Advertisement

Post-traumatic Stress Disorder, Coronary Atherosclerosis, and Mortality

      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Cohen B.E.
        • Marmar C.
        • Ren L.
        • Bertenthal D.
        • Seal K.H.
        Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care.
        JAMA. 2009; 302: 489-492
        • Richardson L.K.
        • Frueh B.C.
        • Acierno R.
        Prevalence estimates of combat-related post-traumatic stress disorder: critical review.
        Aust N Z J Psychiatry. 2010; 44: 4-19
        • Ramchand R.
        • Schell T.L.
        • Karney B.R.
        • Osilla K.C.
        • Burns R.M.
        • Caldarone L.B.
        Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: possible explanations.
        J Trauma Stress. 2010; 23: 59-68
        • Keane T.M.
        • Marshall A.D.
        • Taft C.T.
        Posttraumatic stress disorder: etiology, epidemiology, and treatment outcome.
        Annu Rev Clin Psychol. 2006; 2: 161-197
        • Dedert E.A.
        • Calhoun P.S.
        • Watkins L.L.
        • Sherwood A.
        • Beckham J.C.
        Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evidence.
        Ann Behav Med. 2010; 39: 61-78
        • Kop W.J.
        • Gottdiener J.S.
        • Tangen C.M.
        • Fried L.P.
        • McBurnie M.A.
        • Walston J.
        • Newman A.
        • Hirsch C.
        • Tracy R.P.
        Inflammation and coagulation factors in persons >65 years of age with symptoms of depression but without evidence of myocardial ischemia.
        Am J Cardiol. 2002; 89: 419-424
        • von Känel R.
        • Hepp U.
        • Kraemer B.
        • Traber R.
        • Keel M.
        • Mica L.
        • Schnyder U.
        Evidence for low-grade systemic proinflammatory activity in patients with posttraumatic stress disorder.
        J Psychiatr Res. 2007; 41: 744-752
        • Sibai A.M.
        • Fletcher A.
        • Armenian H.K.
        Variations in the impact of long-term wartime stressors on mortality among the middle-aged and older population in Beirut, Lebanon, 1983–1993.
        Am J Epidemiol. 2001; 154: 128-137
        • Boscarino J.A.
        Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service.
        Ann Epidemiol. 2006; 16: 248-256
        • Baker G.R.
        • MacIntosh-Murray A.
        • Porcellato C.
        • Dionne L.
        • Stelmacovich K.
        • Born K.
        Veterans Affairs New England Healthcare System (Veterans Integrated Service Network 1) High Performing Healthcare Systems: Delivering Quality by Design.
        in: Longwoods Publishing, Toronto2008: 71-114
        • Saleem J.J.
        • Patterson E.S.
        • Militello L.
        • Asch S.M.
        • Doebbeling B.N.
        • Render M.L.
        Using human factors methods to design a new interface for an electronic medical record.
        AMIA Annu Symp Proc. 2007; : 640-644
        • Ahmadi N.
        • Tsimikas S.
        • Hajsadeghi F.
        • Saeed A.
        • Nabavi V.
        • Bevinal M.A.
        • Kadakia J.
        • Flores F.
        • Ebrahimi R.
        • Budoff M.J.
        Relation of oxidative biomarkers, vascular dysfunction, and progression of coronary artery calcium.
        Am J Cardiol. 2010; 105: 459-466
        • Detrano R.
        • Guerci A.D.
        • Carr J.J.
        • Bild D.E.
        • Burke G.
        • Folsom A.R.
        • Liu K.
        • Shea S.
        • Szklo M.
        • Bluemke D.A.
        • O'Leary D.H.
        • Tracy R.
        • Watson K.
        • Wong N.D.
        • Kronmal R.A.
        Coronary calcium as a predictor of coronary events in four racial or ethnic groups.
        N Engl J Med. 2008; 358: 1336-1345
        • Raggi P.
        • Callister T.Q.
        • Shaw L.J.
        Progression of coronary artery calcium and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy.
        Arterioscler Thromb Vasc Biol. 2004; 24: 1272-1277
        • Groen J.M.
        • Greuter M.J.
        • Vliegenthart R.
        • Suess C.
        • Schmidt B.
        • Zijlstra F.
        • Oudkerk M.
        Calcium scoring using 64-slice MDCT, dual source CT and EBT: a comparative phantom study.
        Int J Cardiovasc Imaging. 2008; 24: 547-556
      1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood cholesterol in Adults (Adult Treatment Panel III) final report.
        Circulation. 2002; 106: 3143-3421
        • Weathers F.
        • Ford J.
        Psychometric properties of the PTSD checklist (PCL-C, PCL-S, PCL-M, PCL-PR).
        in: Stamm B.H. Measurement of Stress, Trauma, and Adaptation. Sidran Publishing Group, Lutherville, MD1996: 250-251
        • Blanchard E.B.
        • Jones-Alexander J.
        • Buckley T.C.
        • Forneris C.A.
        Psychometric properties of the PTSD Checklist (PCL).
        Behav Res Ther. 1996; 34: 669-673
        • Maes M.
        • Lin A.H.
        • Delmeire L.
        • Van Gastel A.
        • Kenis G.
        • De Jongh R.
        • Bosmans E.
        Elevated serum interleukin-6 (IL-6) and IL-6 receptor concentrations in posttraumatic stress disorder following accidental man-made traumatic events.
        Biol Psychiatry. 1999; 45: 833-839
        • Frimerman A.
        • Miller H.I.
        • Laniado S.
        • Keren G.
        Changes in hemostatic function at times of cyclic variation in occupational stress.
        Am J Cardiol. 1997; 79: 72-75
        • von Känel R.
        • Hepp U.
        • Buddeberg C.
        • Keel M.
        • Mica L.
        • Aschbacher K.
        • Schnyder U.
        Altered blood coagulation in patients with posttraumatic stress disorder.
        Psychosom Med. 2006; 68: 598-604
        • Ghiadoni L.
        • Donald A.E.
        • Cropley M.
        • Mullen M.J.
        • Oakley G.
        • Taylor M.
        • O'Connor G.
        • Betteridge J.
        • Klein N.
        • Steptoe A.
        • Deanfield J.E.
        Mental stress induces transient endothelial dysfunction in humans.
        Circulation. 2000; 102: 2473-2478
        • Markovitz J.H.
        • Matthews K.A.
        • Kiss J.
        • Smitherman T.C.
        Effects of hostility on platelet reactivity to psychological stress in coronary heart disease patients and in healthy controls.
        Psychosom Med. 1996; 58: 143-149
        • Solter V.
        • Thaller V.
        • Karlović D.
        • Crnković D.
        Elevated serum lipids in veterans with combat-related chronic posttraumatic stress disorder.
        Croat Med J. 2002; 43: 685-689
        • Finney M.L.
        • Stoney C.M.
        • Engebretson T.O.
        Hostility and anger expression in African American and European American men is associated with cardiovascular and lipid reactivity.
        Psychophysiology. 2002; 39: 340-349
        • von Känel R.
        • Hepp U.
        • Traber R.
        • Kraemer B.
        • Mica L.
        • Keel M.
        • Mausbach B.T.
        • Schnyder U.
        Measures of endothelial dysfunction in plasma of patients with posttraumatic stress disorder.
        Psychiatry Res. 2008; 158: 363-373
        • Rosengren A.
        • Hawken S.
        • Ounpuu S.
        • Sliwa K.
        • Zubaid M.
        • Almahmeed W.A.
        • Blackett K.N.
        • Sitthi-amorn C.
        • Sato H.
        • Yusuf S.
        Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 953-962
        • Kubzansky L.D.
        • Koenen K.C.
        • Spiro III, A.
        • Vokonas P.S.
        • Sparrow D.
        Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the Normative Aging Study.
        Arch Gen Psychiatry. 2007; 64: 109-116
        • Nelson K.M.
        The burden of obesity among a national probability sample of veterans.
        J Gen Intern Med. 2006; 21: 915-919

      Linked Article

      • Post-Traumatic Stress Disorder and Cardiovascular Disease Link: Time to Identify Specific Pathways and Interventions
        American Journal of CardiologyVol. 108Issue 7
        • Preview
          Research suggests that post-traumatic stress disorder (PTSD) is associated with increased risks for chronic diseases, including cardiovascular disorders, rheumatoid arthritis, and other health conditions.1–6 The study by Ahmadi et al3 published in The American Journal of Cardiology adds to this research. This study, which was based on a sample of 637 veterans, goes beyond previous work; using coronary artery calcium scores, it suggests that PTSD is associated with the presence and severity of coronary atherosclerosis.
        • Full-Text
        • PDF