.029) as compared to when they were present for the event but not for the drive. Partners who were present during the event, but not the drive, had lower PSS than those who were present for both the event and the drive (difference = −4.64, p = 0.026).

Conclusions: Partners who accompany patients on the drive to the hospital may inadvertently put themselves at risk for greater distress following their loved one’s cardiac event. Future research should enroll couples in an acute care context to inform couple-targeted tailored interventions to reduce distress in patients and their caregiving partners.

Anxiety Disorders and Medical Comorbidity: Treatment Implications

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).

Should Doctors Know Their Patients' Attachment Style? A Psychological Perspective and its Impact on Cardiac Surgery Outcomes

Objective

To increase our understanding of the psychological attachment styles in order to develop a preventative strategy that could potentially improve patients’ perioperative outcomes.

Methods

A comprehensive literature search was performed utilizing major electronic databases. The search was done from inception to January 2019. All of the relevant papers have been extracted and critically appraised in this review.

Results

Understanding the psychological aspects of patients is crucial for a satisfactory postoperative outcome. Depression and anxiety have been shown to increase both mortality and morbidity after coronary artery bypass graft surgery, independently of medical factors, although the behavioural and biological mechanisms are poorly understood. Psychosocial assessment is an important part of the pre-transplant evaluation process. The majority of individuals undergoing a transplant have significant psychosocial problems and can either be deferred or denied the transplant until these psychosocial issues are approached and managed. Psychological distress has been shown to affect long-term prognosis of cardiac patients and as a result, it should be addressed during follow-up of cardiac arrest survivors due to cardiac cause. Several studies have considered different approaches and analyses of different psychological attachments, and the understanding of such parameters perioperatively could possibly minimise perioperatively complications.

Conclusion

Since psychological distress affects long-term prognosis of cardiac surgery patients, it should be addressed during follow-up of cardiac arrest survivors due to cardiac cause.

Association Between Perceived Threat and the Development of Posttraumatic Stress Disorder Symptoms in Patients With Life-threatening Medical Emergencies

BACKGROUND

Our objectives were to test whether during a potentially life-threatening medical emergency, perceived threat (a patient's sense of life endangerment) in the emergency department (ED) is common and associated with the subsequent development of posttraumatic stress disorder (PTSD) symptoms.

METHODS

This study was an ED-based prospective cohort study in an academic hospital. We included adult patients requiring acute intervention in the ED for resuscitation of a potentially life-threatening medical emergency, defined as respiratory or cardiovascular instability. We measured patient-perceived threat in the ED using a validated patient self-assessment measure (score range = 0 to 21, with higher scores indicating greater perceived threat). We performed blinded assessment of PTSD symptoms 30 days after discharge using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5).

RESULTS

Ninety-nine of 113 (88%) patients completed follow-up, with 98% reporting some degree of perceived threat, median (interquartile range [IQR]) perceived threat score 12 (6 to 17), and 72% reported PTSD symptoms in relation to their ED visit (median [IQR] PCL-5 score = 7 [0 to 30]). Patients with respiratory instability had higher median (IQR) perceived threat scores (16 [9 to 18] vs. 9 [6 to 14)] and PCL-5 scores (10 [2 to 40] vs. 3 [0 to 17]) compared to patients without respiratory instability. In a multivariable linear regression model adjusting for potential confounders, greater perceived threat in the ED was independently associated with higher PCL-5 scores (β = 0.79, 95% confidence interval [CI] = 0.15 to 1.42). Among the individual perceived threat items, the feeling of helplessness during resuscitation had the strongest association with PCL-5 score (β = 5.24, 95% CI = 2.29 to 8.18).

CONCLUSIONS

Perceived threat during potentially life-threatening emergencies is common and independently associated with development of PTSD symptoms. Additional research to test whether reduction of perceived threat in the ED attenuates the development of PTSD symptoms following potentially life-threatening emergencies is warranted.

Interventions for posttraumatic stress disorder symptoms induced by medical events: A systematic review

OBJECTIVE

Medical events such as myocardial infarction and cancer diagnosis can induce symptoms of posttraumatic stress disorder (PTSD). The optimal treatment of PTSD symptoms in this context is unknown.

METHODS

A literature search of 6 biomedical electronic databases was conducted from database inception to November 2018. Studies were eligible if they used a randomized design and evaluated the effect of treatments on medical event-induced PTSD symptoms in adults. A random effects model was used to pool data when two or more comparable studies were available.

RESULTS

Six trials met full inclusion criteria. Studies ranged in size from 21 to 81 patients, and included patients with PTSD induced by cardiac events, cancer, HIV, multiple sclerosis, and stem cell transplantation. All trials assessed psychological interventions. Two trials comparing a form of exposure-based cognitive behavioral therapy (CBT) with assessment-only control found that CBT resulted in lower PTSD symptoms [Hedges's g = -0.47, (95% CI -0.82 - -0.12), p = .009]. A third trial compared imaginal exposure (another form of exposure-based CBT) with an attention control and found a trend toward reduced PTSD symptoms. Three trials compared eye movement desensitization and reprocessing (EMDR) with active psychological treatments (imaginal exposure, conventional CBT, and relaxation therapy), and found that EMDR was more effective.

CONCLUSION

CBT and EMDR may be promising approaches to reducing PTSD symptoms due to medical events. However, additional trials are needed in this patient population.

Are patients afraid to go home? Disposition preferences after transient ischaemic attack and minor stroke

BACKGROUND

Recent evidence suggests clinical equipoise for managing transient ischaemic attack and minor stroke (TIAMS) either via discharge from the emergency department (ED) with rapid outpatient follow-up or inpatient admission. Understanding patient preferences may guide decision-making around disposition after TIAMS that can lead to higher patient satisfaction and adherence. Psychological distress, particularly a sense of vulnerability (eg, 'threat perception') is associated with adverse psychological outcomes following TIAMS and may influence patient disposition preference. We hypothesised patients with higher threat perceptions in the ED would prefer inpatient admission versus early discharge with rapid outpatient follow-up.

METHODS

This was a planned secondary analysis of a prospective observational cohort study of ED patients with suspected TIAMS (defined as National Institutes of Health Stroke Scale (NIHSS) score of ≤5). Patients reported disposition preferences and completed a validated scale of threat perception while in the ED (score range: 1-4).

RESULTS

147 TIAMS patients were evaluated (mean age: 59.7±15.4, 45.6% female, 39.5% Hispanic, median NIHSS=1, IQR: 0, 3). A majority of patients (98, 66.7%) preferred inpatient admission compared with discharge from the ED. Overall threat scores were median 1.0 (IQR: 0.43, 1.68). Those preferring admission had similar threat scores compared with those who preferred early disposition (median: 1.00, IQR: 0.43, 1.57) versus 1.00, (IQR: 0.49, 1.68); p=0.40). In a model adjusted for demographic characteristics, threat perceptions remained unassociated with disposition preference.

CONCLUSION

Overall, two-thirds of TIAMS patients preferred inpatient admission over discharge. Disposition preference was not associated with higher threat perception in the ED. Further research examining potential drivers of patient disposition preferences may inform patient discussions and optimise patient satisfaction.

Traumatic Stress, Attachment Style, and Health Outcomes in Cardiac Rehabilitation Patients

OBJECTIVE

Research on psychosocial risk factors in cardiovascular disease (CVD) has identified traumatic stress and attachment style as independent risk factors for the development of CVD and poor prognosis for those with established CVD. Exploring the interrelationships between these variables will inform psychosocial risk factor modeling and potential avenues for intervention. Therefore, the hypothesis that attachment style is related to health outcomes among CR patients and that traumatic stress mediates this relationship was tested.

METHODS

Patients in a cardiac rehabilitation program (n = 201) completed validated self-report measures of traumatic stress and attachment style at baseline (program intake). Health outcomes were assessed at baseline and 3 months, including anxiety, depression, quality of life, fasting blood glucose, glycated hemoglobin (HbA1c), and cholesterol (HDL ratio). Multivariate structural equation modeling was used to fit the data.

RESULTS

Of the 201 participants, 42 (21%) had trauma scores indicating the probable presence of posttraumatic stress disorder. Via greater levels of traumatic stress, greater attachment anxiety at baseline was indirectly related to greater anxiety, depression, fasting blood glucose, and HbA1c, and poorer physical and mental quality of life. There were no significant indirect effects on HDL ratios.

CONCLUSION

Greater attachment anxiety predicted greater traumatic stress; this, in turn, predicted poorer health outcomes. Screening and treatment for these constructs in CVD patients is warranted.

Post-traumatic Stress Disorder in Heart Failure Patients: A Test of the Cardiac Disease-induced PTSD Hypothesis

Background:

Post-traumatic stress disorder (PTSD) is prevalent in approximately 12% of patients with cardiovascular disease (CVD) and such patients are at risk of further CVD morbidity and mortality. It is unknown whether CVD patients with cardiac and non-cardiac traumatic events leading to PTSD differ in medical comorbidities and psychiatric vulnerabilities. Our objective was to compare heart failure (HF) patients with cardiac and non-cardiac PTSD.

Method:

A population of HF patients from 3 hospitals underwent a two-step depression and anxiety screening process to identify potential mental health treatment needs. The post-traumatic stress disorder module of the Structured Clinical Interview for DSM-IV Axis-I disorders was used to classify trauma(s) exposure, and other disorders. The patients with PTSD were sub-divided by cardiac related traumas (e.g. myocardial infarction, sudden cardiac arrest) and non-cardiac related traumas (e.g. sexual abuse, interpersonal violence).

Results:

10 patients met criteria for non-cardiac trauma and 18 patients met criteria for cardiacinduced trauma. There were no significant differences in HF aetiology or severity nor cardiac comorbidities. Time since PTSD, onset was significantly longer for those with non-cardiac PTSD. Among psychiatric comorbidities, alcohol and substance abuse disorders, as well as depression were more prevalent in patients with non-cardiac PTSD.

Conclusion:

Cardiac related PTSD was associated with less alcohol and substance abuse disorders, and depression by comparison to their non-cardiac induced PTSD counterparts. Ongoing research is required to establish if cardiac-induced PTSD truly reflects a unique subtype of PTSD, and whether there are different treatment needs and therapeutic approaches for this subtype.

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

OBJECTIVES

Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long-term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all-cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long-term health and to provide a theoretical framework for future work.

METHODS

A panel of two board-certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co-authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors RESULTS: A meta-analysis of 24 studies (N > 2,300) found the prevalence of ACS-induced PTSD at nearly 12%, while a meta-analysis of nine studies (N = 1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3-year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician-patient communication appear at greater risk for subsequent PTSD.

CONCLUSIONS

Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long-term cardiovascular recovery, while also stimulating future areas of research and discovery.

Trajectories of posttraumatic stress in patients with confirmed and rule-out acute coronary syndrome

Many patients evaluated in the emergency department (ED) for acute coronary syndrome (ACS) develop posttraumatic stress symptoms (PTSS), but little is known about symptom trajectories over time. We estimated longitudinal trajectories of PTSS from ED to 1 year after evaluation for suspected ACS (N = 1000), and the effect of threat perceptions and discharge diagnosis. Participants reported on threat perceptions in the ED, ongoing cardiac threat at 1 month, and PTSS at 1, 6, and 12 months. Latent growth mixture modeling identified 3 PTSS trajectories over 1 year: Resilient (81.75%), Chronic-Worsening (13.69%), and Acute-Recovering (4.56%). Chronic-Worsening and Acute-Recovering classes reported significantly higher ED and cardiac threat perceptions than Resilient class. Discharge diagnosis did not differ (χ²(2) = 2.93, p = .231). PTSS are common following evaluation for suspected ACS, and trajectories vary, but targeting threat perceptions may reduce PTSS and improve clinical course, whether or not patients are ultimately diagnosed with ACS.

Traumatic Events, Personality and Psychopathology in Takotsubo Syndrome: A Systematic Review

OBJECTIVE

Takotsubo syndrome (TTS) is a transient heart disease that has been historically related to the occurrence of psychological (emotional) factors ("broken heart" syndrome). We aimed to conduct a systematic review analyzing the role of psychological factors in TTS.

METHODS

All studies on TTS and psychological factors from January 1991 through April 2019 were scrutinized according to the Cochrane Collaboration and the PRISMA statements. Selected studies were additionally evaluated for the Risk of Bias according to the Newcastle-Ottawa Scale (NOS).

RESULTS

Fifteen case-control studies (by Mayo Clinic criteria) were finally selected. Most studies analyzed stressful life-events or trauma, although with conflicting findings, while a likely role of long-lasting psychological distress seemed to be a homogenous result. Among life-time psychopathology, only anxiety appeared to have a significant role. Some studies outlined a likely role of personality, but findings are conflicting.

CONCLUSION

Our findings do not lead to any definitive assumption on the specific role of psychological factors in TTS, also for scant strong methodology of the most part of the studies. More studies with stronger research methodology are needed to better characterize psychological elements in TTS.

Pharmacological rewriting of fear memories: A beacon for post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a psychopathological response that develops after exposure to an extreme life-threatening traumatic event. Its prevalence ranges from 0.5% to 14.5% worldwide. Due to the complex pathophysiology of PTSD, currently available treatment approaches are associated with high chances of failure, thus further research to identify better pharmacotherapeutic approaches is needed. The traumatic event associated with fear memories plays an important role in the development of PTSD and could be considered as the main culprit. PTSD patient feels frightened in a safe environment as the memories of the traumatic event are revisited. Neurocircuit involving normal processing of fear memories get disturbed in PTSD hence making a fear memory to remain to dominate even after years of trauma. Persistence of fear memories could be explained by acquisition, re-(consolidation) and extinction triad as all of these processes have been widely explored in preclinical as well as clinical studies and set a therapeutic platform for fear memory associated disorders. This review focuses on neurocircuit and pathophysiology of PTSD in context to fear memories and pharmacological targeting of fear memory for the management of PTSD.

Selected psychological comorbidities in coronary heart disease: Challenges and grand opportunities

Evidence of popular interest in the interrelationships between mind, body, and heart disease dates to Ancient Grecian times and paved the way for modern-day scientific inquiry into the relationships between psychological comorbidities in coronary heart disease. Although the systematic evidence has suggested an association of poor medical prognosis and lower quality of life among patients with coronary heart disease with comorbid psychological conditions, the mechanisms are less well understood. In this selective review article, the epidemiology, mechanisms, screening, and treatment recommendations for 4 common psychological conditions (depression, anxiety, stress, and insomnia) comorbid with coronary heart disease are presented. We focus on the grand challenges and unprecedented opportunities for research in this area considering the methodological and technological innovations of the 21st century. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Understanding the association between posttraumatic stress disorder characteristics and physical health conditions: A population-based study

Posttraumatic stress disorder (PTSD) is commonly comorbid with a range of physical health conditions. The aim of this study was to examine the association between index trauma and PTSD symptom clusters with physical health conditions, among individuals with PTSD in a population-based sample. Data were analyzed from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; N = 36,309). Past-year PTSD (n = 1779) was assessed using a clinical interview in accordance with DSM-5 criteria. Multiple logistic regression models examined the associations between PTSD symptom clusters and index trauma with physical health conditions. Results of the most stringent model, adjusting for sociodemographics, other psychiatric conditions, and other PTSD symptom clusters, indicated re-experiencing symptoms were associated with cardiovascular and endocrine/metabolic conditions (adjusted odds ratio (AOR) range: 1.18-1.33) and negative alterations in mood and cognition symptoms were associated with sleep disorder (AOR = 1.16, 95% confidence interval (CI) [1.04-1.30], p = .009). Results also demonstrated significant associations between life-threatening illness with cancer, digestive, and neurologic conditions (AOR range: 2.10-3.42) and life-threatening injury with musculoskeletal and neurologic conditions (AOR range: 1.76-2.04). Finally, significant associations emerged between psychological trauma with musculoskeletal and neurologic conditions (AOR range: 0.48-0.66), and other trauma with digestive conditions and anemia (AOR range: 0.38-0.47). Results suggest PTSD symptomatology and index trauma play a differential role in their association with variable physical health conditions. Results may inform screening practices and targeted interventions to mitigate risk of PTSD and physical health conditions.

Resilience is strongly associated with health-related quality of life but does not buffer work-related stress in employed persons 1 year after acute myocardial infarction

PURPOSE

Resilience may facilitate the adaptation after experiencing a severe disease such as acute myocardial infarction (AMI) and attenuate the negative effects of stress on health-related quality of life (HRQOL). However, it is unclear so far whether resilience moderates a negative association between work-related stress and HRQOL in employed patients after AMI.

METHODS

Patients with confirmed AMI and regular paid employment admitted to a hospital in the study region of the MONICA/KORA Myocardial Infarction Registry, Germany (04/2014-06/2017) were included and completed questionnaires during their hospital stay and 6 and 12 months after discharge. The Resilience Questionnaire (RS-11) and the Effort-Reward Imbalance (ERI) Questionnaire were used to assess trait resilience and ERI, respectively. HRQOL was measured by the Short Form 36 Health Survey (SF-36) mental and physical component summary scales. Generalized estimating equations (GEE) adjusted for relevant potential confounding variables (demographic, social, stress-related, and clinical) were used to determine the association between resilience and HRQOL in the study course.

RESULTS

From the 346 patients enrolled in the study, 270 patients (78.0%) had completed all surveys. High baseline trait resilience was significantly and independently associated with high physical HRQOL (ß = 0.15, p < 0.0001) and high mental HRQOL (ß = 0.37, p < 0.0001) 1 year post AMI. No significant interaction effects between trait resilience and ERI were found in the physical HRQOL GEE model (ß = 0.05, p = 0.7241) and in the mental HRQOL model (ß = 0.05, p = 0.3478).

CONCLUSIONS

The results demonstrated that trait resilience is independently and strongly related with post-AMI HRQOL but does not moderate the association between ERI and HRQOL.

Mediators of gender effects on depression among cardiovascular disease patients in Palestine

BACKGROUND

Among patients suffering from coronary heart disease (CHD) and comorbid depression, women experience a higher burden compared to men. Little is known on the characteristics that differentiate men and women with both diseases and whether these factors mediate gender effects on depression. This study assessed whether women are more likely to suffer from depression and which characteristics mediate gender effects on depression among a cardiac population in Palestine, specifically addressing the role of post-traumatic stress disorder (PTSD).

METHODS

Using a cross-sectional design, patients consecutively admitted with a CHD to one of the four main hospitals in Nablus, Palestine, were interviewed using a structured questionnaire with validated instruments. Data was also obtained from hospital medical records. Patients were assessed for depression using the Cardiac Depression Scale (CDS). Bivariate analysis was conducted to compare characteristics of women and men with and without depressive symptoms. Mediators (direct and indirect effects) of the association between gender and depression were evaluated using a structural equation model (SEM).

RESULTS

Women were more likely to suffer from severe depression than men (28.7% vs. 18.8%). Female gender was positively associated with higher PTSD symptoms, comorbidities, somatic symptoms and income, and with lower resilience, self-esteem, quality of life, education, prevalence of smoking and physical activity. Structural equation modeling revealed negative indirect effects of gender on depression (CDS score) through resilience, self-esteem and physical activity, whereas positive indirect effects of gender on depression were observed through PTSD, comorbidities, somatic symptoms and smoking. There was no direct effect of gender on depression.

CONCLUSION

This study found a higher prevalence of severe depression in female patients with cardiac disease compared to male cardiac patients. Our findings provide novel information on mediating factors of the association between gender and depression among cardiac patients, in particular PTSD. The results emphasize the need for further research on potential mediating factors that could account for gender differences in depression and the need to provide support programs for female patients with comorbid CHD and depression to improve their psycho-social well-being.

Common pathways and communication between the brain and heart: connecting post-traumatic stress disorder and heart failure

Psychiatric illnesses and cardiovascular disease (CVD) contribute to significant overall morbidity, mortality, and health care costs, and are predicted to reach epidemic proportions with the aging population. Within the Veterans Administration (VA) health care system, psychiatric illnesses such as post-traumatic stress disorder (PTSD) and CVD such as heart failure (HF), are leading causes of hospital admissions, prolonged hospital stays, and resource utilization. Numerous studies have demonstrated associations between PTSD symptoms and CVD endpoints, particularly in the Veteran population. Not only does PTSD increase the risk of HF, but this relationship is bi-directional. Accordingly, a VA-sponsored conference entitled "Cardiovascular Comorbidities in PTSD: The Brain-Heart Consortium" was convened to explore potential relationships and common biological pathways between PTSD and HF. The conference was framed around the hypothesis that specific common systems are dysregulated in both PTSD and HF, resulting in a synergistic acceleration and amplification of both disease processes. The conference was not intended to identify all independent pathways that give rise to PTSD and HF, but rather identify shared systems, pathways, and biological mediators that would be modifiable in both disease processes. The results from this conference identified specific endocrine, autonomic, immune, structural, genetic, and physiological changes that may contribute to shared PTSD-CVD pathophysiology and could represent unique opportunities to develop therapies for both PTSD and HF. Some recommendations from the group for future research opportunities are provided.

Can hospitalization be hazardous to your health? A nosocomial based stress model for hospitalization

OBJECTIVE

Hospitalization places patients at elevated risk for the development of "nosocomial" or hospital acquired complications, ranging from multidrug resistant infections to delirium and physical deconditioning. Adverse nosocomial psychological effects of hospitalization may also exist. This paper introduces a nosocomial based stress model, conceptualizing hospitalization as a unique period of biopsychosocial vulnerability, due to physiologic effects of acute illness and psychosocial variables of the hospital experience.

METHOD

A research synthesis and narrative review was performed to evaluate evidence supporting this model, integrating existing knowledge of the psychological and physiological effects of acute life threatening events, with known sequelae associated with hospitalization.

RESULT

Psychosocial factors during hospitalization may act as independent predictors of recovery following hospitalization, moderating variables impacting ongoing physiologic changes due to acute illness, and/or dynamic bidirectional elements, influencing medical and psychological outcomes in the near and long-term setting.

CONCLUSION

The Nosocomial Stress model provides a novel framework to understanding the biopsychosocial interactions between the psychological and physiologic processes associated with illness and hospitalization. Based on this model, a research agenda is proposed to assess the contributions of acute illness, the hospital experience, and their interactions on the recovery of patients following hospitalization.

Sensory contact to the stressor prevents recovery from structural and functional heart damage following psychosocial trauma

Cardiovascular disorders (CVD) and posttraumatic stress disorder (PTSD) are highly comorbid, but the underlying mechanisms are not fully understood. Chronic psychosocial stress was induced in male mice by chronic subordinate colony housing (CSC), a pre-clinically validated mouse model for PTSD. Cardiac structure and function were assessed on day 20 of the CSC paradigm. Following CSC, mice were kept in different sensory contact modalities to the last aggressor for 30 days, and development of cardiac function and behavioral aspects were determined. Here we show that psychosocial trauma affects heart structure by disturbing cell-to-cell integrity of cardiomyocytes, causes tachycardia, disturbance of diurnal heart rate rhythmicity and behavioral deficits in a mouse model for PTSD. Structural and functional alterations were also found in cardiomyocytes upon in vitro treatment with pro-inflammatory cytokines typically increased after psychosocial trauma. Interestingly, sensory contact to the aggressor subsequent to psychosocial trauma prohibits functional and structural heart recovery, while isolation was beneficial for cardiac but detrimental for mental health. These findings contribute to our understanding of potential mechanisms underlying the high comorbidity of CVD and PTSD.

The impact of support provided by close others in the emergency department on threat perceptions

Objective: Having close others present in the emergency department (ED) can cause patients significant distress. The present study tested the hypothesis that close others provide more negative support than non-close others as a potential explanation for this effect.Design: Participants were 493 patients evaluated for an acute coronary syndrome (ACS) in the ED (M_Age = 62.01, SD_Age = 13.55; 49.49% male) and who arrived with close others (i.e. spouse/partner, child) or non-close others (e.g. neighbour). Patients self-reported support from companions and threat perceptions (in-ED and at recall approximately three days later).Main outcome measures: Positive support (comfort, responsiveness); negative support (made patients anxious, required comforting); threat perceptions (feeling helpless, vulnerable).Results: Close (vs non-close) others provided patients with marginally more positive support, but also required more comfort, B = 0.32, p = .050, and caused patients more anxiety, B = 0.24, p = .009. Anxiety was associated with patients' Threat Perceptions: in-ED, B = 0.11, p = .002; recall, B = 0.14, p < .001; as was provision of comfort to support partners: recall, B = .06, p = .005.Conclusion: Negative support may be one mechanism underlying the association between close others and patient distress in the ED.

Trauma exposure and endothelial function among midlife women

OBJECTIVE

Trauma is a potent exposure that can have implications for health. However, little research has considered whether trauma exposure is related to endothelial function, a key process in the pathophysiology of cardiovascular disease (CVD). We tested whether exposure to traumatic experiences was related to poorer endothelial function among midlife women, independent of CVD risk factors, demographic factors, psychosocial factors, or a history of childhood abuse.

METHODS

In all, 272 nonsmoking perimenopausal and postmenopausal women aged 40 to 60 years without clinical CVD completed the Brief Trauma Questionnaire, the Child Trauma Questionnaire, physical measures, a blood draw, and a brachial ultrasound for assessment of brachial artery flow-mediated dilation (FMD). Relations between trauma and FMD were tested in linear regression models controlling for baseline vessel diameter, demographics, depression/anxiety, CVD risk factors, health behaviors, and, additionally, a history of childhood abuse.

RESULTS

Over 60% of the sample had at least one traumatic exposure, and 18% had three or more exposures. A greater number of traumatic exposures was associated with lower FMD, indicating poorer endothelial function in multivariable models (beta, β [standard error, SE] -1.05 [0.40], P = 0.01). Relations between trauma exposure and FMD were particularly pronounced for three or more trauma exposures (b [SE] -1.90 [0.71], P = 0.008, relative to no exposures, multivariable).

CONCLUSIONS

A greater number of traumatic exposures were associated with poorer endothelial function. Relations were not explained by demographics, CVD risk factors, mood/anxiety, or a by history of childhood abuse. Women with greater exposure to trauma over life maybe at elevated CVD risk.

Psychological Distress Among Female Cardiac Patients Presenting to a Women's Heart Health Clinic

Female cardiac patients are at greater risk for mental health disorders than their male counterparts, and these mental health disorders have been associated with increased cardiac morbidity and mortality. However, few studies have closely examined the mental health disorders found among the female cardiac population. The primary aim of this study was to examine the prevalence of psychological distress in a sample of female cardiac outpatients at an academic medical center. A secondary aim was to determine whether different demographic variables, cardiac risk factors, or cardiac diagnoses were associated with different levels of emotional distress. A survey, including demographic information, medical status, and standardized symptom measures was completed by 117 female patients scheduled for medical visits at an outpatient women's heart health clinic over a 4-month period. Using standardized self-report questionnaires, 38% scored in the moderate-to-severe range for at least 1 mental disorder and 50% endorsed current insomnia. Symptoms of clinical depression (20%) and anxiety (42)% were endorsed at higher rates than predominantly male or mixed comparison samples. Although there was no apparent relation between the severity of cardiac problems and the degree of psychological distress, women with diagnoses of hyperlipidemia, prediabetes, and diabetes reported greater psychological distress than those without these problems. Women with lower income also reported more psychological distress. In conclusion, our findings suggest an unmet need for integrated mental health services for female cardiac patients.

Early interventions to prevent posttraumatic stress disorder symptoms in survivors of life-threatening medical events: A systematic review

Post-traumatic stress disorder (PTSD) induced by life-threatening medical events has been associated with adverse physical and mental health outcomes, but it is unclear whether early interventions to prevent the onset of PTSD after these events are efficacious. We conducted a systematic review to address this need. We searched six biomedical electronic databases from database inception to October 2018. Eligible studies used randomized designs, evaluated interventions initiated within 3 months of potentially traumatic medical events, included adult participants, and did not have high risk of bias. The 21 included studies (N = 4,486) assessed a heterogeneous set of interventions after critical illness (9), cancer diagnosis (8), heart disease (2), and cardiopulmonary surgery (2). Fourteen psychological, 2 pharmacological, and 5 other-type interventions were assessed. Four of the psychological interventions emphasizing cognitive behavioral therapy or meaning-making, 1 other-type palliative care intervention, and 1 pharmacological-only intervention (hydrocortisone administration) were efficacious at reducing PTSD symptoms relative to control. One early, in-hospital counseling intervention was less efficacious at lowering PTSD symptoms than an active control. Clinical and methodological heterogeneity prevented quantitative pooling of data. While several promising interventions were identified, strong evidence of efficacy for any specific early PTSD intervention after medical events is currently lacking.

Mental illness and obesity among Veterans undergoing percutaneous coronary intervention: Insights from the VA CART program

Mental illness and obesity are highly prevalent in patients with coronary disease and are frequently comorbid. While mental illness is an established risk factor for major adverse cardiac and cerebrovascular events (MACCEs), prior studies suggest improved outcomes in people with obesity. It is unknown if obesity and mental illness interact to affect cardiac outcomes or if they independently influence MACCE. We identified 55 091 patients undergoing percutaneous coronary intervention (PCI) between 2009 and 2014, using the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program. Cox methods were used to assess the risk of MACCE by weight status and psychiatric diagnosis, and assessed for interaction. Compared to normal weight status, higher weight was associated with reduced MACCE events after PCI (mean follow-up of 2 years) for both stable angina and acute coronary syndromes (ACSs; reduction of >13% in stable angina, >17% in ACS; P < 0.01 for both after adjustment). Having a non-substance abuse mental illness diagnosis increased risk of MACCE compared to patients without mental illness in stable angina over 17%; P < 0.05, but not in ACS. When analysed for interaction, obesity and mental illness did not significantly impact MACCE over their independent influences. These results suggest that mental illness along with weight status have significant impact on MACCE, post-PCI. Clinicians should be aware of patients' mental health status as a significant cardiovascular risk factor after PCI, independent of weight status.

Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study

PURPOSE

We tested the hypothesis that, during a life-threatening medical emergency, patient perception of healthcare provider (HCP) compassion is associated with the subsequent development of post-traumatic stress disorder (PTSD) symptoms.

METHODS

Prospective cohort study in the emergency department (ED) of an urban academic medical center. We included adult patients presenting with a life-threatening medical emergency, defined as respiratory or cardiovascular instability requiring a potentially life-sustaining intervention in the ED. We measured patient perception of HCP compassion in the ED using the Consultation and Relational Empathy (CARE) measure, a validated 40-point scale. Blinded to clinical outcomes (including the CARE measure), we assessed PTSD symptoms 1 month post-discharge using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5.

RESULTS

Of the 99/113 (88%) patients who completed follow-up, 25% (95% CI 17-35%) had PTSD symptoms at 1 month. In a multivariable model adjusting for potential confounders (e.g. severity of illness score in ED, need for intensive care unit admission, ED overcrowding, and family member emotional support in the ED), patient perception of greater HCP compassion in the ED was independently associated with lower PTSD symptoms at 1 month [odds ratio 0.93 (95% CI 0.89-0.98)]. A one-point increase in the CARE measure was associated with a 7% decrease in the odds of developing PTSD symptoms.

CONCLUSIONS

PTSD symptoms are common among ED patients with life-threatening medical emergencies. Patient perception of greater HCP compassion during the emergency is independently associated with lower risk of developing PTSD symptoms.

The Impact of Cardiac-induced Post-traumatic Stress Disorder Symptoms on Cardiovascular Outcomes: Design and Rationale of the Prospective Observational Reactions to Acute Care and Hospitalizations (ReACH) Study

Aims:

As many as 1 in 8 acute coronary syndrome (ACS) patients develop posttraumatic stress disorder (PTSD) due to the ACS, and ACS-induced PTSD may increase secondary cardiovascular disease (CVD) risk. However, prior studies have been small and underpowered to test plausible behavioral or biological mechanisms of the hypothesized PTSD-secondary CVD risk association. In this paper, we describe the design and methods of a large prospective observational cohort study to estimate the prognostic significance of ACS-induced PTSD, mechanisms for its association with CVD risk, and emergency department (ED) factors that may increase PTSD risk, in a cohort of patients evaluated for acute coronary syndrome (ACS) in the ED of a large, urban academic medical center.

Methods:

The Reactions to Acute Care and Hospitalization (ReACH) study follows 1,741 racially, ethnically, and socioeconomically diverse patients initially presenting to the ED with ACS symptoms. Psychosocial factors are assessed at baseline. Medication adherence is monitored by electronic pill bottle (eCAP). Participants are contacted by phone at 1-, 6-, and 12-months post-hospitalization to assess PTSD symptoms, hospital readmission, and recurrent CVD events/mortality (proactively searched and confirmed by medical records).

Conclusion:

This study will provide the most accurate estimates to date of PTSD’s association with recurrent CVD events and mortality and will test whether medication adherence mediates that association. Further, it will provide estimates of the contribution of ED and hospital factors to PTSD risk in ACS patients. If our hypotheses are supported, we will have identified PTSD as a novel target for secondary risk reduction.

Bringing close others to the emergency department for an acute coronary event is associated with increased patient perception of threat

OBJECTIVE

Relationship quality is one of the most consistent psychosocial predictors of physical and mental health. Yet, little research examines relationship types or support within the immediate context of acute health events. We tested the unexplored role that close others play in patients' experience of threat during evaluation for acute coronary syndrome (ACS) in the Emergency Department (ED), as well as the indirect effect of close others on ACS-induced posttraumatic stress disorder (PTSD).

METHOD

Participants were 871 patients evaluated for ACS at an urban academic ED (60.86 years old; 54.08% male; 56.37% Hispanic, 19.86% Black, 16.65% White). Threat perceptions were assessed in-ED and median 3 days later. ACS-induced PTSD was assessed median 41 days later using the PTSD checklist cued to a specific stressor. Non-overlapping categories were created representing close others in the ED (i.e., spouse/significant other, child), non-close others (e.g., neighbor), or no one.

RESULTS

Patients who brought close others recalled experiencing greater threat in the ED: vs. no one, b = 0.11, p = .072; vs. non-close others, b = 0.16, p = .030. There was no direct effect of close others on ACS-induced PTSD; however, recalled threat mediated the effect of close others on development of ACS-induced PTSD, ps < .05.

CONCLUSIONS

Close others were associated with recalling greater threat during ED evaluation, which predicted ACS-induced PTSD. ACS-induced PTSD is associated with medication nonadherence, event recurrence, and mortality, highlighting the need to develop a greater understanding of the impact stressful medical environments have on patients and close others.

Posttraumatic stress disorder is associated with enhanced interleukin-6 response to mental stress in subjects with a recent myocardial infarction

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is prevalent among patients who survived an acute coronary syndrome, and is associated with adverse outcomes, but the mechanisms underlying these associations are unclear. Individuals with PTSD have enhanced sensitivity of the noradrenergic system to stress which may lead to immune activation. We hypothesized that survivors of a myocardial infarction (MI) who have PTSD would show an enhanced inflammatory response to acute psychological stress compared to those without PTSD.

METHODS

Individuals with a verified history of MI within 8 months and a clinical diagnosis of current PTSD underwent a mental stress speech task. Inflammatory biomarkers including interleukin-6 (IL-6), high-sensitivity C reactive protein (HsCRP), matrix metallopeptidase 9 (MMP-9), intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1 and monocyte chemoattractant protein (MCP)-1 were measured at rest and 90 min after mental stress.

RESULTS

Among 271 patients in the study (mean age 51 ± 7 years, 50% female, 60% African-American), the prevalence of PTSD was 12%. Mental stress resulted in a significant increase in IL-6, but the increase was more marked in patients with PTSD (126% increase) than those without (63% increase) (p = 0.001). MCP-1 showed a modest increase with stress which was similar in patients with PTSD (9% increase) and without PTSD (6% increase) (p = 0.35). CRP did not increase with stress in either group.

CONCLUSION

MI patients with current PTSD exhibit enhanced IL-6 response to psychosocial stress, suggesting a mechanistic link between PTSD and adverse cardiovascular outcomes as well as other diseases associated with inflammation.

Current research status on the psychological situation of adults with congenital heart disease

Due to technological and medical advances the population of adults with congenital heart disease (ACHD) is growing. Worldwide, congenital heart disease (CHD) affects 1.35-1.5 million children each year and more than 90% reach adulthood. Given the heterogeneity of CHD, survivors are faced with not only complex medical but also psychological challenges which may manifest in mental health problems, such as depression, anxiety and posttraumatic stress disorder. This review focuses on the emotional dimension of CHD. More precisely, it summarizes the present state of research on the prevalence of emotional distress in ACHD. Theoretical models provide a framework for possible explanations of mental health issues in ACHD. Additionally, the review examines the relation between psychological processes and overall health considering the latest scientific findings on coping with chronic illness (illness identity). There is still insufficient knowledge on the psychosocial treatment of mental health issues in the growing population of ACHD. This review suggests a vital need to further investigate the psychological situation of ACHD on a large-scale basis in order to establish a holistic treatment approach to accommodate the patients' special needs.

A challenge for psychocardiology: Addressing the causes and consequences of patients' perceptions of enduring somatic threat

The enduring somatic threat (EST) model of posttraumatic stress disorder (PTSD) due to life-threatening medical events suggests that PTSD-like symptoms represent patients' sensitization to cues of ongoing threat in the body. In this article, we review research on the prevalence and consequences of such reactions in cardiovascular disease patients, discuss early tests of the EST model, and then report a new test of the EST model in 143 patients enrolled during their first acute coronary syndrome (ACS; i.e., non-ST elevation myocardial infarction or unstable angina-colloquially, "heart attack"). Invasive coronary revascularization procedures are commonly used to reduce secondary ACS risk and may reduce patients' EST, as revascularized patients often report being "cured." We assessed ACS patients' initial threat perceptions during emergency department (ED) evaluation and followed them for 1 month for PTSD symptoms (specific for ACS, by telephone). We compared PTSD symptoms in participants who were revascularized (n = 65), catheterized but not revascularized (n = 35), and medically managed (n = 43). PTSD symptoms were lower for revascularized versus medically managed participants (B = -5.32, 95% confidence interval [-9.77, -0.87]), t(98.19) = -2.37, p = .020. In a multiple regression model adjusted for clinical and psychosocial covariates, the interaction of threat perception in the ED and ACS management group was significant (greater ED threat predicted greater 1-month PTSD symptoms only in medically managed participants). These findings offer further support for the EST model and suggest that psychological interventions to preempt patients' development of EST should be considered in the hospital. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Association of sleep problems with neuroendocrine hormones and coagulation factors in patients with acute myocardial infarction

Background

Obstructive sleep apnea (OSA) and insomnia are frequent sleep problems that are associated with poor prognosis in patients with coronary heart disease. The mechanisms linking poor sleep with an increased cardiovascular risk are incompletely understood. We examined whether a high risk of OSA as well as insomnia symptoms are associated with neuroendocrine hormones and coagulation factors in patients admitted with acute myocardial infarction.

Methods

We assessed 190 patients (mean age 60 years, 83% men) in terms of OSA risk (STOP screening tool for the assessment of high vs. low OSA risk) and severity of insomnia symptoms (Jenkins Sleep Scale for the assessment of subjective sleep difficulties) within 48 h of an acute coronary intervention. Circulating concentrations of epinephrine, norepinephrine, cortisol, fibrinogen, D-dimer, and von Willebrand factor were measured the next morning. The association of OSA risk and insomnia symptoms with neuroendocrine hormones and coagulation factors was computed using multivariate models adjusting for demographic factors, health behaviors, somatic and psychiatric comorbidities, cardiac disease-related variables, and OSA risk in the model for insomnia symptoms, respectively, for insomnia symptoms in the model for OSA risk.

Results

High OSA risk was identified in 41% of patients and clinically relevant insomnia symptoms were reported by 27% of patients. Compared to those with low OSA risk, patients with high OSA risk had lower levels of epinephrine (p = 0.015), norepinephrine (p = 0.049) and cortisol (p = 0.001). More severe insomnia symptoms were associated with higher levels of fibrinogen (p = 0.037), driven by difficulties initiating sleep, and with lower levels of norepinephrine (p = 0.024), driven by difficulties maintaining sleep.

Conclusions

In patients with acute myocardial infarction, sleep problems are associated with neuroendocrine hormones and coagulation activity. The pattern of these relationships is not uniform for patients with a high risk of OSA and those with insomnia symptoms, and whether they contribute to adverse cardiovascular outcomes needs to be established.

Trial registration

ClinicalTrials.gov NCT01781247.

The intriguing relationship between coronary heart disease and mental disorders

Coronary heart disease (CHD) and mental illness are among the leading causes of morbidity and mortality worldwide. Decades of research has revealed several, and sometimes surprising, links between CHD and mental illness, and has even suggested that both may actually cause one another. However, the precise nature of these links has not yet been clearly established. The goal of this paper, therefore, is to comprehensively review and discuss the state-of-the-art nature of the epidemiological and pathophysiological aspects of the bidirectional links between mental illness and CHD. This review demonstrates that there exists a large body of epidemiological prospective data showing that people with severe mental illness, including schizophrenia, bipolar disorder, and major depressive disorder, as a group, have an increased risk of developing CHD, compared with controls [adjusted hazard ratio (adjHR)=1.54; 95% CI: 1.30-1.82, P<0.0001]. Anxiety symptoms or disorders (Relative Risk (RR)=1.41, 95% CI: 1.23-1.61, P<0.0001), as well as experiences of persistent or intense stress or posttraumatic stress disorder (PTSD) (adjHR=1.27, 95% CI: 1.08-1.49), although to a lesser degree, may also be independently associated with an increased risk of developing CHD. On the other hand, research also indicates that these symptoms/mental diseases are common in patients with CHD and may be associated with a substantial increase in cardiovascular morbidity and mortality. Finally, mental diseases and CHD appear to have a shared etiology, including biological, behavioral, psychological, and genetic mechanisms.

An Examination of the Association Between Post-traumatic Growth and Stress Symptomatology in Cardiac Outpatients

This study examined the association between post-traumatic growth (PTG), post-traumatic stress disorder (PTSD), and trauma-related factors in cardiac outpatients. Participants recruited from four cardiology clinics between November 2014 and July 2015 (N = 52, 69.2% men, M_age = 65 years) completed self-assessments of PTG and PTSD along with demographic, cardiac health index, and trauma-related factors. In total, 75% of the sample endorsed their cardiac event as traumatic, while 17.2% reported their cardiac event as their 'worst trauma'; those endorsing the latter did not significantly differ from those endorsing 'other traumas' as their worst. Chi-square analyses indicated that the lifetime traumas of experiencing loss or abandonment, witnessing trauma, and experiencing a natural disaster were significantly related to PTG factors of new possibilities, relating to others, and spirituality. Bivariate correlations on all PTSD symptom clusters and factors of PTG revealed the strongest associations between the PTG factors of spiritual change and appreciation of life. Lifetime PTSD symptoms, duration of negative reactions, and re-experiencing symptoms were found to be significantly associated with higher PTG, and a unique independent effect emerged with avoidance symptoms. Our results suggest that PTG may be associated with particular facets of PTSD symptomatology.

Neural Mechanisms Linking Emotion with Cardiovascular Disease

PURPOSE OF REVIEW

The present review discusses brain circuits that are engaged by negative emotions and possibly linked to cardiovascular disease risk. It describes recent human brain imaging studies that relate activity in these brain circuits to emotional processes, peripheral physiology, preclinical pathophysiology, as well as clinical outcomes.

RECENT FINDINGS

Negative emotions and the regulation of negative emotions reliably engage several brain regions that cross-sectional and longitudinal brain imaging studies have associated with CVD risk markers and outcomes. These brain regions include the amygdala, anterior cingulate cortex, medial prefrontal cortex, and insula. Other studies have applied advanced statistical techniques to characterize multivariate patterns of brain activity and brain connectivity that associate with negative emotion and CVD-relevant peripheral physiology. Brain imaging studies on emotion and cardiovascular disease risk are expanding our understanding of the brain-body bases of psychosocial and behavioral risk for cardiovascular disease.