PTSD, anxiety related to out-of-hospital cardiac arrest

Stress-related disorders and anxiety are associated with a higher risk of out-of-hospital cardiac arrest (OHCA), suggests a new case-control study.

The researchers compared more than 35,000 OHCA cases with a similar number of matched controls and found an almost 1.5-fold increased risk of long-term stressful conditions among OHCA patients compared with controls, with a similar risk for anxiety. Post-traumatic stress disorder (PTSD) has been associated with an almost double risk of OHCA.

The findings applied equally to men and women and were independent of the presence of cardiovascular disease (CVD).

\”This study raises awareness of the increased risks of OHCA and early risk monitoring to prevent OHCA in patients with stress-related disorders and anxiety,\” write Talip Eroglu, Department of Cardiology, Copenhagen University Hospital, Denmark, and colleagues. .

The study was published online May 10 in BMJ extension Open heart.

Overrepresented stress and anxiety disorders

OHCA \”arises predominantly from lethal cardiac arrhythmias … most frequently occurring in the context of coronary artery disease,\” the authors write. However, mounting evidence suggests that OHCA rates may also increase in association with non-heart disease.

Individuals with stress-related disorders and anxiety are \”overrepresented\” among cardiac arrest victims as are those with multiple CVDs. But previous studies of OHCA have been limited by a small number of cardiac arrests. Furthermore, such studies included only data from selected populations or used in-hospital diagnosis to identify cardiac arrest, thereby potentially omitting OHCA patients who died before hospital admission.

The researchers then turned to data from Danish health registries that include a large, unselected cohort of OHCA patients to investigate whether long-term stressful conditions (for example, PTSD and adjustment disorder) or anxiety disorder were associated with OHCA.

They stratified the cohort by gender, age, and CVD to identify which risk factor confers the highest risk of OHCA in patients with long-term stressful or anxious conditions, and conducted sensitivity analyzes of potential confounders, such as depression. .

The design was a nested control model in which individual patient-level records across registries were cross-referenced with data from other national registries and compared to matched control persons from the general population (35,195 OHCA and 351,950 matched control persons; median [IQR] age, 72 [62 81] years; 66.82% men).

The prevalence of comorbidities and cardiovascular drug use was higher among patients with OHCA than among non-OHCA controls.

Be aware of stress and anxiety as risk factors

Among OHCA and non-OHCA participants, long-term stressful conditions were diagnosed in 0.92% and 0.45%, respectively. Anxiety was diagnosed in 0.85% of OHCA patients and 0.37% of non-OHCA control persons.

These conditions were associated with a higher rate of OHCA after adjustment for common OHCA risk factors.

Table. Risk of OHCA from stress-related disorders and anxiety

I disturb	Hazard Ratio (95% CI)
Long-term stressful conditions in general	1.44 (1.27 1.64)
Post-traumatic stress disorder	1.80 (1.13 2.86)
Adjustment disorders	1.42 (1.24 1.63)
Anxiety	1.56 (1.37 1.79)

There were no significant differences in the results when the researchers adjusted for the use of anti-anxiety medications and antidepressants.

When they looked at the prevalence of concomitant medication use or comorbidities, they found that depression was more frequent among patients with long-term stress and anxiety than among individuals with none of these diagnoses. In addition, patients with long-term stress and anxiety more often used anxiolytics, antidepressants, and QT-prolonging drugs.

Stratifying the analyzes by gender revealed that the OHCA rate was increased in both women and men with long-term stress and anxiety. No significant differences between genders were found. There were also no significant differences between the association between the different age groups, nor between patients with and those without CVD, ischemic heart disease, or heart failure.

Previous research has shown associations of stress- or anxiety-related disorders with cardiovascular outcomes, including myocardial infarction, heart failure, and cerebrovascular disease. These disorders could be \”biological mediators in the causal pathway of OHCA\” and contribute to the increased rate of OHCA associated with stress- and anxiety-related disorders, suggest the authors.

However, they note, stress-related disorders and anxiety remained significantly associated with OHCA after controlling for these variables, \”suggesting that traditional OHCA risk factors alone are unlikely to explain this relationship.\”

They suggest several potential mechanisms. One is that the relationship is likely mediated by sympathetic autonomic nervous system activity, which \”leads to increased heart rate, release of neurotransmitters into the circulation, and local release of neurotransmitters in the heart.\”

Each of these factors \”may potentially affect cardiac electrophysiology and facilitate ventricular arrhythmias and OHCA.\”

In addition to a biological mechanism, behavioral and psychosocial factors may also contribute to the risk of OHCA, as stress-related disorders and anxiety \”often lead to an unhealthy lifestyle, such as smoking and less physical activity, which a in turn they may increase the risk of OHCA.” Given the absence of data on these characteristics in the registries used by the investigators, they were unable to explain them.

However, \”it is unlikely that knowledge of these factors would have altered our conclusions considering we adjusted for all relevant cardiovascular comorbidities.\”

Similarly, other psychiatric disorders, such as depression, may contribute to the risk of OHCA but were adjusted for depression in their multivariate analyses.

\”Awareness of the increased risks of OHCA in patients with stress-related disorders and anxiety is important when treating these patients,\” they conclude.

Bad for the heart, not just for the psyche

Commenting for heart.org | Medscape Cardiology, Glenn Levine, MD, clinical master and professor of medicine, Baylor College of Medicine, Houston, Texas, called it an \”important study as it is a large national cohort study and therefore provides important information to complement much smaller studies.\” and aim for it.”

Like those other studies, it \”finds that negative psychological health, particularly long-term stress (as well as anxiety), is associated with a significantly increased risk of out-of-hospital cardiac arrest,\” continued Levine, who is the chief of the cardiology section at Michael E. DeBakey VA Medical Center and was not involved in the study.

Levine thinks the study \”does a good job, in the best possible way for a study of its kind, trying to control for other factors and focusing specifically on stress (and anxiety), trying to assess their independent contributions to the risk of developing diseases cardiac arrest.\”

The take-home message for physicians and patients \”is that negative psychological stressors, such as stress and anxiety, are not only detrimental to psychological health, but likely increase the risk of adverse cardiac events, such as cardiac arrest,” he said.

No specific funding for the study has been disclosed. Eroglu did not disclose any relevant financial relationships. Other authors\’ revelations are listed in the original article. Levine discloses no material financial dealings.

Open heart. Published online May 10, 2023. Abstract

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