Susan Jeffrey

June 08, 2015

TORONTO – Posttraumatic stress disorder (PTSD) is associated with impaired coronary distensibility and an increased risk for major adverse cardiac events (MACE), a new study shows.

Researchers report that PTSD was independently associated with impaired coronary distensibility, as reflected in the coronary distensibility index (CDI), as well as atherosclerosis and that it predicted MACE independent of age, sex, or other conventional coronary risk factors. Impaired coronary distensibility was also independently associated with the severity of PTSD symptoms.

"These results clearly point to the important role of impaired CDI as a first step in the continuum of the actual manifestations of coronary atherosclerosis on PTSD and its related poor cardiovascular outcome," Naser Ahmadi, MD, PhD, concluded. "This highlights incremental value of CDI in the identification and management of individuals with PTSD."

"Our conclusion was basically that there's a significant linkage between these two that can be used as a prognostication tool, coronary distensibility, to screen patients who are at risk for future problems," Dr Ahmadi told Medscape Medical News. It also supports a case for monitoring, he said, "because it's related to the severity of symptoms, and that's the direction that we're heading next."

Dr Ahmadi presented the results here at the American Psychiatric Association (APA) 2015 Annual Meeting.

Endothelial Dysfunction

Previous studies have linked PTSD to cardiovascular disease, including myocardial infarction, but "a conclusive link between PTSD and atherosclerosis has not been made," he said.

A recent article, for example, showed that PTSD was linked to increasing levels of coronary artery calcium. In comparison with those participants who did have have PTSD, the presence of PTSD was associated with increased risk for death at the same levels of coronary artery calcium.

Coronary endothelial-dependent microvascular dysfunction is an early reversible process in coronary artery disease (CAD) and is associated with poor clinical outcome, he noted.

Impaired CDI is an endothelial-dependent process and is associated with vulnerable plaque composition and cardiovascular mortality. "We recently reported that PTSD is independently associated with impaired CDI," Dr Ahmadi said.

In this study, they investigated the relationship of impaired CDI, as measured by CT angiography, with PTSD, as well as the combination of impaired CDI and PTSD with MACE, using data from the Veterans Health Administration, the largest healthcare system in the United States, which provides comprehensive physical and psychological care for veterans.

The study included 246 participants (mean age, 63 years; 12% women) with PTSD (n = 50) and without PTSD (n = 196). All underwent clinically indicated CT angiography (CTA) and CDI assessment, as well as assessment of psychological status to distinguish patients with PTSD from those without PTSD. CDI in the left anterior descending artery (LAD) was defined as follows: [(Early diastole - mid diastole lumen cross-section area (CSA) ÷ (lumen CSA in mid diastole × central pulse pressure) x 1000].

The PTSD Checklist–Military (PCL-M), and the Clinician Administered PTSD Scale (CAPS) were used to diagnose PTSD.

Electronic medical record review was used to determine diagnoses and outcomes; patients were followed for a mean of 50 months. MACE was defined as myocardial infarction or cardiovascular death. The investigators used survival regression to assess the relation of impaired CDI and PTSD with MACE.

The primary endpoint was the occurrence of myocardial infarction or cardiovascular death, verified by the Social Security Death Index obtained from electronic medical records, telephone interview follow-up, and primary physician verification.

They found that CDI was significantly lower in patients with PTSD than in patients without PTSD (3.4 ± 1.4 vs 4.8 ± 1.5; P = .01). This effect was more prominent in women than men (P = .0001).

CDI was inversely associated with severity of CAD and was more prominent in patients with PTSD than in patients without PTSD.

Table 1.

Model No PTSD PTSD P-value
Each standard deviation decrease in CDI 1.0 1.75 (1.23 - 2.56) .002
Decreased CDI and nonobstructive CAD 1.0 5.1 (2.5 - 8.8) .01
Decreased CDI and obstructive CAD 1.0 7.5 (2.3 - 15.2) .001


After adjustment for risk factors, the relative risk for MACE was 56% higher in those with PTSD than in those without PTSD (P = .001). Similarly, the relative risk for MACE was 95% higher with each unit decrease in CDI (P = .001).

However, regression analyses showed significant linkage between PTSD and impaired CDI with increased risk for MACE, Dr Ahmadi said. After adjustment for age, sex, conventional risk factors, and CTA-diagnosed CAD, the relative risk for MACE was 234% higher with each unit decrease in CDI and presence of PTSD as compared with those without PTSD (P = .001).

Table 2. Risk for MACE With PTSD, Decrease in CDI, or Combination

Measure Hazard Ratio 95% Confidence Interval P -value
PTSD 1.56 1.34 - 3.14 .001
Each standard deviation decrease in CDI 1.95 1.27 - 3.01 .001
PTSD plus each standard deviation decrease in CDI 3.24 2.02 - 5.53 .001


Receiving operating characteristic (ROC) curves showed that the area under the curve for PTSD alone in predicting MACE was .69 but increased to .94 for the combination of PTSD, impaired CDI plus confirmed CAD.

After adjustment for risk factors, event-free survival was 98% among those without PTSD whose CDI values were normal; it was 86.2% for those without PTSD but whose CDI values indicated impairment; it was 89.5% for those with PTSD but with normal CDI; and it was 67.5% for those with both PTSD and impaired CDI (P = .001).

Dr Naser Ahmadi

"Further studies are warranted to investigate early diagnosis of PTSD and its related coronary atherosclerosis, and management can prevent MACE," Dr Ahmadi concluded.

Their group is already investigating further, Dr Ahmadi told Medscape Medical News. In one study, they are investigating whether treatment of PTSD can positively affect coronary distensibility. They hope to then conduct a longer-term study to see whether successful PTSD intervention at an early stage might prevent long-term MACE.

The authors report no relevant financial relationships.

American Psychiatric Association (APA) 2015 Annual Meeting. Psychosomatic and consultative psychiatry presentation 1. Presented May 18, 2015.


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