In patients who receive implantable cardiac defibrillators after a sudden heart event, there is a higher likelihood of death within five years if they experience symptoms of post-traumatic stress disorder, according to a report released on November 3, 2008 in Archives of General Psychiatry, one of the JAMA/Archives journals.
When a life-threatening heart condition is severe and has acute onset, such as a case of heart attack or cardiac arrest, even survival can cause significant distress for the patient. As a result, many patients experience symptoms that indicate a diagnosis of post-traumatic stress disorder (PTSD,) including intense fear, painful intrusive memories, and hyperarousal, which is a state of internal tension due to the fight-or-flight response. According to the article, PTSD is developed by between 8% and 20% of all patients with acute coronary syndromes and by 27% to 38% of cardiac arrest survivors.
To investigate the effects of PTSD on these patients, Karl-Heinz Ladwig, Ph.D., M.D., of Technische Universitaet Muenchen, Munich, and Helmholtz Zentrum National Research Center for Environmental Health, Neuherberg, Germany, and colleagues examined 211 patients who had received implantable cardiac defibrilators following a heart event in 1998. The subjects were questioned an average of 27 months after implementation. Further tracking continued using medical records, telephone interviews, family member surveys, and death certificates through March 2005.
A total 38 patients reported symptoms of severe PTSD. In an average five year follow up period, 30.6% (45) patients died — this included 29% of patients with low or moderate PTSD symptoms (32 of 109), and 34% of patients with high levels of these symptoms (13 of 38). The authors emphasize this correlation: “Our findings provide direct evidence for an independent influence of PTSD symptoms on fatal outcome in these patients,” they write. “Experiencing PTSD symptoms conferred a 2.4-fold long-term age- and sex-adjusted mortality risk for patients with implantable cardiac defibrillators.”
Chest pain and other cardiac symptoms were more prevalent in patients with PTSD than those without. Clinical characteristics such as defibrilator function, which often account for survival differences, were similar between the two groups. The authors note that this may be an affect of perception: “Therefore, the perceived severity rather than the objective severity of a cardiac condition as determined by cardiac criteria may be associated with PTSD.”
The authors note that more research must be done to understand this association: “Further investigations are required to assess the behavioral and biologic pathways by which post-traumatic maladaptation contributes to the excess mortality risk in patients with implantable cardiac defibrillators.” For instance, the medical measures taken in cardiac care, such as prescriptions, could create “traumatic reminders” for patients with PTSD. A potential future action might be to ignore or avoid these actions.
The authors conclude that psychosocial care is necessary for patients with implantable cardiac defibrilators. “The findings underline the urgent need for routinely applied comprehensive and interdisciplinary psychosocial aftercare for patients with implantable cardiac defibrillators.” They continue: “Although the serious mortality risk of PTSD in patients with implantable cardiac defibrillators needs to be further investigated before firm recommendations can be made, screening for PTSD symptoms in patients with implantable cardiac defibrillators is likely to be clinically beneficial, and treatment in selected patients should be attempted.”
Posttraumatic Stress Symptoms and Predicted Mortality in Patients With Implantable Cardioverter-Defibrillators
Results From the Prospective Living With an Implanted Cardioverter-Defibrillator Study
Karl-Heinz Ladwig, PhD, MD; Jens Baumert, PhD; Birgitt Marten-Mittag, PhD; Christof Kolb, MD; Bernhard Zrenner, MD; Claus Schmitt, MD
Arch Gen Psychiatry. 2008;65(11):1324-1330.
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Written by Anna Sophia McKenney