Coronary Procedures and Outcomes in Veterans With PTSD
Overall, 14,917 (12.8%) patients undergoing coronary angiography had a diagnosis of PTSD (Table I). Compared with patients without PTSD, patients with PTSD were younger (median age 61.9 vs 63.7; P < .001), had higher rates of cardiovascular risk factors, including smoking, hypertension, hyperlipidemia, and diabetes, and were more likely to have had a prior MI (26.4% vs 24.7%; P < .001) or PCI (31.0% vs 29.9%; P < .001). However, global estimates of coronary risk were lower in patients with PTSD (high Framingham risk category 22.9% vs 25.0%; P < .001). Patients with PTSD had much higher rates of concurrent depression and anxiety as compared with patients without PTSD. Patients with PTSD were also more likely to have a diagnosis of alcohol abuse or dependence or substance abuse or dependence. Patients with PTSD were more likely to undergo angiography for elective indications of stable angina (22.4% vs 17.0%) or atypical chest pain (58.5% vs 48.6%). The results of coronary angiography were less likely to demonstrate obstructive CAD in patients with PTSD (55.9% vs 62.2%; P < .001).
In analyses stratified on the presence or absence of depression or anxiety in addition to PTSD, patients with PTSD and/or depression or anxiety were younger, more likely to have cardiovascular risk factors, have a history of prior MI or PCI, and have diagnoses of substance or alcohol dependence or abuse, relative to patients without PTSD, depression, or anxiety (Table I). Furthermore, patients with PTSD and/or depression or anxiety were more likely to undergo angiography for elective indications and less likely to have obstructive CAD identified at angiography. In analyses restricted to patients undergoing coronary angiography for elective indications, patients with PTSD were also less likely to have angiographic findings of obstructive CAD (41.0% vs 49.4%; P < .001) (see online Appendix Supplementary Table I in the Online Supplement).
Within 1-year of coronary angiography, 1,990 patients (1.71%) had an MI; 9,574 (8.22%) coronary revascularization; and 6,952 patients (5.97%) died. In unadjusted analyses, PTSD was associated with lower 1-year rates of MI (HR, 0.86; 95% CI [0.75–1.00]; P = .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 and nonpsychiatric comorbidities, PTSD was associated with lower risk-adjusted 1-year combined outcome (HR, 0.95; 95% CI [0.90–1.00]; P = 0.03) and all-cause mortality (HR, 0.91; 95% CI [0.84–0.99]; P = .03) but not with 1-year MI or revascularization outcomes (Table II). This association was not changed by further adjustment for depression and anxiety, substance or alcohol use, or outpatient follow-up frequency. In sensitivity analysis, the exclusion of patients without a prior year diagnosis of PTSD who were seen for PTSD in the year subsequent to the diagnosis of obstructive CAD did not influence our findings (see online Appendix Supplementary Table II in the Online Supplement). In addition, analyses that adjusted for preprocedural hemoglobin level among patients with available data for this covariate did not alter our results (see online Appendix Supplementary Table III in the Online Supplement).
Analyses stratified on the presence or absence of depression or anxiety and PTSD demonstrated are shown in Table III. Compared with patients without PTSD, depression, or anxiety, this analysis demonstrated that patients with PTSD had similar or lower risk-adjusted outcomes regardless of the presence or absence of concurrent depression or anxiety. In contrast, patients with depression or anxiety in the absence of PTSD appeared to have worse fully risk-adjusted 1-year all-cause mortality (HR, 1.14, 95% CI [1.08–1.20s; P < .001), similar MI rates (HR, 1.02; 95% [CI 0.93–1.13]; P = .63), and lower rates of revascularization at 1-year (HR, 0.92; 95% [CI 0.87–0.97]; P = .004).
In subgroup analyses stratified on the presence or absence of obstructive CAD identified at angiography, PTSD was not associated with 1-year combined or individual outcomes after all levels of risk adjustment among patients without obstructive CAD (online Appendix Supplementary Table IV). In patients with obstructive CAD, PTSD was not associated with 1-year outcomes after adjustment for cardiovascular and nonpsychiatric comorbidities (online Appendix Supplementary Table IV). After further adjustment for depression and anxiety, PTSD was not associated with 1-year MI or revascularization but was associated with lower risk-adjusted 1-year all-cause mortality (HR, 0.89; 95% CI [0.80–0.99]; P = .03). This association was not changed by additional risk adjustment for substance or alcohol use or frequency of outpatient follow-up.
Results
Patient Characteristics at Coronary Angiography
Overall, 14,917 (12.8%) patients undergoing coronary angiography had a diagnosis of PTSD (Table I). Compared with patients without PTSD, patients with PTSD were younger (median age 61.9 vs 63.7; P < .001), had higher rates of cardiovascular risk factors, including smoking, hypertension, hyperlipidemia, and diabetes, and were more likely to have had a prior MI (26.4% vs 24.7%; P < .001) or PCI (31.0% vs 29.9%; P < .001). However, global estimates of coronary risk were lower in patients with PTSD (high Framingham risk category 22.9% vs 25.0%; P < .001). Patients with PTSD had much higher rates of concurrent depression and anxiety as compared with patients without PTSD. Patients with PTSD were also more likely to have a diagnosis of alcohol abuse or dependence or substance abuse or dependence. Patients with PTSD were more likely to undergo angiography for elective indications of stable angina (22.4% vs 17.0%) or atypical chest pain (58.5% vs 48.6%). The results of coronary angiography were less likely to demonstrate obstructive CAD in patients with PTSD (55.9% vs 62.2%; P < .001).
In analyses stratified on the presence or absence of depression or anxiety in addition to PTSD, patients with PTSD and/or depression or anxiety were younger, more likely to have cardiovascular risk factors, have a history of prior MI or PCI, and have diagnoses of substance or alcohol dependence or abuse, relative to patients without PTSD, depression, or anxiety (Table I). Furthermore, patients with PTSD and/or depression or anxiety were more likely to undergo angiography for elective indications and less likely to have obstructive CAD identified at angiography. In analyses restricted to patients undergoing coronary angiography for elective indications, patients with PTSD were also less likely to have angiographic findings of obstructive CAD (41.0% vs 49.4%; P < .001) (see online Appendix Supplementary Table I in the Online Supplement).
Outcomes After Coronary Angiography
Within 1-year of coronary angiography, 1,990 patients (1.71%) had an MI; 9,574 (8.22%) coronary revascularization; and 6,952 patients (5.97%) died. In unadjusted analyses, PTSD was associated with lower 1-year rates of MI (HR, 0.86; 95% CI [0.75–1.00]; P = .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 and nonpsychiatric comorbidities, PTSD was associated with lower risk-adjusted 1-year combined outcome (HR, 0.95; 95% CI [0.90–1.00]; P = 0.03) and all-cause mortality (HR, 0.91; 95% CI [0.84–0.99]; P = .03) but not with 1-year MI or revascularization outcomes (Table II). This association was not changed by further adjustment for depression and anxiety, substance or alcohol use, or outpatient follow-up frequency. In sensitivity analysis, the exclusion of patients without a prior year diagnosis of PTSD who were seen for PTSD in the year subsequent to the diagnosis of obstructive CAD did not influence our findings (see online Appendix Supplementary Table II in the Online Supplement). In addition, analyses that adjusted for preprocedural hemoglobin level among patients with available data for this covariate did not alter our results (see online Appendix Supplementary Table III in the Online Supplement).
Analyses stratified on the presence or absence of depression or anxiety and PTSD demonstrated are shown in Table III. Compared with patients without PTSD, depression, or anxiety, this analysis demonstrated that patients with PTSD had similar or lower risk-adjusted outcomes regardless of the presence or absence of concurrent depression or anxiety. In contrast, patients with depression or anxiety in the absence of PTSD appeared to have worse fully risk-adjusted 1-year all-cause mortality (HR, 1.14, 95% CI [1.08–1.20s; P < .001), similar MI rates (HR, 1.02; 95% [CI 0.93–1.13]; P = .63), and lower rates of revascularization at 1-year (HR, 0.92; 95% [CI 0.87–0.97]; P = .004).
In subgroup analyses stratified on the presence or absence of obstructive CAD identified at angiography, PTSD was not associated with 1-year combined or individual outcomes after all levels of risk adjustment among patients without obstructive CAD (online Appendix Supplementary Table IV). In patients with obstructive CAD, PTSD was not associated with 1-year outcomes after adjustment for cardiovascular and nonpsychiatric comorbidities (online Appendix Supplementary Table IV). After further adjustment for depression and anxiety, PTSD was not associated with 1-year MI or revascularization but was associated with lower risk-adjusted 1-year all-cause mortality (HR, 0.89; 95% CI [0.80–0.99]; P = .03). This association was not changed by additional risk adjustment for substance or alcohol use or frequency of outpatient follow-up.
SHARE
