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在突发心脏事件之后接受植入型心脏去颤器(ICDs) 者，如果发生创伤后压力症候群(PTSD)，则5年内的死亡风险达2倍以上。
德国慕尼黑Muenchen科技大学的研究者在一篇前溯世代研究中发现，这类病患的PTSD症状造成死亡风险增加了2.4倍。
主要研究者、Karl-Heinz Ladwig博士向Medscape Psychiatry表示，我们对此发现感到震惊，遭受PTSD症状的病患死亡风险大大提高，校正已知的风险因素后，此一关联更是令人瞩目。本研究揭橥了PTSD单独影响死亡率风险的直接证据。
本研究登载在11月的一般精神学志上。
【PTSD 通常被忽略】
Ladwig博士表示，心脏病患的PTSD往往被忽略。虽然一般认为ICD病患应该接受心理筛检与在追踪照护时进行可能的治疗，但是临床实务并未皆能如此。Ladwig博士表示，某种程度上，这和病患本身有关，许多人抗拒这类照护，认为可以自我应付，但是无疑的，他们确实需要帮助。
估计约有8%至20%的急性冠心症状病患，其中27%至38%的存活者发生了PTSD；作者指出，经历心脏停止或者急性心肌梗塞后存活的ICD病患，有一大部份会引起急性心理压力。使用 ICD治疗虽然相当有效且可保命，但却可能在后来成为时时提醒自己有潜在疾病的心理压力来源。
最近，Veterans Affairs Normative Aging Study这篇研究指出PTSD症状与冠心病在一群看来健康的男性之间的关系；不过，研究者指出，有关PTSD和ICDs病患之间的关系，仍所知有限。
【对预后的影响】
为了确认PTSD对长期死亡率的影响，研究者追踪了211名ICD病患，这些病患在1998年发作心脏病事件之后，定期回心脏科门诊。此研究的初步结果是每1,000人年的死亡率风险。
参与者在植入后平均27个月时接受调查，当时，有38人报告有严重的PTSD症状，109人报告有低或中度PTSD症状；在平均 5.1年间，45人(30.6%)死亡：低或中度PTSD症状的109人中有32人死亡，严重PTSD症状的38人中有13人死亡。
在他们控制了年纪、性别、糖尿病、心脏病、焦虑与忧郁等因素的校正分析中，研究者发现，PTSD症状大大增加了死亡率风险。
作者指出，相较于没有PTSD者的每1,000人年有55件死亡，PTSD病患的每1,000人年之长期绝对死亡风险为80件死亡；除了死亡率风险增加之外，PTSD病患报告指出较多的心脏方面症状，包括胸痛。不过，两组之间有此临床特征之病患的存活并无差异。
作者写道，因此，所察觉的严重度并不是依照心脏规范测得之心脏状况的客观严重度，而是和PTSD有关。
根据Ladwig博士表示，需要更多研究以表达PTSD造成ICD病患激增之死亡风险的行为和生物路径。
【心脏病患常有精神上的异常】
Medscape Psychiatry邀请俄亥俄州立大学医学中心心血管内科主任William T. Abraham医师对此研究提出评论，表示本研究点出高品质心理支持的需要。
Abraham医师指出，心血管疾病患者经常有心理上的异常，至少有50%的心衰竭病患在患病期间，或多或少有临床忧郁症状。
Abraham医师表示，这类病患以及其他心血管异常，如缺血性心脏病和心律不整者的忧郁症状经常伴有更糟的结果；他也指出，这个有病理生理上的根据。
他表示，忧郁与发炎媒介和其他造成疾病恶化的物质有关。PTSD略有不同，且在ICD之后常见。不过，PTSD的精神效应可能和忧郁所见相似。在极端类型中，休克引起的PTSD可能会导致一些病患要求关闭他们的ICD。我在这几年看过几次这种状况。谘商与支持团体对治疗这些病患很重要。
Deutsche Forschungsgemeinschaft支持本研究，Boston Scientific Guidant提供不设限的教育资金。Ladwig博士报告接受Medtronic Inc.的演讲费用。
PTSD Symptoms More Than Double Mortality Risk in Patients with ICDs
By Caroline Cassels
Medscape Medical News
Individuals who receive implantable cardiac defibrillators (ICDs) after a sudden cardiac event are more than twice as likely to die within 5 years if they experience symptoms of posttraumatic stress disorder (PTSD), regardless of disease severity.
In a prospective cohort study, researchers from the Technische Universitat Muenchen, in Munich, Germany, found that PTSD symptoms in this patient population were associated with a 2.4-fold increased mortality risk.
"We were struck by the finding that patients suffering from PTSD symptoms had a substantially higher risk of mortality, and it was particularly striking that this association was strengthened after adjustment for known risk factors. This study shows there is direct evidence that PTSD independently influences mortality risk," principal investigator Karl-Heinz Ladwig, MD, PhD, told Medscape Psychiatry.
The study was published in the November issue of Archives of General Psychiatry.
PTSD Generally Overlooked
According to Dr. Ladwig, PTSD is often overlooked in cardiac patients. Although it is generally recognized that ICD patients should undergo psychologic screening and possible treatment as part of their follow-up care, this does not always translate into clinical practice. "In part, this may have to do with the patients themselves, many of whom are resistant to this type of care and are intent on coping by themselves, but there is no doubt that they need help," said Dr. Ladwig.
It is estimated that between 8% and 20% of patients with acute coronary syndromes and 27% to 38% of those who survive a cardiac arrest develop PTSD. The authors point out that a significant proportion of patients with an ICD have survived a cardiac arrest or an acute myocardial infarction, which can cause acute psychologic distress. Treatment with an ICD, although highly effective and lifesaving, could further contribute to psychologic distress by serving as a constant reminder of the underlying disease.
Recent research from the Veterans Affairs Normative Aging Study linked PTSD symptoms and coronary heart disease in a cohort of apparently healthy men. However, the researchers note, little is known about the effect of PTSD on patients with ICDs.
Impact on Prognosis
To determine the impact of PTSD on long-term mortality, investigators followed 211 patients with ICDs who routinely attended a cardiac outpatient clinic after a cardiac event in 1998. The study's primary outcome was mortality risk per 1000 person-years.
Participants were surveyed an average of 27 months after implantation and, at that time, 38 reported severe PTSD symptoms and 109 reported low or moderate PTSD symptoms. During an average of 5.1 years, 45 (30.6%) of the patients died: 32 of 109 patients with low or moderate symptoms and 13 of 38 with high levels of symptoms.
In their adjusted analyses, which controlled for age, sex, diabetes mellitus, measures of cardiac disease, and comorbid anxiety and depression, the researchers found that PTSD symptoms substantially increased mortality risk.
Compared with 55 fatal events per 1000 person-years in patients without PTSD, the long-term absolute mortality risk accounted for 80 fatal events per 1000 person-years in patients with PTSD, the authors report. In addition to increased mortality risk, patients with PTSD reported more cardiac symptoms, including chest pain. However, clinical characteristics that typically account for survival differences in such patients did not differ between the 2 groups.
"Therefore, the perceived severity rather than the objective severity of a cardiac condition, as determined by cardiac criteria, may be associated with PTSD," the authors write.
According to Dr. Ladwig, more research is needed to assess the behavioral and biologic pathways by which PTSD contributes to excess mortality risk in patients with ICDs.
Psychologic Disorders Common in Heart Patients
Asked by Medscape Psychiatry to comment on the study, William T. Abraham, MD, director of the division of cardiovascular medicine at Ohio State University Medical Center, in Columbus, highlighted the need for high-quality psychologic support.
Dr. Abraham pointed out that psychologic disorders are common in patients with cardiovascular disease. At least 50% of heart failure patients are clinically depressed at some point in the natural history of their disease.
Depression in this setting and in the setting of other cardiovascular disorders, including ischemic heart disease and arrhythmias, said Dr. Abraham, is associated with worse outcomes. He also pointed out there is a pathophysiologic basis for this.
"Depression is associated with an increase in inflammatory mediators and other substances that may contribute to disease progression. PTSD is a little different and not uncommon following ICD shocks. However, the physiological effects of PTSD may be similar to those seen with depression. In its extreme form, shock-induced PTSD may lead some patients to ask that their ICDs be turned off. I have seen this more than a few times over the years. Counseling and support groups are very important in treating these patients," he said.
The study was supported by the Deutsche Forschungsgemeinschaft and an unrestricted educational grant from Boston Scientific Guidant. Dr. Ladwig reports receiving lecture fees from Medtronic Inc.
Arch Gen Psychiatry. 2008;65:1324-1330.