Coronary Procedures and Outcomes in Veterans With PTSD
Coronary Procedures and Outcomes in Veterans With PTSD
Background Posttraumatic stress disorder (PTSD) is prevalent in the general population and US veterans in particular and is associated with an increased risk of developing coronary artery disease (CAD). We compared the patient characteristics and postprocedural outcomes of veterans with and without PTSD undergoing coronary angiography.
Methods This is a multicenter observational study of patients who underwent coronary angiography in Veterans Affairs hospitals nationally from October 2007 to September 2011. We described patient characteristics at angiography, angiographic results, and after coronary angiography, we compared risk-adjusted 1-year rates of all-cause mortality, myocardial infarction (MI), and revascularization by the presence or absence of PTSD.
Results Overall, of 116,488 patients undergoing angiography, 14,918 (12.8%) had PTSD. Compared with those without PTSD, patients with PTSD were younger (median age 61.9 vs 63.7; P < .001), had higher rates of cardiovascular risk factors, and were more likely to have had a prior MI (26.4% vs 24.7%; P < .001). Patients with PTSD were more likely to present for stable angina (22.4% vs 17.0%) or atypical chest pain (58.5% vs 48.6%) and less likely to have obstructive CAD identified at angiography (55.9% vs 62.2%; P < .001). After coronary angiography, PTSD was associated with lower unadjusted 1-year rates of MI (hazard ratio (HR), 0.86; 95% CI [0.75–1.00]; P = 0.04), revascularization (HR, 0.88; 95% CI [0.83–0.93]; P < .001), and all-cause mortality (HR, 0.66; 95% CI [0.60–0.71]; P < .001). After adjustment for cardiovascular risk, PTSD was no longer associated with 1-year rates of MI or revascularization but remained associated with lower 1-year all-cause mortality (HR, 0.91; 95% CI [0.84–0.99]; P = .03). Findings were similar after further adjustment for depression, anxiety, alcohol or substance use disorders, and frequency of outpatient follow-up.
Conclusions Among veterans undergoing coronary angiography in the Veterans Affairs, those with PTSD were more likely to present with elective indications and less likely to have obstructive CAD. After coronary angiography, PTSD was not associated with adverse 1-year outcomes of MI, revascularization, or all-cause mortality.
Posttraumatic stress disorder (PTSD) is thought to affect 7% of the US population, with a higher prevalence among combat veterans. The disorder is a cause of substantial mental and physical health burden. One contributor to this burden is coronary artery disease (CAD). Studies have consistently demonstrated that patients with PTSD are at increased risk for developing and dying of CAD, relative to patients without PTSD. However, the diagnosis and management of CAD among patients with PTSD, with its consequent effects on cardiac outcomes, are poorly described.
In the diagnosis and management of CAD, coronary angiography has an important role. The clinical decision to proceed with coronary angiography is based upon patient symptoms, risk of CAD, and the implications of possible angiographic findings. Among patients with PTSD, consideration for coronary angiography may be complicated by somatic symptoms, including chest pain as well as a higher prevalence of cardiovascular risk factors. Thus, providers may be more likely to refer patients with PTSD for coronary angiography. Alternatively, ischemic symptoms may be incorrectly attributed to somatic symptoms of PTSD, either by the provider or by the patient, leading to delays in referral to coronary angiography. To date, the results of coronary angiography have not been described among patients with PTSD.
In addition to implications for patient selection, PTSD may impact patient outcomes after coronary angiography. Not only is PTSD independently associated with cardiovascular mortality, PTSD is also strongly associated with concurrent depression and anxiety, both of which are associated with cardiovascular mortality. Furthermore, PTSD is associated with alcohol and substance use as well as differences in frequency of outpatient follow-up that may contribute to postprocedural outcomes. However, outcomes after coronary angiography among patients with PTSD have not been studied.
The VA Clinical Assessment, Reporting, and Tracking (CART) Program provides a unique opportunity to evaluate the patient characteristics, procedural indications, and results of coronary angiography among patients with and without PTSD as well as their longitudinal outcomes. The CART Program collects patient and procedural data from all veterans undergoing coronary angiography. Using these data, we described the characteristics and angiographic results of patients diagnosed with PTSD who have undergone coronary angiography. We then evaluated risk-adjusted 1-year outcomes of patients after coronary angiography, comparing them by the presence or absence of PTSD diagnosis. Finally, we determined whether concurrent depression or anxiety, alcohol or substance use disorders, or frequency of postprocedural follow-up explained differences in risk-adjusted outcomes among patients with versus without PTSD.
Abstract and Introduction
Abstract
Background Posttraumatic stress disorder (PTSD) is prevalent in the general population and US veterans in particular and is associated with an increased risk of developing coronary artery disease (CAD). We compared the patient characteristics and postprocedural outcomes of veterans with and without PTSD undergoing coronary angiography.
Methods This is a multicenter observational study of patients who underwent coronary angiography in Veterans Affairs hospitals nationally from October 2007 to September 2011. We described patient characteristics at angiography, angiographic results, and after coronary angiography, we compared risk-adjusted 1-year rates of all-cause mortality, myocardial infarction (MI), and revascularization by the presence or absence of PTSD.
Results Overall, of 116,488 patients undergoing angiography, 14,918 (12.8%) had PTSD. Compared with those without PTSD, patients with PTSD were younger (median age 61.9 vs 63.7; P < .001), had higher rates of cardiovascular risk factors, and were more likely to have had a prior MI (26.4% vs 24.7%; P < .001). Patients with PTSD were more likely to present for stable angina (22.4% vs 17.0%) or atypical chest pain (58.5% vs 48.6%) and less likely to have obstructive CAD identified at angiography (55.9% vs 62.2%; P < .001). After coronary angiography, PTSD was associated with lower unadjusted 1-year rates of MI (hazard ratio (HR), 0.86; 95% CI [0.75–1.00]; P = 0.04), revascularization (HR, 0.88; 95% CI [0.83–0.93]; P < .001), and all-cause mortality (HR, 0.66; 95% CI [0.60–0.71]; P < .001). After adjustment for cardiovascular risk, PTSD was no longer associated with 1-year rates of MI or revascularization but remained associated with lower 1-year all-cause mortality (HR, 0.91; 95% CI [0.84–0.99]; P = .03). Findings were similar after further adjustment for depression, anxiety, alcohol or substance use disorders, and frequency of outpatient follow-up.
Conclusions Among veterans undergoing coronary angiography in the Veterans Affairs, those with PTSD were more likely to present with elective indications and less likely to have obstructive CAD. After coronary angiography, PTSD was not associated with adverse 1-year outcomes of MI, revascularization, or all-cause mortality.
Introduction
Posttraumatic stress disorder (PTSD) is thought to affect 7% of the US population, with a higher prevalence among combat veterans. The disorder is a cause of substantial mental and physical health burden. One contributor to this burden is coronary artery disease (CAD). Studies have consistently demonstrated that patients with PTSD are at increased risk for developing and dying of CAD, relative to patients without PTSD. However, the diagnosis and management of CAD among patients with PTSD, with its consequent effects on cardiac outcomes, are poorly described.
In the diagnosis and management of CAD, coronary angiography has an important role. The clinical decision to proceed with coronary angiography is based upon patient symptoms, risk of CAD, and the implications of possible angiographic findings. Among patients with PTSD, consideration for coronary angiography may be complicated by somatic symptoms, including chest pain as well as a higher prevalence of cardiovascular risk factors. Thus, providers may be more likely to refer patients with PTSD for coronary angiography. Alternatively, ischemic symptoms may be incorrectly attributed to somatic symptoms of PTSD, either by the provider or by the patient, leading to delays in referral to coronary angiography. To date, the results of coronary angiography have not been described among patients with PTSD.
In addition to implications for patient selection, PTSD may impact patient outcomes after coronary angiography. Not only is PTSD independently associated with cardiovascular mortality, PTSD is also strongly associated with concurrent depression and anxiety, both of which are associated with cardiovascular mortality. Furthermore, PTSD is associated with alcohol and substance use as well as differences in frequency of outpatient follow-up that may contribute to postprocedural outcomes. However, outcomes after coronary angiography among patients with PTSD have not been studied.
The VA Clinical Assessment, Reporting, and Tracking (CART) Program provides a unique opportunity to evaluate the patient characteristics, procedural indications, and results of coronary angiography among patients with and without PTSD as well as their longitudinal outcomes. The CART Program collects patient and procedural data from all veterans undergoing coronary angiography. Using these data, we described the characteristics and angiographic results of patients diagnosed with PTSD who have undergone coronary angiography. We then evaluated risk-adjusted 1-year outcomes of patients after coronary angiography, comparing them by the presence or absence of PTSD diagnosis. Finally, we determined whether concurrent depression or anxiety, alcohol or substance use disorders, or frequency of postprocedural follow-up explained differences in risk-adjusted outcomes among patients with versus without PTSD.