Posttraumatic Stress Disorder Symptoms May Increase Coronary Heart Disease Risk  CME/CE

News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD
Disclosures

Release Date: January 11, 2007; Valid for credit through January 11, 2008

Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians; Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians; Nurses - 0.25 nursing contact hours (None of these credits is in the area of pharmacology)

January 11, 2007 — A higher level of symptoms of posttraumatic stress disorder may increase the risk for coronary heart disease in older men, according to the results of the prospective Veterans Affairs Normative Aging Study (NAS) reported in the January issue of the Archives of General Psychiatry.

"Various correlates of posttraumatic stress disorder (PTSD), such as high levels of sympathetic activation and hypothalamic-pituitary-adrenal axis dysregulation, have been linked to arterial damage and coronary heart disease (CHD) risk," write Laura D. Kubzansky, PhD, from the Harvard School of Public Health in Boston, Massachusetts, and colleagues. "While psychological disturbance is frequently found among patients with cardiac disease, whether psychological problems precede or occur as a result of having a potentially fatal disease is not clear. To our knowledge, no prospective studies to date have evaluated whether PTSD is associated with increased risk of CHD."

The investigators evaluated data provided by community-dwelling men from the Greater Boston, Massachusetts, area who served in the military and who completed either the Mississippi Scale for Combat-Related PTSD in 1990 (n = 1002) or the Minnesota Multiphasic Personality Inventory 2 Keane PTSD (MMPI-1 PK) scale in 1986 (n = 944). Men with preexisting CHD at baseline were excluded, and the primary end point was incident CHD occurring during follow-up through May 2001.

In this cohort, levels of PTSD symptoms were low to moderate. For each standard-deviation (SD) increase in symptom level on the Mississippi Scale for Combat-Related PTSD, men had age-adjusted relative risks of 1.26 (95% confidence interval [CI], 1.05 - 1.51) for nonfatal myocardial infarction and fatal CHD combined, and 1.21 (95% CI, 1.05 - 1.41) for all of the CHD outcomes combined (nonfatal myocardial infarction, fatal CHD, and angina). This pattern of results was similar using the MMPI-1 PK scale and somewhat stronger after controlling for levels of depressive symptoms.

"To our knowledge, this is the first study to demonstrate a prospective association between PTSD symptoms and CHD even after controlling for depressive symptoms," the authors write. "These results suggest that a higher level of PTSD symptoms may increase the risk of incident CHD in older men."

Study limitations include older age of the sample; lack of generalizability to women, nonwhite populations, or civilians; assessment of PTSD symptoms relying on self-report scales; and lack of data on the chronicity and duration of PTSD symptoms or on specific exposure to trauma.

"Although an association between PTSD and CHD has often been speculated, much of the evidence to date has been indirect, linking PTSD with coronary risk factors or with neuroendocrine processes known to be related to cardiovascular dysregulation," the authors conclude. "These data suggest that prolonged stress and significant levels of PTSD symptoms may increase the risk for CHD in older male veterans. These results are provocative and suggest that exposure to trauma and prolonged stress not only may increase the risk for serious mental health problems but are also cardiotoxic."

The National Institutes of Health, Veterans Affairs Merit Reviews, the National Institute of Mental Health, and the Cooperative Studies Program/Epidemiologic Research and Information Center, Department of Veterans Affairs supported this study in part. The authors have disclosed no relevant financial relationships.

Arch Gen Psychiatry. 2007;64:109-116.

Clinical Context

PTSD reflects dysregulation of the stress response system, and many studies have shown that CHD and cardiovascular risk factors are more common in people with PTSD. Previously, however, no prospective study has evaluated the association between PTSD and CHD risk to determine whether these conditions share common pathways or whether PTSD itself is a risk factor for CHD.

In earlier studies, 29% of an outpatient sample with stable CHD also had PTSD and, compared with controls, men with PTSD had more than twice the risk for atrioventricular conduction defects and infarctions. Other studies, predominantly in veterans, suggest that adverse experiences increase CHD risk, in part because of psychological factors.

The biological mechanisms by which PTSD might increase risk for CHD are still unknown, but these most likely involve the neuroendocrinology of PTSD, such as the enhanced negative feedback sensitivity of glucocorticoid receptors in the stress response system; below-normal urinary and plasma cortisol levels; and exaggerated catecholamine responses to trauma-related stimuli. The hemodynamic and/or biochemical processes of catecholamine release can injure the endothelium of coronary arteries and can also enhance release of fatty acids, promoting the development of atherosclerosis.

Although evidence to date suggests that prolonged stress promotes the development of CHD, it is less clear whether PTSD has pathophysiological or atherogenic effects. Further compounding the difficulty in analysis is the overlap between symptoms of PTSD and depression. Using the Normative Aging Study (NAS), a community-dwelling cohort of mostly older male veterans, the investigators tested the hypothesis that PTSD symptoms are prospectively associated with CHD, even when controlling for depression.

Study Highlights

• Inclusion criteria at baseline were community-dwelling male veterans (primarily white; n = 2280) from the Greater Boston area, aged 21 to 80 years in 1961, and free of any known chronic medical conditions.
• Enrolled participants were male veterans who completed either the Mississippi Scale for Combat-Related PTSD in 1990 (n = 1002) or the MMPI-1 PK scale in 1986 (n = 944).
• Men with preexisting CHD or diabetes (n = 357) were excluded.
• The main outcome was incident CHD (defined as angina pectoris, nonfatal myocardial infarction, and fatal CHD) during follow-up through May 2001.
• The Mississippi Scale for Combat-Related PTSD, a 35-item self-report scale evaluating DSM-III PTSD symptoms and associated PTSD symptoms in which higher scores represent greater symptom severity, was used.
• The MMPI-2 PK scale also was used to evaluate symptoms and diagnose PTSD.
• Both scales yielded similar results, with results skewed toward lower levels of symptoms for PTSD.
• A board-certified cardiologist blind to the patients' PTSD symptom scores reviewed hospital records for every report of a possible CHD event.
• Every 3 to 5 years, participants were assessed by physical examination, medical history update, and measure of biochemical values.
• Coronary risk factors, including cigarette smoking status, systolic and diastolic blood pressure in both arms, body mass index, family history of CHD, alcohol consumption, and level of education were examined.
• Depressive symptoms were also assessed.
• Those completing the Mississippi Scale had a mean age of 63.0 ± 7.4 years; 15.8% were current smokers; 53.4% were former smokers; mean systolic blood pressure was 127.8 ± 16.4 mm Hg; mean diastolic blood pressure was 78.3 ± 8.9 mm Hg; mean serum cholesterol was 233.4 ± 42.9 mg/dL; mean body mass index was 26.6 ± 3.2 kg/m².
• Those completing the MMPI-2 PK scale had a mean age of 59.6 ± 7.4; 21.9% were current smokers; 44.9% were former smokers; mean systolic blood pressure was 127.6 mm Hg; diastolic blood pressure was 78.2 mm Hg; mean serum cholesterol level was 246.7 mg/dL; and mean body mass index was 26.5 kg/m².
• During the follow-up period, 116 men from the Mississippi Scale developed CHD (36 cases of incident myocardial infarction; 27, fatal CHD; 53, angina pectoris) and 139 from the MMPI-2 PK scale (52 cases of incident myocardial infarction; 24, fatal CHD; 63, angina pectoris).
• For each SD increase in symptom level on the Mississippi Scale, age-adjusted relative risk for total CHD was 1.26 (95% CI, 1.05 - 1.51; P = .01), with a marginally significant relationship after controlling for standard coronary risk factors.
• For each SD increase in symptom level on the MMPI-2 PK scale, age-adjusted relative risk for total CHD was 1.18 (95% CI, 0.97 - 1.43; P = .10), with a significant relationship after controlling for standard coronary risk factors.
• When all of the CHD end points were combined, each SD increase in the Mississippi Scale and the MMPI-2 PK scores was associated with an approximately 18% and 20% increased risk for combined angina and total CHD after controlling for known coronary risk factors, respectively.
• After controlling for levels of depressive symptoms, the link between PTSD and CHD was somewhat strengthened on both scales, particularly for nonfatal myocardial infarction and fatal CHD.
• On both scales, a positive association between angina and the Mississippi Scale (age adjusted relative risk [RR] = 1.16; 95% CI, 0.93 - 1.46; P = .19) and MMPI-2 PK scores (age adjusted RR = 1.23; 95% CI, 1.01 - 1.50; P = .04) existed.
• Scores from neither scale were significantly linked with all-cause mortality or mortality, excluding deaths due to CHD.

Pearls for Practice

• Higher levels of PTSD symptoms are associated with higher risk for CHD, especially for nonfatal myocardial infarction and fatal CHD combined, suggesting a possible dose-response relationship.
• Risk for combined angina and total CHD was increased by about 18% and 20% after controlling for known coronary risk factors, based on scores from the Mississippi Scale and the MMPI-2 PK scale, respectively.

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