Disrupted Sleep After Cardiac Event May Increase PTSD Risk

Megan Brooks

June 05, 2018

BALTIMORE — Patients with disrupted sleep in the month after acute coronary syndrome (ACS) are at increased risk for posttraumatic stress disorder (PTSD), results of an observational study suggest.

"These findings suggest that targeting and addressing sleep difficulties after an ACS event may be helpful in preventing adverse psychological outcomes like PTSD," Ari Shechter, PhD, from the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University, New York City, told Medscape Medical News.

The findings were presented here at SLEEP 2018: 32nd Annual Meeting of the Associated Professional Sleep Societies.

"ACS-induced PTSD is relatively common, occurring in about 1 in 8 patients. Sleep disturbances are a hallmark of PTSD, so we were interested in looking at the relationship between short-duration and poor-quality sleep after an ACS event and the subsequent development of PTSD," Schechter added.

Striking Results

The researchers analyzed data on 270 patients (mean age, 61 years; 48% women) enrolled in the Reactions to Acute Care and Hospitalization (REACH) study, an ongoing observational cohort study to determine factors associated with poor long-term psychiatric and medical outcomes after evaluation for ACS.

One month after ACS evaluation, patients reported sleep duration and sleep quality. PTSD was assessed at 6 months by using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) PTSD checklist (PCL-5).

One month after ACS, 56% of patients reported short sleep (<7 hours/night) and 30% reported poor sleep quality (fairly/very bad).

"It is striking," said Schechter, "that close to 60% of the patients were reporting sleep that is of short duration in the month following their ACS event, and that more than 1 in 4 patients reported a combination of short-duration and poor-quality sleep during this time. This is important," he noted, "since we know from other studies that short-duration sleep — and, in particular, the combination of short and poor-quality sleep —  is associated with adverse cardiovascular outcomes."

More than 1 in 10 patients (11%) developed PTSD (PCL-5 score ≥ 38). Sleep was significantly shorter and of worse quality in those with PTSD than in  those without. 

Patients with short sleep or with both short and poor-quality sleep in the month after an ACS evaluation had a greater than threefold odds of developing PTSD at 6 months compared with those with sufficient and/or good-quality sleep.

Table. Sleep at 1 Month and Odds of PTSD at 6 Months After ACS

Variable Adjusted Odds Ratio (95% Confidence Interval)
Short sleep (≤6 h/night) 3.34 (1.08 - 10.32)
Poor sleep quality 2.68 (0.99 - 7.23)
Short and poor sleep 3.54 (1.29 to 9.68)


"It is important to note that we can't tell exactly the mechanism linking poor sleep to ACS-induced PTSD from this study, or even really the direction of the relationship: for example, whether the poor sleep is causing PTSD or whether the individuals who have PTSD experience worsened sleep," Schechter told Medscape Medical News.

"Poor sleep can contribute to physiological stress, for example by causing autonomic nervous system dysregulation and increasing sympathetic nervous system activation. Short or poor-quality sleep can also cause us to feel anxious or stressed out, and the combination of this psychological and physiological stress and arousal might be one way that poor sleep can contribute to the development of PTSD," he noted.

"We also know that poor sleep following an ACS event can contribute to recurrent events and mortality. So overall, while there is more work to be done, these findings suggest that the prevention and/or treatment of poor sleep should be prioritized following a coronary event to help enhance psychological and physiological health," said Schechter.

Interesting Observation

Commenting on the findings for Medscape Medical News, David Rapoport, MD, director of the Sleep Medicine Research Program at Mount Sinai in New York City, noted that "people who have had a stressful event are known to develop PTSD. According to this study, people who are not sleeping [after ACS] are statistically likely to develop PTSD."

But one shouldn't assume causality, he cautioned. "Disturbed sleep is one of the cardinal symptoms of PTSD, so I don't know if poor sleep is actually the cause of the PTSD. The conclusion that attending to sleep will prevent PTSD is probably not clearly proven by this data," said Rapoport. 

Nonetheless, he said, this is "an interesting observation and it's perhaps useful for the clinician to ask about these things."

The study had no commercial funding. The authors and Rapoport have disclosed no relevant financial relationships.

SLEEP 2018: 32nd Annual Meeting of the Associated Professional Sleep Societies. Abstract 0944. Presented June 5, 2018.

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