No Relief for Some Heart Attack Survivors

Friday, December 28, 2012

Post-traumatic stress disorder (PTSD) initiated by a cardiac event, such as a heart attack, may precipitate a second event, according to recent studies.

Authors of a June 2012 study published by PLoS ONE, led by Donald Edmondson, Ph.D., assistant professor of behavioral medicine at the Center for Behavioral Cardiovascular Health at Columbia University, found a 12% prevalence rate of PTSD caused by an acute cardiovascular syndrome (ACS), such as myocardial infarction or unstable angina, in 48 studies dating back to 1994. The study also found that PTSD caused by an initial cardiovascular event approximately doubled the risk for a repeated cardiac event or death.

Doubling the Risk of Recurrence

According to statistics compiled by the American Heart Association, the Centers for Disease Control and Prevention, and the National Institutes of Health, 610,000 people in the United States suffer their first heart attack every year. The PLoS ONE study, titled “Posttraumatic Stress Disorder Prevalence and Risk of Recurrence in Acute Coronary Syndrome Patients: A Meta-Analytic Review,” suggests 73,200 of these patients will develop PTSD following their initial heart attack.

“If you’re looking at a patient and evaluating how this person is doing after a heart attack — any concerns you may have about them going forward — let depression and PTSD both come to mind,” says Dr. Edmondson. “If depression is not happening, then PTSD very well may be.”

Through physiological and behavioral pathways, PTSD leads patients to increased risk for recurrent cardiac events, says Dr. Edmondson. PTSD causes increased autonomic nervous system activity, which is responsible for the “fight or flight” mechanism. Reminders of the initial heart attack may prove unavoidable for patients who have developed PTSD. Meeting with increased autonomic activity, each intrusive thought causes physiologic hyperarousal, resulting in elevated blood pressure and spikes in heart rate, eventually leading to cardiovascular inflammation and atherosclerosis, which lead to hypertension and plaque rupture — conditions that contribute to further cardiovascular events.

Although only one study has been conducted to examine the efficacy of psychotherapy on patients with heart attack-related PTSD, Dr. Edmondson says prolonged exposure — a treatment during which the patient and therapist discuss the traumatic aspects of the heart attack — may be able to change how patients react to intrusive thoughts.

In an effort to stave off intrusive thoughts, patients may attempt to avoid reminders of their cardiac events. This sounds practical in theory, but when physicians prescribe medicine for cardiovascular conditions and ask patients to closely monitor their heart rates, every instance of elevated heart rate may trigger reminders of the initial episode and usher in physiological and psychological arousal symptoms. To prevent this, patients often avoid taking medications or monitoring their heart rates, increasing the risk for a second cardiac event.

"Like a Loaded Gun"

Avoidance may be easier for people who have developed PTSD as a result of external trauma such as war or assault. As Dr. Edmondson points out, war veterans can avoid the battlefield or places reminiscent of war. Sexual assault victims may be able to avoid the people who assaulted them or the places where the traumas occurred. However, people who have developed PTSD triggered by an internal event, such as a heart attack or another medical emergency, carry the reminder with them at all times. Every heartbeat serves as a reminder of their mortality.

“A stroke survivor told me, ‘It’s like having a loaded gun pointed at my head at all times,’” Dr. Edmondson relates. “I think it is really important that we consider this when it comes to patients who have developed PTSD due to cardiac or cardiovascular events. We have to take into account that, even after patients have been cleared by their physicians, the patients walk around with what is, in their minds, a loaded weapon pointed at them.”

The Younger Patient’s Dilemma

Dr. Edmondson’s study reported a greater prevalence of PTSD following cardiac episodes in younger patients. Although sufficient testing has not been conducted to explore the age connection, Dr. Edmondson theorizes it’s because younger patients view heart attacks as “out of the blue” occurrences. Younger patients have not yet reached the stage in life where it is expected for their bodies to break down, and psychologically, Dr. Edmondson says, it simply does not make sense for a potentially fatal cardiac event to occur. With the associated emotions compounded by this sense of self-doubt, the event may take on even more threatening qualities.

Severity Doesn’t Matter

Physicians need not dismiss patients’ fears simply because their cardiac events weren’t serious. In fact, Dr. Edmondson says severity doesn’t have anything to do with the development of PTSD.

“We’ve found that the objective severity of the heart attack doesn’t matter very much,” says Dr. Edmondson. “It’s really about the subjective experience. As the field of cardiology continues to make treatment breakthroughs, the more patients find that heart attacks are not the death penalty they once were, which may lessen the traumatization of the precipitating event.”