American Journal of Cardiology
Volume 108, Issue 1 , Pages 29-33, 1 July 2011

Post-traumatic Stress Disorder, Coronary Atherosclerosis, and Mortality

  • Naser Ahmadi, MD, MS

      Affiliations

    • Greater Los Angeles Veterans Administration Medical Center, University of California–Los Angeles School of Medicine, Los Angeles, California
    • Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center, Torrance, California
    • ,
  • Fereshteh Hajsadeghi, MD

      Affiliations

    • Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center, Torrance, California
    • ,
  • Hormoz B. Mirshkarlo, MD

      Affiliations

    • Greater Los Angeles Veterans Administration Medical Center, University of California–Los Angeles School of Medicine, Los Angeles, California
    • ,
  • Matthew Budoff, MD

      Affiliations

    • Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center, Torrance, California
    • ,
  • Rachel Yehuda, PhD

      Affiliations

    • James J Peters Veterans Affairs Medical Center, Mount Sinai School of Medicine, New York, New York
    • ,
  • Ramin Ebrahimi, MD

      Affiliations

    • Greater Los Angeles Veterans Administration Medical Center, University of California–Los Angeles School of Medicine, Los Angeles, California
    • Corresponding Author InformationCorresponding author: Tel: 310-268-3109; fax: 310-268-4178

Received 30 December 2010; received in revised form 24 February 2011; accepted 24 February 2011. published online 02 May 2011.

Article Outline

Post-traumatic stress disorder (PTSD) is associated with increased risk of multiple medical problems including myocardial infarction. However, a direct link between PTSD and atherosclerotic coronary artery disease (CAD) has not been made. Coronary artery calcium (CAC) score is an excellent method to detect atherosclerosis. This study investigated the association of PTSD to atherosclerotic CAD and mortality. Six hundred thirty-seven veterans without known CAD (61 ± 9 years of age, 12.2% women) underwent CAC scanning for clinical indications and their psychological health status (PTSD vs non-PTSD) was evaluated. In subjects with PTSD, CAC was more prevalent than in the non-PTSD cohort (76.1% vs 59%, p = 0.001) and their CAC scores were significantly higher in each Framingham risk score category compared to the non-PTSD group. Multivariable generalized linear regression analysis identified PTSD as an independent predictor of presence and extent of atherosclerotic CAD (p <0.01). During a mean follow-up of 42 months, the death rate was higher in the PTSD compared to the non-PTSD group (15, 17.1%, vs 57, 10.4%, p = 0.003). Multivariable survival regression analyses revealed a significant linkage between PTSD and mortality and between CAC and mortality. After adjustment for risk factors, relative risk (RR) of death was 1.48 (95% confidence interval [CI] 1.03 to 2.91, p = 0.01) in subjects with PTSD and CAC score >0 compared to subjects without PTSD and CAC score equal to 0. With a CAC score equal to 0, risk of death was not different between subjects with and without PTSD (RR 1.04, 95% CI 0.67 to 6.82, p = 0.4). Risk of death in each CAC category was higher in subjects with PTSD compared to matched subjects without PTSD (RRs 1.23 for CAC scores 1 to 100, 1.51 for CAC scores 101 to 400, and 1.81 for CAC scores ≥400, p <0.05 for all comparisons). In conclusion, PTSD is associated with presence and severity of coronary atherosclerosis and predicts mortality independent of age, gender, and conventional risk factors.

 

Psychological stress and mental disorders have long been linked to cardiovascular disorders.1 Post-traumatic stress disorder (PTSD) is a growing and well-recognized psychological disorder stemming from previous significant stressful conditions. Lifetime prevalence of combat PTSD is 5% to 20% in the United States2, 3 and is even more prevalent in military personnel serving in Iraq and Afghanistan.3 In addition to debilitating declines in physical and psychological health,4 PTSD is associated with increased rates of multiple medical disorders5 and many surrogate and biomarker abnormalities.6, 7 Although many studies have linked PTSD to cardiovascular diseases and myocardial infarction (MI),5, 8, 9 a conclusive link between PTSD and atherosclerotic coronary artery disease (CAD) has not been made. The Veterans Health Administration, the largest health care system in the nation, provides integrated comprehensive physical and psychological assessment of veterans in the primary care setting.10 This provides a unique opportunity to evaluate the relation between psychological disorders such as PTSD and CAD.10, 11 Coronary artery calcium (CAC) is an accurate marker of the presence and overall atherosclerotic burden and correlates with oxidative stress,12 vascular dysfunction, plaque burden, presence of obstructive CAD,13 and increased cardiovascular events.14 The present study investigated the (1) association of PTSD to coronary artery atherosclerosis as measured by CAC score and (2) relation of PTSD to coronary atherosclerosis and mortality in veterans without known CAD.

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Methods 

The study population consisted of 637 consecutive veterans without known CAD (61 ± 9 years of age, 12.2% women) who underwent CAC scanning for clinical indications. Subjects with established CAD, schizophrenia, and major psychological disorders were excluded.

CAC was detected using a Siemens Definition dual-source 64-slice scanner (Siemens Medical Solutions, Forchheim, Germany). The dual-source computed tomographic protocol has been described previously and validated by comparison to electron beam computed tomography.15 Coronary arteries were imaged with 30 to 40 contiguous 3-mm slices during mid-diastole using electrocardiographic triggering during a 15-second breath-hold. CAC was considered present in a coronary artery when a density >130 HU was detected in ≥3 contiguous pixels (>1 mm2) overlying the coronary artery and then quantified.

Conventional cardiovascular risk factors were measured using the Framingham Risk Score.16 Medical information was obtained from electronic medical records. Subjects receiving antihypertensive drugs or with systolic or diastolic blood pressures ≥140 and 90 mm Hg were considered hypertensive. Subjects were deemed dyslipidemic if they were receiving lipid-lowering therapy. Subjects were considered diabetic if they were being treated for diabetes. Risk factors were determined and Framingham Risk Score was calculated to assess the risk of developing coronary disease events (MI or coronary heart disease death) over the next 10 years.16 Mortality verified by Social Security Death Index was obtained from electronic medical records.

The PTSD Checklist–Military and Clinician Administered PTSD Scale were administered. The PTSD Checklist–Military is a 17-item questionnaire adapted from PTSD criteria B to D from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,17 which inquires about the 3 symptom clusters of PTSD: 5 re-experiencing symptoms, 7 numbing/avoidance symptoms, and 5 hyperarousal symptoms.18 The Clinician Administered PTSD Scale assesses the frequency and intensity of PTSD symptoms during the previous month. Those patients with positive Clinician Administered PTSD Scale and PTSD Checklist–Military scores were classified as having PTSD. PTSD diagnosis was collected from Veteran Health Administration electronic medical records.

All continuous data are presented as mean ± SD, and all categorical data are reported as percentage or absolute number. Chi-square and t tests were used to assess differences between groups. Multivariable generalized linear models were used to assess the association of PTSD with presence and severity of coronary atherosclerosis. Multivariable Cox regression survival analysis was employed to assess the inter-relation of PTSD and CAC with mortality risk before and after adjustment for cardiovascular risk factors. Relative risk (RR) of death and confidence intervals (CIs) were calculated using a bootstrapping technique. Kaplan–Meier survival curves were constructed for categories of CAC with and without PTSD and compared with log-rank test. Independent predictors of mortality were determined using Cox regression survival analysis using a bootstrapping technique. All statistical analyses were performed with SAS 9.2 (SAS Institute, Cary, North Carolina, available at: http://www.sas.com) and PASW 18 (SPSS, Inc., Chicago, Illinois, available at: http://www.spss.com). This study was approved by the institutional review board committee of the Greater Los Angeles VA Health Care System (Los Angeles, California).

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Results 

Demographic and conventional risk factors in subjects with and without PTSD are presented in Table 1. There were no significant differences between veterans with and without PTSD in age, hypertension, diabetes mellitus, family history of premature CAD, systolic and diastolic blood pressures, triglyceride, and low-density lipoprotein cholesterol. Prevalence of hypercholesterolemia, male gender, and current smoking was higher in subjects with PTSD. CAC was more prevalent in the PTSD group compared to the non-PTSD group (76.1% vs 59%, p = 0.001). Similarly, prevalence ratio of PTSD increased with severity of CAC from <10% in CAC score 0 to 18.2% in CAC score ≥400 (Figure 1) and an increase in Framingham Risk Score (Figure 2). CAC was significantly greater in each Framingham Risk Score category in the PTSD cohort compared to subjects without PTSD (Figure 2).

Table 1. Baseline characteristics of patients with and without post-traumatic stress disorder
VariableNo PTSDPTSDp Value
(n = 549)(n = 88)
Age (years)58±1059±90.3
Men84%98%0.001
Hypertension⁎54%63%0.1
Hypercholesterolemia†47%63%0.006
Diabetes mellitus‡25%29%0.4
Current smoker30%42%0.03
Body mass index (kg/m2)29.3±6.231.0±5.90.02
Creatinine (mg/dl)1.03±0.221.05±0.240.3
Systolic blood pressure (mm Hg)128±14127±140.7
Diastolic blood pressure (mm Hg)77±877±90.9
Total cholesterol (mg/dl)174±46163±450.04
Low-density lipoprotein (mg/dl)104±34100±370.3
High-density lipoprotein (mg/dl)44±1738±130.005
Triglyceride (mg/dl)133±69141±760.3
Framingham Risk Score12.1±8.114.1±6.70.02
Coronary artery calcium score332±336448±4720.0001
Follow-up (months)43±1239±150.04
Mortality10.4%17.1%0.003

Values presented as mean ± SD or percentage of patients.

⁎Self-reported diagnosis of hypertension, prescribed medication for hypertension, or current systolic blood pressure >140 mm Hg or diastolic blood pressure >90 mm Hg diastolic (>130/80 mm Hg if diabetic).

†Self-reported diagnosis of high cholesterol, prescribed medication for high cholesterol, or current total cholesterol level >200 mg/dl.

‡Self-reported diagnosis of diabetes (type 1 or 2) or prescribed medication for diabetes.

  • View full-size image.
  • Figure 2. 

    Association of increasing Framingham Risk Score (FRS) and coronary artery calcium in patients with (black bars) and without (gray bars) post-traumatic stress disorder.

Multivariable generalized linear regression analysis identified PTSD as an independent predictor of presence and extent of atherosclerotic CAD. After adjustment for risk factors, RR of presence of CAC was 1.59 in the PTSD compared to the non-PTSD groups. Similarly, mean CAC was 86 HU higher in subjects with PTSD compared to subjects with a similar profile without PTSD (Table 2).

Table 2. Association of post-traumatic stress disorder with presence and severity of coronary artery calcium
ModelPresence of CAC⁎Severity of CAC†
Odds Ratio (95% CI)p ValueBeta (95% CI)p Value
I
Unadjusted
Post-traumatic stress disorder2.17(1.16–3.95)0.001116(78–262)0.001
II‡
Post-traumatic stress disorder1.59(1.20–2.91)0.0186(37–137)0.008

⁎Logistic regression analysis.

†Generalized linear regression analysis.

‡Covariates were age, gender, diabetes mellitus, hypertension, hypercholesterolemia, family history of coronary heart disease, and smoking status.

During a mean follow-up of 42 months, there were 72 (11.3%) deaths in the entire population. The death rate was higher in the PTSD compared to the non-PTSD group (15, 17.1%, vs 57, 10.4%, p = 0.003). After adjustment for cardiovascular risk factors, CAC and PTSD were independent predictors of mortality, in which the risk of death increased 2.28-fold with presence of PTSD (Table 3). Furthermore, multivariable survival regression analyses showed a significant linkage of PTSD and CAC with increased RR of death independent of risk factors (Figure 3 and Table 4). The RR of death was 1.48 (95% CI 1.03 to 2.91, p = 0.01) in subjects with PTSD and CAC score >0 compared to those without PTSD and CAC score 0 after adjustment for risk factors.

Table 3. Relative risk of death across cardiovascular risk factors and post-traumatic stress disorder
ModelRR of Death (95% CI)p Value
I
Unadjusted
Post-traumatic stress disorder1.82(1.05–3.17)0.003
Coronary artery calcium⁎12.54(2.83–17.85)0.001
II†
Diabetes mellitus3.58(1.37–4.65)0.01
Hypertension2.81(1.12–3.41)0.02
Post-traumatic stress disorder1.77(1.02–3.14)0.03
III‡
Coronary artery calcium⁎10.85(1.41–24.27)0.0001
Post-traumatic stress disorder2.28(1.19–4.37)0.001

⁎Coronary artery calcium score 0 versus ≥100.

†Cox regression survival analysis (covariates were age, gender, diabetes mellitus, hypertension, hypercholesterolemia, family history of coronary heart disease, smoking status, and post-traumatic stress disorder).

‡Cox regression survival analysis (covariates were age, gender, diabetes mellitus, hypertension, hypercholesterolemia, family history of coronary heart disease, smoking status, post-traumatic stress disorder, and coronary artery calcium).

Table 4. Relative risk of death between subjects with and without post-traumatic stress disorder based on absence and presence of coronary artery calcium
ModelRR of Death (95% CI)p Value
Coronary artery calcium score 0 and no psychological disorder1.0(reference)
Coronary artery calcium score >0 and post-traumatic stress disorder1.48(1.03–2.91)0.01

Cox regression survival analysis; adjusted for age, gender, diabetes mellitus, hypertension, hypercholesterolemia, family history of coronary heart disease, and smoking status.

Event-free survival rate decreased proportionally with increase in severity of CAC that was more robust in the PTSD group compared to the matched non-PTSD cohort (p <0.05; Figure 3) with CAC score 0; risk of death was not statistically significant different in subjects with or without PTSD (adjusted RR 1.04, 95% CI 0.67 to 6.82, p = 0.4). However, risk of death increased proportionally with presence of PTSD and increase in severity of CAC compared to the corresponding matched non-PTSD cohort after adjustment for risk factors (RRs 1.23 for CAC scores 1 to 100, 1.51 for CAC scores 101 to 400, and 1.81 for CAC scores ≥400, p <0.05 for all comparisons; Table 5).

Table 5. Relative risk of death across coronary artery calcium categories in subjects with and without post-traumatic stress disorder
CACNo PTSDPTSDp Value
01.0(reference)1.04(0.67–6.82)0.4
1–1001.0(reference)1.23(1.04–6.55)0.03
101–4001.0(reference)1.51(1.16–4.86)0.01
≥4001.0(reference)1.81(1.16–3.74)0.001

Cox regression survival analysis; adjusted for age, gender, diabetes mellitus, hypertension, hypercholesterolemia, family history of coronary heart disease, and smoking status.

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Discussion 

The present study demonstrates that (1) PTSD is associated with presence and severity of coronary atherosclerosis as measured by CAC independent of conventional risk factors, (2) PTSD is an independent predictor of mortality, and (3) multivariable survival regression analyses showed a significant linkage of PTSD and CAC with increased RR of death independent of risk factors.

PTSD has long been associated with multiple medical and psychological disorders.5 Alterations in inflammatory state,7, 19 increased coagulation factors,20, 21 vascular dysfunction,22 increased platelet activity,23 increased lipid levels and lipid reactivity,24, 25 and dysregulation of the hypothalamic–pituitary–adrenal axis26 have been cited as possible mechanisms.

More recently PTSD has been associated with cardiovascular disease, mortality, and MI.5, 8, 9 Boscarino9 studied clinical outcomes of 15,288 men retired from the United States Army with and without PTSD approximately 30 years after their military service. After adjustment for risk factors, PTSD was associated with increased risk of all-cause mortality (hazards ratio 2.2, p <0.001) and cardiovascular mortality (hazard ratio 1.7, p = 0.03).

Rosengren et al27 conducted a case-control study in 11,119 patients with first MI and 13,648 age- and gender-matched controls from 262 centers in 52 countries evaluating the relation of psychosocial factors to risk of MI. This study indicated that presence of psychosocial stressors including stress at work or home, financial stress, and major life events are associated with increased risk of acute MI in men and women worldwide. Similarly, Kubzansky et al28 evaluated the relation of PTSD to incidence of cardiovascular diseases in a prospective cohort study of 1,946 men who were veterans. Age-adjusted RR of fatal and nonfatal MI per SD increase in PTSD symptoms was 1.26 (95% CI 1.05 to 1.51), suggesting that higher levels of PTSD symptoms may increase the risk of incident cardiovascular diseases in men who are veterans.

Although these studies point to an association between PTSD and ischemic heart disease, one limitation remains the lack of a direct association between PTSD and atherosclerotic CAD.5, 9, 27, 28 MI may occur from other causes than atherosclerosis including coronary artery spasm, embolic events, and demand ischemia.

Our study is the first to make a direct association between PTSD and atherosclerotic CAD as measured by CAC, which revealed that PTSD is an independent risk factor for development of coronary atherosclerosis.

Our results also point to a significant linkage of PTSD and CAC with increased risk of mortality independent of conventional risk factors. In addition, risk of mortality in patients with PTSD was significantly higher in each CAC category compared to the corresponding non-PTSD cohort.

Recent studies have shown that prevalence of combat PTSD is increasing.3 Our study reconfirms the previous studies1, 27 and clearly points to a strong association between PTSD and cardiovascular disease and untoward cardiovascular outcomes. This highlights the value of an integrated comprehensive medical and psychological assessment to improve risk stratification and management of at-risk subjects. Although PTSD treatment has clear implications for psychiatric well-being, its implications for cardiovascular health are not established. Further studies are warranted to evaluate whether therapies attempting to ameliorate PTSD symptoms and whether early detection and management of atherosclerosis can decrease the burden of atherosclerosis and improve quality of life and outcomes in such subjects.

Veterans have disproportionately high rates of obesity, diabetes, hypertension, psychological disorders,3 and incidence of CAD compared to the general population in the United States. As a result, the conclusions of this study may not be applicable to the general population.29 Furthermore, the study population was mainly composed of men who were veterans; however, the present findings suggest a significant interaction of PTSD and CAC with mortality in men and women.

PTSD is associated with presence and severity of atherosclerosis measured by CAC and predicts mortality independent of age, gender, and other conventional risk factors in primary care patients. Furthermore, the significant interaction of PTSD and CAC is associated with the increased risk of mortality. These results clearly point to the important role of early assessment of coronary atherosclerosis in patients with PTSD to identify and manage high-risk patients.

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PII: S0002-9149(11)01138-6

doi:10.1016/j.amjcard.2011.02.340

American Journal of Cardiology
Volume 108, Issue 1 , Pages 29-33, 1 July 2011

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