VA Study Looks at Relationship Between PTSD, Outcomes After Coronary Angiography

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Veterans with posttraumatic stress disorder (PTSD) who undergo coronary angiography are younger and more likely to present with elective indications and less likely to have obstructive disease than those without the diagnosis, according to a study published online June 11, 2014, ahead of print in the American Heart Journal. Moreover, PTSD does not increase the risk of adverse events at 1-year. 

Investigators led by Steven M. Bradley, MD, MPH, of the VA Eastern Colorado Health Care System (Denver, CO), analyzed data from the VA Clinical Assessment, Reporting, and Tracking ( CART) program on 116,488 patients (14,918 diagnosed with PTSD) who had coronary angiography from October 2007 to September 2011.    
Patients with PTSD were younger (median age 61.9 vs 63.7 years; P < .001) and more likely to have prior MI or PCI and present with stable angina or atypical chest pain than those without PTSD. They also had higher rates of cardiovascular risk factors (smoking, hypertension, hyperlipidemia, and diabetes), depression, anxiety, and substance/alcohol abuse (P < .001 for all).    

Angiography indicated that patients with PTSD vs those without were less likely to have obstructive CAD (55.9% vs 62.2%; P < .001).    

At 1 year, 1.71% of patients had experienced an MI, 8.22% revascularization, and 5.97% died. Crude rates of MI, revascularization, and all-cause mortality all were lower in conjunction with PTSD.    

After adjustment for baseline cardiovascular risk, however, the relationship between PTSD and outcome appeared to mainly relate to all-cause death. Neither MI nor revascularization risk was affected by the condition (table 1).

Table 1. One-Year Outcomes Adjusted for CV Risk: PTSD vs No PTSD



95% CI

P Value

MI, Revascularization, All-Cause Mortality




All-Cause Mortality












Results were maintained when further adjusted for depression/anxiety, alcohol/substance abuse, and follow-up frequency.   

Determining Need for Angiography in PTSD Patients Difficult   

Frequent use of angiography for elective indications in patients with PTSD is partially due to the challenges of sifting through the overlapping somatic symptoms (eg, chest pain and shortness of breath) of PTSD and coronary artery disease, Dr. Bradley and colleagues say.   

The effect is amplified, they continue, because of the higher prevalence of cardiovascular risk factors and prior coronary disease in patients with PTSD, resulting in a higher likelihood of undergoing angiography, “even when symptoms are atypical for coronary disease.” Also, the younger age of patients with PTSD greatly contributed to their lower global estimate of coronary risk than those without the condition, the authors add.   

Mladen I. Vidovich, MD, of University of Illinois at Chicago and Jesse Brown VA Medical Center (Chicago, IL), told TCTMD in a telephone interview that it can be difficult to distinguish between the similar symptoms of CAD and those of PTSD and depression, adding that aside from a comprehensive psychological evaluation at presentation, “there are not good answers.” PTSD cannot be diagnosed using “troponins or hemoglobin,” he elaborated. “It is difficult to measure.”   

Results Not Generalizable   

Dr. Vidovich suggested that Department of Veterans Affairs (VA) hospitals are in a good position to study PTSD because the prevalence of normal angiograms in the VA’s patient population is “significantly lower than elsewhere,” and the system as a whole “does a very good job in screening patients for depression and mental health.” In hospitals outside of the VA, “it may be the case that we are not paying as much attention [to the possibility of comorbid PTSD],” he continued.    

However, the unique characteristics of the VA and its patient population make it difficult to generalize the results, the authors say.    

Another potential limitation of the study is that it did not assess patients for PTSD and other mental health issues at the time of angiography but during an annual screening, Dr. Vidovich explained. Nonetheless, he said, it represents a “good early step in learning about PTSD and coronary disease.”


Bradley SM, Stanislawski MA, Bekelman DB, et al. Invasive coronary procedure use and outcomes among veterans with post-traumatic stress disorder: insights from the VA CART program. Am Heart J. 2014;Epub ahead of print. 

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  • Dr. Bradley is supported by a Career Development Award from VA Health Sciences Research and Development.
  • Dr. Vidovich reports acting as the current American College of Cardiology Governor-Elect of the Department of Veterans Affairs.

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