PTSD Independently Linked to Ischemic Heart Disease

Caroline Cassels

November 14, 2013

Posttraumatic stress disorder (PTSD) has been linked to an increased risk for ischemic heart disease, new research shows.

A prospective study conducted by investigators at University of California, San Francisco, showed that myocardial ischemia was approximately twice as prevalent in patients with PTSD compared with those without the disorder.

"Posttraumatic stress disorder was associated with ischemic changes on exercise treadmill tests independent of traditional cardiac risk factors, C-reactive protein, and several health behaviors and psychosocial risk factors, suggesting additional mechanisms linking PTSD and ischemia should be explored," investigators led by Beth E. Cohen, MD, University of San Francisco and Department of Veterans Affairs Medical Center, write.

The study was published in the November issue of Biological Psychiatry.

Research Gap

Although it is already well known that patients with PTSD are at increased risk for cardiovascular disease (CVD), the investigators point out that few studies have included objective measures of CVD. In addition, how PTSD causes CVD remains unclear.

According to investigators, "there is a need for additional research on PTSD and CVD to address concerns from prior studies, including the limited use of objective measures of CVD and the lack of data on the mechanisms responsible for this association."

To examine the link between PTSD and objectively assessed CVD and the potential underlying mechanisms, the investigators enrolled 744 outpatients from 2 Veterans Affairs Medical Centers between 2008 and 2010.

PTSD was identified using the Clinician Administered PTSD Scale (CAPS); standardized exercise treadmill tests were performed to identify myocardial ischemia.

The investigators found that of the 663 participants with complete data, 230 (35%) had PTSD, with a mean CAPS score of 66.2. Participants' mean age was 58 years, 6% were women, and 59% identified their race as white.

Dose-Response Relationship

Myocardial ischemia was present in 43 (10%) of 433 participants without PTSD vs 40 (17%) of 233 patients with PTSD (P = .006).

After adjusting for potential confounders such as age, sex, and prior CVD as well as potential CVD mediators, including traditional cardiac risk factors, C-reactive protein, obesity, alcohol use, sleep quality, social support, and depression, the association between PTSD and myocardial ischemia remained significant (adjusted odds ratio, 2.42; 95% confidence interval, 1.39 - 4.22).

When researchers used past-month PTSD symptom score rather than a diagnosis of PTSD as a predictor, they found that patients with more severe symptoms were also significantly more likely to have myocardial ischemia.

The investigators note that this is the first study to evaluate PTSD and CVD using exercise treadmill testing, and as such, their findings "provide important validation of PTSD and increased CVD risk."

They add that although research into the underlying mechanisms of this relationship continues, the current findings suggest that by reducing PTSD symptom severity, clinicians may be able to lower cardiac risk in this patient population.

Potential Limitations

In an accompanying editorial, Viola Vaccarino, MD, PhD, and J. Douglas Bremner, MD, from Emory University in Atlanta, Georgia, write that the study has several limitations, including a potential for selection bias.

They note that study participants with PTSD who are identified through medical encounters may differ from those in nonselected populations.

"That this might be true is suggested by the fact that, in this study, patients with and without PTSD did not vary in smoking behavior or socioeconomic factors, which is surprising and inconsistent with previous studies," they write.

Nevertheless, they add that the current study provides "welcome new evidence of a link between PTSD and coronary heart disease."

The authors and editorialists report no relevant financial relationships.

Biol Psychiatry. 2013;74:861-866, 790-792. Abstract, Editorial

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