A challenge for psychocardiology: Addressing the causes and consequences of patients’ perceptions of enduring somatic threat.

Abstract

The enduring somatic threat (EST) model of posttraumatic stress disorder (PTSD) due to life-threatening medical events suggests that PTSD-like symptoms represent patients’ sensitization to cues of ongoing threat in the body. In this article, we review research on the prevalence and consequences of such reactions in cardiovascular disease patients, discuss early tests of the EST model, and then report a new test of the EST model in 143 patients enrolled during their first acute coronary syndrome (ACS; i.e., non-ST elevation myocardial infarction or unstable angina—colloquially, “heart attack”). Invasive coronary revascularization procedures are commonly used to reduce secondary ACS risk and may reduce patients’ EST, as revascularized patients often report being “cured.” We assessed ACS patients’ initial threat perceptions during emergency department (ED) evaluation and followed them for 1 month for PTSD symptoms (specific for ACS, by telephone). We compared PTSD symptoms in participants who were revascularized (n =65), catheterized but not revascularized (n = 35), and medically managed (n = 43). PTSD symptoms were lower for revascularized versus medically managed participants (B =−5.32, 95% confidence interval [−9.77, −0.87]), t(98.19) =−2.37, p = .020. In a multiple regression model adjusted for clinical and psychosocial covariates, the interaction of threat perception in the ED and ACS management group was significant (greater ED threat predicted greater 1-month PTSD symptoms only in medically managed participants). These findings offer further support for the EST model and suggest that psychological interventions to preempt patients’ development of EST should be considered in the hospital.

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

“…myocardial infarction or stroke leads to the development of PTSD-like symptoms which is unique and goes beyond what is traditionally accepted as an adjustment disorder. 6,35 In the appraisal of this EST model, interestingly, for patients undergoing ACS evaluation, threat perception levels were not significantly different between patients who were ultimately diagnosed with ACS versus those without ACS. 36 Additionally those with higher peritraumatic ED cardiac threat had higher ongoing cardiac threat levels at 1 month follow-up evaluations which were associated with ACS-induced PTSD.…”

“…17 Interestingly, in a study of 143 patients with either non-ST elevation myocardial infarction or unstable angina, patients who were managed medically had higher rates of ACS-induced PTSD than those who underwent catheterization regardless of whether they were revascularized. 6 The presence of sustained psychological outcomes exists along the spectrum of CVD, including transient ischemic attack (TIA) and stroke survivors, where approximately 25% are found to have developed significant PTSD symptoms within one year of the event according to a meta-analysis of more than 1100 patients. 18 Unfortunately these PTSD symptoms are long-lasting and not only associated with worse overall health status including poor quality of life but also adverse effects on overall cardiovascular wellbeing.…”

“…4 While these psychological outcomes are important in and of themselves, they have also been associated with cardiovascular recovery and increased risk for the development of new and recurrent CVD events. [4][5][6] The interplay of psychological stress with personality and emotion is multidimensional and complex 7 . Further, the psychological experience of acute illness may impact CVD patients on multiple levels, from autonomic stress to secondary cardiovascular behavior (e.g.…”

The potential role of anxiety sensitivity in the risk for and recovery from heart attacks: Comment on Edmondson et al. (2018).

“…Also, cognitive bias modification training has been tasked to modify anxiety-related symptom interpretation via repeated practice of cognitive tasks that reinforce non-threat processing. Any of these interventions may be of use in the cardiac clinic, where they can be implemented to reduce AS more generally as well as the specific fears of cardiac-related sensations and symptoms that lead to maladaptive avoidance as characterized by Edmondson et al (2018). Importantly, for a CVD population, relevant cautions need to be applied, such as medical clearance for interoceptive exposure using physical exercise or hyperventilation.…”

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Edmondson et al (2018) provided a compelling account of the causes and consequences of patients' perceptions of enduring somatic threat following a heart attack or related cardiac event. The purpose of the current article is to place some of these observations in the context of research on anxiety sensitivity and its role as a risk factor for cardiovascular disease, posttraumatic stress disorder, and negative health behaviors.

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