Post-traumatic stress disorder and cardiovascular disease

Summary

In this paper, a first in a Series of two, we look at the evidence for an association of post-traumatic stress disorder with incident cardiovascular disease risk and the mechanisms that might cause this association, as well as the prevalence of post-traumatic stress disorder due to cardiovascular disease events and its associated prognostic risk. We discuss research done after the publication of previous relevant systematic reviews, and survey currently funded research from the two most active funders in the field: the National Institutes of Health and the US Veterans Administration. We conclude that post-traumatic stress disorder is a risk factor for incident cardiovascular disease, and a common psychiatric consequence of cardiovascular disease events that might worsen the prognosis of the cardiovascular disease. There are many candidate mechanisms for the link between post-traumatic stress disorder and cardiovascular disease, and several ongoing studies could soon point to the most important behavioural and physiological mechanisms to target in early phase intervention development. Similarly, targets are emerging for individual and environmental interventions that might offset the risk of post-traumatic stress disorder after cardiovascular disease events.

Introduction

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that occurs in 7–8% of civilians1, 2 and as many as 20% of military veterans,³ although changes in diagnostic criteria might alter these estimates slightly.⁴ PTSD symptoms include re-experiencing symptoms, avoidance of trauma reminders, physiological hyperarousal, and persistent negative alterations in cognition and mood.⁵ Investigation of the association of PTSD symptoms with the development and prognosis of cardiovascular disease began less than 20 years ago,⁶ but it has progressed rapidly thanks to the more established literature describing the effect of stress on cardiovascular risk.

The current understanding of the link between PTSD and cardiovascular disease is that PTSD is probably an independent risk factor for acute cardiac events including acute coronary syndromes (ie, myocardial infarction or unstable angina) and possibly stroke.⁷ The association of PTSD with cardiovascular disease risk is probably due to interacting behavioural and physiological mechanisms that relate to PTSD symptoms and, in turn, influence cardiovascular disease risk. Additionally, acute and potentially life-threatening cardiovascular disease events can themselves cause PTSD, and PTSD secondary to cardiovascular disease events might be associated with increased risk for subsequent cardiovascular disease events and mortality.⁸

In this paper we describe the emerging epidemiological, mechanistic, and intervention literature on the association of PTSD with incident cardiovascular disease risk in individuals exposed to potentially traumatic events such as combat and sexual assault, and with recurrent cardiovascular disease risk in patients with cardiovascular disease who develop PTSD secondary to an acute cardiovascular disease event. Where possible, we include estimates from the most recent systematic review and meta-analyses (table), and report on research identified in systematic searches. We also highlight important unanswered questions and active funded research in each area.