Posttraumatic stress disorder and mortality in VA patients with implantable cardioverter-defibrillators.

BACKGROUND: The association between posttraumatic stress disorder (PTSD) and mortality in patients undergoing implantable cardioverter-defibrillator (ICD) placement has not been evaluated in US veterans. HYPOTHESIS: PTSD in veterans with ICD is associated with increased mortality. METHODS: We studied a retrospective cohort of 25 678 veterans who underwent ICD implantation between September 30, 2002, and December 31, 2011. Of these subjects, 3280 carried the diagnosis of PTSD prior to ICD implantation. Primary outcome was all-cause mortality between date of ICD implantation and end of follow-up (September 30, 2013). We used Cox proportional hazard models to compute multivariable adjusted hazard ratios with corresponding 95% confidence intervals for the relation between PTSD diagnosis and death following ICD placement. RESULTS: During a mean follow-up of 4.21 ± 2.62 years, 11 015 deaths were reported. The crude incidence rate of death was 87.8 and 103.9/1000 person-years for people with and without PTSD, respectively. We did not find an association between presence of PTSD before or after ICD implantation and incident death when adjusted for multiple risk factors (hazard ratio: 1.003, 95% confidence interval: 0.948-1.061). In secondary analysis, no statistically significant association was found. CONCLUSIONS: In this retrospective cohort study among more than 25 000 veterans undergoing ICD implantation, almost 13% had a diagnosis of PTSD. Subjects with PTSD were significantly younger, yet they had a higher incidence of coronary heart disease, major cardiac comorbidities, cancer, and mental health conditions. We found no association between presence of PTSD before or after ICD implantation and incident death when adjusting for all covariates.

Cardiovascular Disease Risk Factors in Patients with Posttraumatic Stress Disorder (PTSD): A Narrative Review.

Posttraumatic stress disorder (PTSD) is a chronic condition related to severe stress and trauma. There is a mounting evidence about increased prevalence and mortality from cardiovascular diseases (CVD) in patients with PTSD. This review summarizes the current data on possible relations between PTSD and increased risks of CVD, including biological, psychological and behavioral factors. Biological factors refer to increased prevalence of metabolic syndrome (MetS), hypertension, elevation of pro-inflammatory cytokines and homocysteine levels. Peripheral Brain-derived neurotropic factor (BDNF), serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and quantitative electroencephalogram (qEEG) are promising surrogate markers of increased cardiovascular risk. Among psychological factors, some personality traits, such as neuroticism and trait impulsivity/hostility, contribute to the development of PTSD, and are associated with general cardiovascular distress. Recently, type-D (distressed) personality is usually investigated in relation to cardiovascular morbidity, but in populations other than PTSD patients. Behavioral factors refer to unhealthy life-styles, encompassing high smoking rate, drug substances abuse and addiction, physical inactivity and unhealthy diet. The relationships among all these factors are complex and yet incompletely taken into consideration. Because of a high prevalence of CVD in patients with PTSD, there is a strong need for a more intensive focus on this vulnerable population in both primary and secondary cardiovascular prevention as well as in effective treatment possibilities.

Effect of elective surgery on subjective health in veterans with chronic posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is common, is often chronic, and has been associated with greater risk of postoperative mortality in veterans. The purpose of this study was to determine if elective outpatient surgery had a persistent effect on the physical or mental health of veterans with chronic PTSD. A longitudinal, quasi-experimental study was conducted that followed up 60 veterans with chronic PTSD over 12 weeks. Self-reported physical and mental health, depressive symptom severity, and posttraumatic symptom severity were measured in 29 veterans undergoing outpatient elective surgery and 31 veterans not having elective surgery (controls). Data collection was performed at baseline and repeated 1, 4, and 12 weeks after surgery or enrollment. At baseline, both surgical and control subjects reported poor physical and mental subjective health status. After surgery, surgical group subjects reported mean age- and gender-adjusted reductions of 3.9 points on the Physical Component Summary score and 2.9 points on the Mental Component Summary score of the Veterans Rand 36-item Health Survey, which resolved by 4 weeks after surgery. These findings suggest that veterans with PTSD were at greater risk of mortality because of poor baseline health, but did not demonstrate persistent decline in health following common elective surgical procedures.

Cardiac biomarkers, mortality, and post-traumatic stress disorder in military veterans.

Post-traumatic stress disorder (PTSD) is gaining increasing recognition as a risk factor for morbidity and mortality. The aim of this study was to examine the impact of PTSD and abnormal cardiovascular biomarkers on mortality in military veterans. Eight hundred ninety-one patients presenting for routine echocardiography were enrolled. Baseline clinical data and serum samples for biomarker measurement were obtained and echocardiography was performed at the time of enrollment. Patients were followed for up to 7.5 years for the end point of all-cause mortality. Ninety-one patients had PTSD at the time of enrollment. There were 33 deaths in patients with PTSD and 221 deaths in those without PTSD. Patients with PTSD had a trend toward worse survival on Kaplan-Meier analysis (p = 0.057). Among patients with elevated B-type natriuretic peptide (>60 pg/ml), those with PTSD had significantly increased mortality (p = 0.024). Among patients with PTSD, midregional proadrenomedullin (MR-proADM), creatinine, and C-terminal proendothelin-1 were significant univariate predictors of mortality (p = 0.006, p = 0.024, and p = 0.003, respectively). In a multivariate model, PTSD, B-type natriuretic peptide, and MR-proADM were independent predictors of mortality. In patients with PTSD, MR-proADM was a significant independent predictor of mortality after adjusting for B-type natriuretic peptide, cardiovascular risk factors, cancer, and sleep apnea. Adding MR-proADM to clinical predictors of mortality increased the C-statistic from 0.572 to 0.697 (p = 0.007). In conclusion, this study demonstrates an association among PTSD, abnormal cardiac biomarker levels, and increased mortality.

The perioperative implications of posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is an anxiety disorder that develops after exposure to a traumatic event and is characterized by symptoms of reexperiencing, emotional numbing, persistent arousal, and avoidance. Approximately 6.8% of the people in the United States will be diagnosed with PTSD at some point in their lives. The presence of PTSD in a surgical patient can be important because PTSD is associated with the use of psychoactive medications, risky health behaviors, cardiovascular comorbidities, depression, chronic pain, and cognitive dysfunction, all of which may influence the risk of perioperative morbidity and mortality. In addition, patients with PTSD are anxious around unfamiliar people and in unfamiliar environments. The purposes of this journal course are to provide anesthetists with a working knowledge of the symptoms, treatments, and comorbidities associated with PTSD and to suggest ways of interacting with patients with the disorder that increase trust and decrease the risk of evoking posttraumatic symptoms in the perioperative environment.

Miocardiopatía por estrés como causa de muerte súbita durante un asalto: presentación de un caso y revisión del tema / Stress cardiomyopathy as a cause of sudden death during an assault: a case report and review of the literature

La muerte súbita de una persona durante un asalto o una agresión física resulta de gran importancia e interér en el medio forense debido a las interrogantes que genera la determinación de la causa y manera de muerte, principalmente en aquellas cuyos traumatismo por si solos no justifiquen la muerte. En estos casos especiales trasciende la Miocardiopatía por Estrés como una hipótesis que se debe analizar. En la actualidad, ésta patología se encuentra ampliamente descrita tanto a nivel de la medicina curativa como en la Patología Forense; y en ésta última su demostración objetiva es esencial, con el fin de cumplir los criterios de casualidad. En este artículo se expone la valoración de un caso valorado en la Sección de Patología Forense del Departamento de Medicina Legal de Costa Rica...

War stress and late-life mortality in World War II male civilian resistance veterans.

The mental and physical health of 146 Dutch males exposed to severe war stress during their young adulthood were examined in 1986-1987 when they were at ages 61 to 66 years. The veterans' data were compared with a randomly selected population-based sample of same-aged males. In 2005, 70% of the war stress veterans had died, and only 35% of the comparison group. The baseline quality of life was significantly poorer in the war stress veterans than in the comparison group. Baseline variables explained 42% of the increased risk of mortality among war stress veterans. Smoking was the largest single contributor to mortality.

Association of psychiatric illness and all-cause mortality in the National Department of Veterans Affairs Health Care System.

OBJECTIVE: To assess the independent association of seven psychiatric illnesses with all-cause mortality in a representative national sample of veterans, after adjustment for demographic factors, psychiatric and medical comorbidity, obesity, tobacco use, and exercise frequency. METHODS: Analyses were conducted using data from the 1999 Large Health Survey of Veteran Enrollees (n = 559,985). Cox proportional hazards models were used to examine the relationship of seven psychiatric diagnoses with mortality. Date of all-cause mortality was determined from the Department of Veterans Affairs' Beneficiary Identification and Records Locator System. All-cause mortality rates were calculated as the total number of deaths in each group divided by the person-years of follow-up time in each group. RESULTS: During the 9-year study period, 27% of the subjects (n = 131,396) died. Each of the psychiatric diagnoses was associated with significantly increased HR for all-cause mortality after adjusting for age, race, and gender. Hazard ratios ranged from 1.02 (95% confidence interval, 1.01, 1.04) for posttraumatic stress disorder to 1.97 (95% confidence interval, 1.89, 2.04) for alcohol use disorders. After adjustment for psychiatric and medical comorbidity, obesity, current smoking and exercise frequency, alcohol and drug abuse and dependence, and schizophrenia were statistically significantly associated with an increased risk of mortality. CONCLUSIONS: In this study of a large representative national sample of veterans, schizophrenia and alcohol and drug use disorders were independently associated with an increased risk of all-cause mortality over a 9-year period.

Factors associated with civilian mortality in Australian Vietnam veterans three decades after the war.

A prospective cohort study of a random sample of 1,000 Australian Army Vietnam veterans analyzed risk factors for postwar mortality using information from Army records and personal interview assessments of physical and mental health measured approximately 15 years earlier. This enabled examination of the role of combat, military service, and psychiatric status including post-traumatic stress disorder (PTSD) on postwar civilian mortality. Factors predicting mortality were identified using multivariate statistical methods including logistic and Cox regression. Mortality was associated principally with age, enlistment route (regular vs. national service conscripts), and conduct while in service in the whole cohort. Additional analysis using interview data revealed that mortality was predicted by age, smoking status, chronic diabetes, bronchitis and blood diseases, and treatment for cancer and heart disease. Psychiatric status including PTSD diagnosis was not associated with mortality. Veterans' mortality risk may be reduced by attention to smoking and alcohol both in-service and postservice.

Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service.

PURPOSE: Research suggests that posttraumatic stress disorder (PTSD) may be associated with later medical morbidity. To assess this, we examined all-cause and cause-specific mortality among a national random sample of U.S. Army veterans with and without PTSD after military service. METHODS: We used Cox proportional hazards regressions to examine the causes of death among 15,288 male U.S. Army veterans 16 years after completion of a telephone survey, approximately 30 years after their military service. These men were included in a national random sample of veterans from the Vietnam War Era. Our analyses adjusted for race, Army volunteer status, Army entry age, Army discharge status, Army illicit drug abuse, intelligence, age, and, additionally -- for cancer mortality -- pack-years of cigarette smoking. RESULTS: Our findings indicated that adjusted postwar mortality for all-cause, cardiovascular, cancer, and external causes of death (including motor vehicle accidents, accidental poisonings, suicides, homicides, injuries of undetermined intent) was associated with PTSD among Vietnam Theater veterans (N = 7,924), with hazards ratios (HRs) of 2.2 (p < 0.001), 1.7 (p = 0.034), 1.9 (p = 0.018), and 2.3 (p = 0.001), respectively. For Vietnam Era veterans with no Vietnam service (N = 7,364), PTSD was associated with all-cause mortality (HR = 2.0, p = 0.001). PTSD-positive era veterans also appeared to have an increase in external-cause mortality as well (HR = 2.2, p = 0.073). CONCLUSIONS: Our study suggests that Vietnam veterans with PTSD may be at increased risk of death from multiple causes. The reasons for this increased mortality are unclear but may be related to biological, psychological, or behavioral factors associated with PTSD and warrant further investigation.

Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation.

BACKGROUND: Poor medical compliance has been held responsible for a large proportion of deaths occurring subsequent to initial postoperative recovery. However, beyond clinical reports, there has been little empirical examination of this issue, or of the extent to which major psychiatric disorder and failure to adjust to the transplant predict long-term physical morbidity and mortality. We prospectively examined whether a full range of compliance behaviors and psychiatric outcomes during the first year post-transplant predicted subsequent mortality and physical morbidity through 3 years post-transplant. METHODS: A total of 145 heart recipients who had received detailed compliance and mental health assessments during the first year post-transplant were followed up at 3 years post-transplant. Interview data and corroborative information from family members were used to determine compliance in multiple domains, psychiatric diagnoses, and psychiatric symptomatology during the first year post-surgery. Medical record reviews were performed to abstract data on acute graft rejection episodes, incident cardiac allograft disease (CAD) and mortality from 1 to 3 years post-transplant. RESULTS: After controlling for known transplant-related predictors of outcome, multivariate analyses yielded the following significant (p < 0.05) results: (a) risk of acute graft rejection was 4.17 times greater among recipients who were not compliant with medications; (b) risk of incident CAD was elevated by persistent depression (Odds Ratio, OR = 4.67), persistent anger-hostility (OR = 8.00), medication noncompliance (OR = 6.91), and obesity (OR = 9.92); and (c) risk of mortality was increased if recipients met criteria for Post-Traumatic Stress Disorder related to the transplant (OR = 13.74). CONCLUSIONS: The findings, plus data we have previously reported that showed which patients are most likely to have compliance and psychiatric problems early post-transplant, suggest that interventions focused on maximizing patients' psychosocial status in these areas may further improve long-term physical health outcomes in this population.