Early Trauma-Focused Counseling for the Prevention of Acute Coronary Syndrome-Induced Posttraumatic Stress: Social and Health Care Resources Matter

Cardiac disease-induced trauma and stress-related disorders

OBJECTIVE

This review aims to present an updated overview of cardiac disease-induced trauma and stress-related disorders such as acute stress disorder (ASD), adjustment disorder (AjD), and posttraumatic stress disorder (PTSD). First, the prevalence of these disorders, their diagnostic criteria, and their differences from other trauma-related disorders are described. Special challenges in diagnosis and treatment are identified, with various screening tools being evaluated for symptom assessment. Additionally, the risk factors studied so far for the development of symptoms of cardiac-induced posttraumatic stress disorder and the bidirectional relationship between posttraumatic stress disorder and cardiovascular diseases are summarized. Various therapeutic interventions, including pharmacological approaches, are also discussed. Finally, various areas for future research are outlined.

BACKGROUND

Experiencing a cardiovascular disease, particularly a life-threatening cardiac event, can potentially lead to stress-related disorders such as ASD, AjD, and cardiac disease-induced PTSD (CDI-PTSD). If left untreated, these disorders are associated with a worsening cardiac prognosis and higher mortality rates. Approaching treatment through a trauma-focused lens may be beneficial for managing CDI-PTSD and stress-related disorders.

CONCLUSION

Future research should explore treatment options for both the patients and the caregivers as well as investigate the long-term effects of trauma-focused interventions on physical and mental health outcomes.

Temporal characteristics and associated factors of discontinuation and outcomes after percutaneous coronary intervention

Background: Medication adherence in patients after percutaneous coronary intervention (PCI) is suboptimal, and discontinuation is common. Information on the temporal characteristics and associated factors of discontinuation and outcomes after PCI is insufficient to improve medication adherence interventions. Methods: We conducted a single-center retrospective study of post-PCI patients by telephone survey and medical record extraction. Temporal characteristics and associated factors of discontinuation and outcomes were examined by survival curve analysis, Cox regression, or time-dependent Cox regression. Results: Discontinuation and major adverse cardiovascular events (MACE) after PCI had similar temporal characteristics, with the highest incidence in the first year, followed by a decline. Temporary discontinuation was associated with pre-PCI medication nonadherence (HR 1.63; 95% CI: 1.09-2.43), lack of medication necessity (HR 2.33; 95% CI: 1.44-3.78), economic difficulties (HR 2.09; 95% CI: 1.26-3.47), routine disruption (HR 2.09; 95% CI: 1.10-3.99), and emotional distress (HR 2.76; 95% CI: 1.50-5.09). Permanent discontinuation was associated with residence in rural areas (HR 4.18; 95% CI: 1.84-9.46) or small to medium-sized cities (HR 4.21; 95% CI: 1.82-9.73), lack of medication necessity (HR 10.60; 95% CI: 6.45-17.41), and side effects (HR 3.30; 95% CI: 1.94-5.62). The MACE after PCI was associated with pre-PCI hypertension (HR 1.42; 95% CI: 1.04-1.96), two coronary stents (HR 1.42; 95% CI: 1.01-1.99) or three coronary stents (HR 1.66; 95% CI: 1.11-2.49) compared to one coronary stent up to this PCI, and temporary discontinuation (≤60 months HR 2.18; 95% CI: 1.47-3.25; >60 months HR 8.82; 95% CI: 3.65-21.28). Conclusion: Discontinuation and MACE after PCI have similar temporal characteristics, temporary discontinuation and permanent discontinuation have different associated factors, and the former is associated with MACE. These findings may provide guidance for medication adherence interventions.

Prevalence of posttraumatic stress disorder following acute coronary syndrome and clinical characteristics of patients referred to cardiac rehabilitation

BACKGROUND

Studies have demonstrated that patients who have experienced acute coronary syndrome (ACS) have an increased risk of developing posttraumatic stress disorder (PTSD) and experiencing worse survival outcomes than those who do not develop PTSD. Nevertheless, the prevalence rates of PTSD following ACS vary widely across studies, and it is noteworthy that in most cases, the diagnosis of PTSD was based on self-report symptom questionnaires, rather than being established by psychiatrists. Additionally, the individual characteristics of patients who develop PTSD after ACS can differ widely, making it difficult to identify any consistent patterns or predictors of the disorder.

AIM

To investigate the prevalence of PTSD among a large sample of patients undergoing cardiac rehabilitation (CR) after ACS, as well as their characteristics in comparison to a control group.

METHODS

The participants of this study are patients who have experienced ACS with or without undergoing percutaneous coronary intervention and are enrolled in a 3-wk CR program at the largest CR center in Croatia, the Special Hospital for Medical Rehabilitation Krapinske Toplice. Patient recruitment for the study took place over the course of one year, from January 1, 2022, to December 31, 2022, with a total of 504 participants. The expected average follow-up period for patients included in the study is about 18 mo, and currently ongoing. Using self-assessment questionnaire for PTSD criteria and clinical psychiatric interview, a group of patients with a PTSD diagnosis was identified. From the participants who do not have a PTSD diagnosis, patients who would match those with a PTSD diagnosis in terms of relevant clinical and medical stratification variables and during the same rehabilitation period were selected to enable comparability of the two groups.

RESULTS

A total of 507 patients who were enrolled in the CR program were approached to participate in the study. Three patients declined to participate in the study. The screening PTSD Checklist-Civilian Version questionnaire was completed by 504 patients. Out of the total sample of 504 patients, 74.2% were men (n = 374) and 25.8% were women (n = 130). The mean age of all participants was 56.7 years (55.8 for men and 59.1 for women). Among the 504 participants who completed the screening questionnaire, 80 met the cutoff criteria for the PTSD and qualified for further evaluation (15.9%). All 80 patients agreed to a psychiatric interview. Among them, 51 patients (10.1%) were diagnosed with clinical PTSD by a psychiatrist according to Diagnostic and Statistical Manual of Mental Disorders criteria. Among the variables analyzed, there was a noticeable difference in the percentage of theoretical maximum achieved on exercise testing between the PTSD and non-PTSD groups. Non-PTSD group achieved a significantly higher percentage of their maximum compared to the PTSD group (P = 0.035).

CONCLUSION

The preliminary results of the study indicate that a significant proportion of patients with PTSD induced by ACS are not receiving adequate treatment. Furthermore, the data suggest that these patients may exhibit reduced physical activity levels, which could be one of the possible underlying mechanisms in observed poor cardiovascular outcomes in this population. Identifying cardiac biomarkers is crucial for identifying patients at risk of developing PTSD and may derive benefits from personalized interventions based on the principles of precision medicine in multidisciplinary CR programs.

Posttraumatic Stress Disorder as a Consequence of Acute Cardiovascular Disease

PURPOSE OF REVIEW

To provide an update of the current evidence of cardiac disease-induced posttraumatic stress disorder (CDI-PTSD) with a focus on acute coronary events.

RECENT FINDINGS

A cardiovascular disease, particularly a life-threatening cardiac event is often a highly stressful experience that can induce PTSD in patients and their caregivers, taking a chronic course if left untreated. There are several features distinguishing CDI-PTSD from "traditional" PTSD induced by external trauma, namely enduring somatic threat, inability to avoid trauma-related cues and hyperarousal with internal body sensations leading to constant fear of recurrent cardiac events. An increased risk of recurrent CVD events may be explained by pathophysiological changes, an unhealthy lifestyle and non-adherence to cardiac treatment. A trauma-focused approach might be useful to treat CDI-PTSD. Treatment options for patients and caregivers as well as long-term effects of trauma-focused interventions on physical and mental health outcomes should be future research directions.

Reply to Sopek Merkaš, I.; Lakušić, N. Comment on "von Känel et al. Early Trauma-Focused Counseling for the Prevention of Acute Coronary Syndrome-Induced Posttraumatic Stress: Social and Health Care Resources Matter. J. Clin. Med. 2022, 11, 1993"

We thank Merkaš and Lakušić for commenting on our recently published paper; in the paper, we suggested that resources in a patient's social environment may moderate the benefit of one single-session trauma-focused counseling in the prevention of acute coronary syndrome (ACS)-induced posttraumatic stress disorder (PTSD) symptoms [...].

Comment on von Känel et al. Early Trauma-Focused Counseling for the Prevention of Acute Coronary Syndrome-Induced Posttraumatic Stress: Social and Health Care Resources Matter. J. Clin. Med. 2022, 11, 1993

Posttraumatic stress disorder (PTSD) is a debilitating disorder, and it is known that it can be triggered by acute coronary syndrome (ACS). Patients with ACS-induced PTSD have an increased risk of recurrent adverse cardiovascular events and mortality. This is still an insufficiently recognized subgroup of patients among clinicians that could benefit from specific therapeutic and rehabilitation approaches.