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. 2013 Sep 10;62(11):970-8.
doi: 10.1016/j.jacc.2013.04.085. Epub 2013 Jun 27.

Post-traumatic stress disorder and incidence of coronary heart disease: a twin study

Viola Vaccarino  1 , Jack Goldberg, Cherie Rooks, Amit J Shah, Emir Veledar, Tracy L Faber, John R Votaw, Christopher W Forsberg, J Douglas Bremner
Affiliations

Post-traumatic stress disorder and incidence of coronary heart disease: a twin study

Viola Vaccarino et al. J Am Coll Cardiol. .

Abstract

Objectives: The aim of this study was to determine whether post-traumatic stress disorder (PTSD) is associated with coronary heart disease (CHD) using a prospective twin study design and objective measures of CHD.

Background: It has long been hypothesized that PTSD increases the risk of CHD, but empirical evidence using objective measures is limited.

Methods: We conducted a prospective study of middle-aged male twins from the Vietnam Era Twin Registry. Among twin pairs without self-reported CHD at baseline, we selected pairs discordant for a lifetime history of PTSD, pairs discordant for a lifetime history of major depression, and pairs without either condition. All underwent a clinic visit after a median follow-up of 13 years. Outcomes included clinical events (myocardial infarction, other hospitalizations for CHD and coronary revascularization) and quantitative measures of myocardial perfusion by [(13)N] ammonia positron emission tomography, including a stress total severity score and coronary flow reserve.

Results: A total of 562 twins (281 pairs) with a mean age of 42.6 years at baseline were included in this study. The incidence of CHD was more than double in twins with PTSD (22.6%) than in those without PTSD (8.9%; p < 0.001). The association remained robust after adjusting for lifestyle factors, other risk factors for CHD, and major depression (odds ratio: 2.2; 95% confidence interval: 1.2 to 4.1). Stress total severity score was significantly higher (+95%, p = 0.001) and coronary flow reserve was lower (-0.21, p = 0.02) in twins with PTSD than in those without PTSD, denoting worse myocardial perfusion. Associations were only mildly attenuated in 117 twin pairs discordant for PTSD.

Conclusions: Among Vietnam-era veterans, PTSD is a risk factor for CHD.

Keywords: CFR; CHD; CI; DIS; DSM-III-R; Diagnostic Interview Schedule; Diagnostic and Statistical Manual of Mental Disorders-Third Edition-Revised; OR; PET; PTSD; STSS; cardiovascular diseases; confidence interval; coronary flow reserve; coronary heart disease; epidemiology; odds ratio; positron emission tomography; post-traumatic stress disorder; risk factors; stress; stress total severity score.

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Figures

Figure 1
Figure 1. Incidence of CHD based on PTSD status at baseline
CHD: coronary heart disease; MI: myocardial infarction; PTSD: posttraumatic stress disorder.
Figure 2
Figure 2. Relationship between a 3-level classification of PTSD at baseline (no PTSD, subthreshold, and PTSD) and CHD outcomes
“Adjusted1”: model adjusted for socio-demographic, lifestyle and CHD risk factors and service in Southeast Asia. “Adjusted2”: Also adjusted for lifetime history of major depression and lifetime history of alcohol or drug abuse/dependence. Socio-demographic, lifestyle and CHD risk factors included in these models are the same as those listed in tables 2 through 4. CHD: coronary heart disease; CFR: coronary flow reserve; OR: odds ratio; PTSD: posttraumatic stress disorder; STSS: stress total severity score. * p<0.01 compared with no PTSD † p<0.01 compared with subthreshold. ‡ p<0.05 compared with no PTSD. § p<0.05 compared with subthreshold.
Figure 3
Figure 3. Relationship between quartiles of the PTSD symptom scale score and CHD outcomes
“Adjusted1”: model adjusted for socio-demographic, lifestyle and CHD risk factors and service in Southeast Asia. “Adjusted2”: Also adjusted for lifetime history of major depression and lifetime history of alcohol or drug abuse/dependence. Socio-demographic, lifestyle and CHD risk factors included in these models are the same as those listed in tables 2 through 4. P values shown are for trend. CHD: coronary heart disease; CFR: coronary flow reserve; OR: odds ratio; PTSD: posttraumatic stress disorder; STSS: stress total severity score.
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