PTSD Associated With Increase of Mental Stress Induced Myocardial Infarction

Viola Vaccarino, MD, PhD

New research from Emory University is shedding light on a potential link between post-traumatic stress disorder (PTSD) and mental stress-induced myocardial ischemia in patients with stable coronary artery disease.

The study, which was led by Viola Vaccarino, MD, PhD, of the department of epidemiology at Emory University Rollins School of Public Health, yielded results indicating patients who survived a recent myocardial infarction (MI) and had PTSD were at a greater risk of developing myocardial ischemia than those who did not have PTSD.

In an effort to explore potential mechanisms through which PTSD may increase risk of adverse cardiovascular outcomes in patients with a recent MI, Vaccarino and colleagues designed a cross-sectional study of patients from the Myocardial infarction and Mental Stress Study. In total, the investigators' analysis included 303 patients from an Emory University-affiliated hospital in Atlanta with a documented MI in the previous 8 months.

The mean age of this cohort was 51 (7) years, 48.8% were women, 65.3% were African American and 44 patients (14.5%) had PTSD. Investigators assessed PTSD through a villain version of the PTSD Symptom Checklist, which is a 17-item scale that evaluates PTSD symptoms from within the past month.

Mental stress was evaluated through a standardized published speaking task in a controlled room after a 12-hour fast. Conventional stress testing was performed on a separate day but within a week of the mental stress evaluation—conventional stress was measured using the Bruce protocol or, when contraindicated, pharmacologic testing with regadenoson.

Additionally, vascular testing was performed before and after the mental stress test using Endo-PAT 2000 and endothelium-dependent brachial artery flow-mediated vasodilation. Investigators also noted myocardial perfusion imaging was performed at rest, after mental stress, and after conventional stress. High-sensitivity C-reactive protein levels were measured using serum samples collected prestress.

Patients with PTSD had greater rates of ischemia with mental stress than those without PTSD (27.3% vs. 14.7%; P=.04) and more than twice the mean number of ischemic segments (1.2 [95% CI, 0.5-1.8] vs. 0.5 [95% CI, 0.3-0.7]; P <.001). Conversely, there was no difference between the groups in regards to conventional stress ischemia (22.7% vs. 23.2%; P=.91).

Analysis revealed increasing levels of PTSD symptoms were associated with greater odds of ischemia with mental stress (adjusted Odds Ratio [aOR] per 5-point score increase, 1.18; 95% CI, 1.04-1.35; P=.01), but not with conventional stress (aOR per 5-point score increase, 1.05; 95% CI, 0.92-1.21; P=.47). When examining symptoms, reexperiencing trauma was most robustly associated with presence of ischemia with mental stress—other symptoms associated with presence of ischemia with mental stress were avoidance and numbing (aOR per 5-point score increase, 1.51; 95% CI, 1.07-2.14; P=.02).

Vaccarino and colleagues noted there were multiple limitations within their study. Limitations specially mentioned by investigators included lack of outcome data, being conducted at a single institution, and limited sensitivity and specificity from the mental stress test among others.

This study, “Association of Posttraumatic Stress Disorder With Mental Stress—Induced Myocardial Ischemia in Adults After Myocardial Infarction,” was published in JAMA Network Open.