Observational Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatry. Jun 19, 2023; 13(6): 376-385
Published online Jun 19, 2023. doi: 10.5498/wjp.v13.i6.376
Prevalence of posttraumatic stress disorder following acute coronary syndrome and clinical characteristics of patients referred to cardiac rehabilitation
Ivana Sopek Merkaš, Nenad Lakušić, Zdenko Sonicki, Barbara Koret, Sandra Vuk Pisk, Igor Filipčić
Ivana Sopek Merkaš, Nenad Lakušić, Department of Cardiology, Special Hospital for Medical Rehabilitation Krapinske Toplice, Krapinske Toplice 49217, Croatia
Nenad Lakušić, Department of Clinical Medicine, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
Nenad Lakušić, Department of Internal Medicine, Family Medicine and History of Medicine, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
Zdenko Sonicki, Department of Medical Statistics, Epidemiology, and Medical Informatics, School of Public Health Andrija Stampar, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
Barbara Koret, Sandra Vuk Pisk, Igor Filipčić, Department of Psychiatry, Clinic for Psychiatry “Sveti Ivan”, Zagreb 10000, Croatia
Sandra Vuk Pisk, Igor Filipčić, Department of Psychiatry and Neurology, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
Igor Filipčić, Department of Psychiatry and Psychological Medicine, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
Author contributions: Sopek Merkaš I conducted research and wrote first version of the manuscript; Lakušić N and Sonicki Z designed the study and corrected the manuscript; Sonicki Z is involved in analytical tools; Koret B and Vuk Pisk S diagnosed PTSD, contributed in literature review and data processing; Lakušić N, Sonicki Z, and Filipčić I served as scientific advisors, literature review and participate in making critical revisions related to the important intellectual content.
Institutional review board statement: The study was reviewed and approved by the Ethics Committiee and Institutional Review Board of Special Hospital for Medical Rehabilitation Krapinske Toplice on the date 25.5.2021.
Informed consent statement: Written informed consent was obtained from every patient who agreed to participate in the study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement and the manuscript was prepared and revised according to the STROBE Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nenad Lakušić, PhD, Full Professor, Department of Cardiology, Special Hospital for Medical Rehabilitation Krapinske Toplice, Gajeva 2, Krapinske Toplice 49217, Croatia. nenad.lakusic@post.t-com.hr
Received: March 26, 2023
Peer-review started: March 26, 2023
First decision: April 28, 2023
Revised: May 4, 2023
Accepted: May 25, 2023
Article in press: May 25, 2023
Published online: June 19, 2023
Processing time: 84 Days and 15.7 Hours
Abstract
BACKGROUND

Studies have demonstrated that patients who have experienced acute coronary syndrome (ACS) have an increased risk of developing posttraumatic stress disorder (PTSD) and experiencing worse survival outcomes than those who do not develop PTSD. Nevertheless, the prevalence rates of PTSD following ACS vary widely across studies, and it is noteworthy that in most cases, the diagnosis of PTSD was based on self-report symptom questionnaires, rather than being established by psychiatrists. Additionally, the individual characteristics of patients who develop PTSD after ACS can differ widely, making it difficult to identify any consistent patterns or predictors of the disorder.

AIM

To investigate the prevalence of PTSD among a large sample of patients undergoing cardiac rehabilitation (CR) after ACS, as well as their characteristics in comparison to a control group.

METHODS

The participants of this study are patients who have experienced ACS with or without undergoing percutaneous coronary intervention and are enrolled in a 3-wk CR program at the largest CR center in Croatia, the Special Hospital for Medical Rehabilitation Krapinske Toplice. Patient recruitment for the study took place over the course of one year, from January 1, 2022, to December 31, 2022, with a total of 504 participants. The expected average follow-up period for patients included in the study is about 18 mo, and currently ongoing. Using self-assessment questionnaire for PTSD criteria and clinical psychiatric interview, a group of patients with a PTSD diagnosis was identified. From the participants who do not have a PTSD diagnosis, patients who would match those with a PTSD diagnosis in terms of relevant clinical and medical stratification variables and during the same rehabilitation period were selected to enable comparability of the two groups.

RESULTS

A total of 507 patients who were enrolled in the CR program were approached to participate in the study. Three patients declined to participate in the study. The screening PTSD Checklist-Civilian Version questionnaire was completed by 504 patients. Out of the total sample of 504 patients, 74.2% were men (n = 374) and 25.8% were women (n = 130). The mean age of all participants was 56.7 years (55.8 for men and 59.1 for women). Among the 504 participants who completed the screening questionnaire, 80 met the cutoff criteria for the PTSD and qualified for further evaluation (15.9%). All 80 patients agreed to a psychiatric interview. Among them, 51 patients (10.1%) were diagnosed with clinical PTSD by a psychiatrist according to Diagnostic and Statistical Manual of Mental Disorders criteria. Among the variables analyzed, there was a noticeable difference in the percentage of theoretical maximum achieved on exercise testing between the PTSD and non-PTSD groups. Non-PTSD group achieved a significantly higher percentage of their maximum compared to the PTSD group (P = 0.035).

CONCLUSION

The preliminary results of the study indicate that a significant proportion of patients with PTSD induced by ACS are not receiving adequate treatment. Furthermore, the data suggest that these patients may exhibit reduced physical activity levels, which could be one of the possible underlying mechanisms in observed poor cardiovascular outcomes in this population. Identifying cardiac biomarkers is crucial for identifying patients at risk of developing PTSD and may derive benefits from personalized interventions based on the principles of precision medicine in multidisciplinary CR programs.

Keywords: Cardiac rehabilitation, Acute coronary syndrome, Posttraumatic stress disorder, Psychiatric interview, Multidisciplinary team, Cardiac biomarkers

Core Tip: The preliminary results of the first large-scale study on a sample of cardiac rehabilitation (CR) patients with posttraumatic stress disorder induced by acute coronary syndrome indicate a significant number of patients who have a persistently increased risk of adverse events, and yet are still insufficiently recognized and treated. The study demonstrates that one possible mechanism of poorer outcomes is the avoidance of physical activity. A multidisciplinary approach involving cardiologists, psychiatrists, and psychologists is required for the identification and early intervention in these patients, and CR and comprehensive social support play a critical role.