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Cardiac Arrest and Subsequent Hospitalization–Induced Posttraumatic Stress Is Associated With 1-Year Risk of Major Adverse Cardiovascular Events and All-Cause Mortality

Agarwal, Sachin MD, MPH1; Presciutti, Alex MA1; Cornelius, Talea PhD, MSW2; Birk, Jeffrey PhD2; Roh, David J. MD1; Park, Soojin MD1; Claassen, Jan MD, PhD1; Elkind, Mitchell S. V. MD, MS1,3; Edmondson, Donald PhD, MPH2

doi: 10.1097/CCM.0000000000003713
Online Brief Reports

Objectives: To compare 1-year all-cause mortality and major adverse cardiovascular events in cardiac arrest survivors with and without posttraumatic stress disorder symptomatology at hospital discharge.

Design: Prospective, observational cohort.

Setting: ICUs at a tertiary-care center.

Patients: Adults with return of spontaneous circulation after in-hospital or out-of-hospital cardiac arrest between September 2015 and September 2017. A consecutive sample of survivors with sufficient mental status to self-report cardiac arrest and subsequent hospitalization–induced posttraumatic stress disorder symptoms (cardiac arrest–induced posttraumatic stress symptomatology) at hospital discharge were included.

Interventions: None.

Measurements and Main Results: The combined primary endpoint was all-cause mortality or major adverse cardiovascular event—hospitalization for nonfatal myocardial infarction, unstable angina, congestive heart failure, emergency coronary revascularization, or urgent implantable cardio-defibrillators/permanent pacemaker placements within 12 months of discharge. An in-person posttraumatic stress disorder symptomatology was assessed at hospital discharge via the Posttraumatic Stress Disorder Checklist-Specific scale; a suggested diagnostic cutoff of 36 for specialized medical settings was adopted. Outcomes for patients meeting (vs not meeting) this cutoff were compared using Cox-hazard regression models. Of 114 included patients, 36 (31.6%) screened positive for cardiac arrest–induced posttraumatic stress symptomatology at discharge (median 21 d post cardiac arrest; interquartile range, 11–36). During the follow-up period (median = 12.4 mo; interquartile range, 10.2–13.5 mo), 10 (8.8%) died and 29 (25.4%) experienced a recurrent major adverse cardiovascular event: rehospitalizations due to myocardial infarction (n = 4; 13.8%), unstable angina (n = 8; 27.6%), congestive heart failure exacerbations (n = 4; 13.8%), emergency revascularizations (n = 5, 17.2%), and urgent implantable cardio-defibrillator/permanent pacemaker placements (n = 8; 27.6%). Cardiac arrest–induced posttraumatic stress symptomatology was associated with all-cause mortality/major adverse cardiovascular event in univariate (hazard ratio, 3.19; 95% CI, 1.7–6.0) and in models adjusted for age, sex, comorbidities, preexisting psychiatric condition, and nonshockable initial rhythm (hazard ratio, 3.1; 95% CI, 1.6–6.0).

Conclusions: Posttraumatic stress disorder symptomatology is common after cardiac arrest, and cardiac arrest–induced posttraumatic stress symptomatology was associated with significantly higher risk of death and cardiovascular events. Further studies are needed to better understand the underlying mechanisms.

1Department of Neurology, Columbia University Medical Center, New York, NY.

2Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY.

3Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.

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Supported, in part, by the institutional funds provided to Dr. Agarwal.

Dr. Park received grant support from the National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke (K01ES026833). Dr. Edmondson received grant support from the National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (HL117832). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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