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Findings From the Heart and Soul Study

Beth E. Cohen, MD, MAS; Charles R. Marmar, MD; Thomas C. Neylan, MD; Nelson B. Schiller, MD; Sadia Ali, MD, MPH; Mary A. Whooley, MD

Arch Gen Psychiatry. 2009;66(11):1214-1220.

Context  Posttraumatic stress disorder (PTSD) is increasingly recognized as a cause of substantial disability. In addition to its tremendous mental health burden, PTSD has been associated with worse physical health status and an increased risk of cardiovascular disease.

Objective  To determine whether PTSD is associated with cardiovascular health status in patients with heart disease and whether this association is independent of cardiac function.

Design  Cross-sectional study.

Setting  The Heart and Soul Study, a prospective cohort study of psychological factors and health outcomes in adults with stable cardiovascular disease.

Participants  One thousand twenty-two men and women with coronary heart disease.

Main Outcome Measures  Posttraumatic stress disorder was assessed using the Computerized Diagnostic Interview Schedule for DSM-IV. Cardiac function was measured using left ventricular ejection fraction, treadmill exercise capacity, and inducible ischemia on stress echocardiography. Disease-specific health status was assessed using the symptom burden, physical limitation, and quality of life subscales of the Seattle Angina Questionnaire. We used ordinal logistic regression to evaluate the association of PTSD with health status, adjusted for objective measures of cardiac function.

Results  Of the 1022 participants, 95 (9%) had current PTSD. Participants with current PTSD were more likely to report at least mild symptom burden (57% vs 36%), mild physical limitation (59% vs 44%), and mildly diminished quality of life (62% vs 35%) (all P  .001). When adjusted for cardiovascular risk factors and objective measures of cardiac function, PTSD remained independently associated with greater symptom burden (odds ratio, 1.9; 95% confidence interval, 1.2-2.9; P = .004); greater physical limitation (odds ratio, 2.2; 95% confidence interval, 1.4-3.6; P = .001); and worse quality of life (odds ratio, 2.5; 95% confidence interval, 1.6-3.9; P < .001). Results were similar after excluding participants with depression.

Conclusions  Among patients with heart disease, PTSD is more strongly associated with patient-reported cardiovascular health status than objective measures of cardiac function. Future studies should explore whether assessing and treating PTSD symptoms can improve function and quality of life in patients with heart disease.

Author Affiliations: Section of General Internal Medicine (Drs Cohen, Ali, and Whooley) and Mental Health Services (Drs Marmar and Neylan), Department of Veterans Affairs Medical Center, and Departments of Medicine (Drs Cohen, Schiller, and Whooley), Radiology (Dr Schiller), Anesthesia (Dr Schiller), and Psychiatry (Drs Marmar and Neylan), University of California, San Francisco.

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