Cardiac arrest-induced PTSD ups risk for death, major CV events

Sachin Agarwal

CHICAGO — Patients who exhibit signs of posttraumatic stress disorder after cardiac arrest are nearly three times as likely to die or experience a major adverse CV event within 1 year, according to a study presented at the American Heart Association Resuscitation Science Symposium.

“Medical and public health advances have recently made cardiac arrest a survivable event, but 1 in 3 survivors screen positive for cardiac arrest-induced PTSD as they leave the hospital. Clinicians have no way of knowing the psychological consequences of cardiac arrest, as researchers and the health care system are only recently coming to expect that cardiac arrest patients will survive neurologically intact,” lead researcher Sachin Agarwal, MD, MPH, from Columbia University Medical Center, wrote in an email to Cardiology Today

“Our prior research on ACS patients suggests that patients’ psychological response to cardiac arrest may powerfully influence the behaviors and underlying physiology that determine whether patients will have a CVD event or die within the year,” he said.

Heightened risks

Agarwal and colleagues conducted a prospective, observational cohort study of consecutive adults who survived cardiac arrest with mild to moderate brain injury at a tertiary care center from 2015 to 2017. The PTSD Checklist – Specific (PCL-5) Scale, administered within 24 hours of hospital discharge, was used to evaluate cardiac arrest-induced PTSD symptoms.

The primary endpoint was all-cause mortality or major adverse cardiac events, including hospitalization for nonfatal MI, unstable angina, congestive HF, emergency coronary revascularization or urgent ICD or pacemaker placement within 12 months after cardiac arrest. Median follow-up was 12.4 months.

At a median 21 days after cardiac arrest, 31.6% of 114 patients had cardiac arrest-induced PTSD. During the following 12 months, 8.8% of the patients with PTSD died and 25.4% had recurrent major adverse cardiac events. Of those who experienced major adverse cardiac events, 13.8% were rehospitalized for MI, 27.6% had unstable angina, 13.8% had congestive HF exacerbations, 17.2% underwent emergency revascularization and 27.6% had ICDs or permanent pacemakers implanted.

In univariate analysis, cardiac arrest-induced PTSD was linked to a threefold increased risk for all-cause mortality or major adverse cardiac events (HR = 3.19; 95% CI, 1.7-6). Risk remained higher in patients with PTSD in models adjusted for age, sex, comorbidities and non-shockable initial rhythms (HR = 3.2; 95% CI, 1.7-6.1).

Agarwal noted that the 30% prevalence of posttraumatic stress symptoms after cardiac arrest is on par with findings from previous studies. This study, however, demonstrates powerful associations between cardiac arrest-induced posttraumatic stress symptoms and CVD events within 1 year after the index event, even after adjustment for confounders.

“Because of the large effect size, high event rates and prevalence of PTSD, the study could achieve 90% power with a sample size of 114,” he said.

Future implications

These findings, according to Agarwal, have established a link between cardiac arrest-induced PTSD and both survival and CVD outcomes in the largest prospective cohort of survivors of cardiac arrest.

“There are no current clinical practice guidelines for identifying or treating the psychological consequences of cardiac arrest because there is no evidence to support such guidelines. The findings of the current research may form the foundation for future guidelines to improve event-free survival in cardiac arrest through improved detection and management of cardiac arrest-induced PTSD,” he told Cardiology Today. “Given the increasing number of Americans living with the consequences of cardiac arrest and the high costs to both individuals and the health care system, a better understanding of the factors that influence cardiac arrest prognosis and quality of life in cardiac arrest survivors with good neurological recovery is a major public health priority.”

Although these results shed light on an important aspect of cardiac arrest care, there are still questions that need answering, Agarwal noted.

“The mechanisms by which PTSD is thought to increase secondary CVD risk include autonomic imbalance and its downstream effects (eg, increased BP, endothelial dysfunction, excess inflammation, atherosclerosis) and behavioral dysregulation (eg, medication nonadherence, sedentary behavior, excess tobacco and alcohol use). These mechanisms need to be clarified and studied in patients with cardiac arrest,” he said. – by Melissa Foster

Reference:

Agarwal S, et al. Presentation 13. Presented at: American Heart Association Resuscitation Science Symposium; Nov. 10-11, 2018; Chicago.

For more information:

Sachin Agarwal, MD, MPH, can be reached at sa2512@columbia.edu; Twitter: @sacagarw.

Disclosure: The researchers report no relevant financial disclosures.