Search
Close
Search
Advanced Search
Search Menu
AI Discovery Assistant

Post-traumatic stress disorder (PTSD), a psychological disorder characterized by avoidance of reminders of a particular traumatic event, is an emerging risk factor for cardiac event recurrence.1 The mechanisms by which PTSD worsens prognosis in acute coronary syndrome (ACS) patients, however, remain poorly understood. Physical activity is considered an essential element in recovery from ACS and is recommended immediately after discharge.2 A hallmark of PTSD is behavioral and emotional avoidance of reminders of the traumatic event. Patients avoid going near places where the event occurred, news reports about similar events, or other sights, sounds, or sensations that are reminders of the event.3 The Enduring Somatic Threat (EST) model suggests that when PTSD is induced by an ACS event, survivors may avoid physical activity due to fear of trauma-related bodily sensations (e.g. increased heart rate, shortness of breath), as these feelings could trigger distressing reminders of the acute event.4,5 The purpose of this study was to test our hypothesis that patients with ACS-induced PTSD symptoms avoid physical activity due to fear of trauma-related bodily sensations.

We studied 132 patients (53% men, 54% Hispanic, mean age 63 ± 13 years) who presented to the emergency department of a Manhattan hospital for evaluation of suspected ACS.6 PTSD symptoms were evaluated 1-month post-hospitalization using the 17-item PTSD checklist for a specific stressor (PCL-S).7–9 Aversive cognitions about physical activity were measured with the following items: (a) ‘It scares me when my heart beats rapidly during physical activity’; (b) ‘When I notice my heart beating rapidly during physical activity, it reminds me of my heart event’; (c) ‘When I become short of breath during physical activity, it reminds me I’m at risk of having another heart event’; (d) ‘I sometimes avoid physical activity because I’m afraid it will cause me to have a heart event’. Patients responded using a five-point Likert scale, and those who reported ‘often’ or ‘very often’ were classified as having aversive cognitions for each item. Items were based on the EST framework4 and were adapted from the Anxiety Sensitivity Index.10

Among the 132 patients, 40 (30.3%) reported one or more aversive cognition about physical activity. In unadjusted and multivariable-adjusted models, higher PCL-S scores (e.g. PTSD symptoms) were significantly associated with a higher likelihood of reporting each aversive cognition towards physical activity (Table 1).

Table 1.
Open in new tab

Association of PTSD symptoms with aversive cognitions about physical activity (n = 132).

Aversive cognitions about physical activityUnadjusted OR (95% CI) per 5 points on PCL-SP valueAdjusteda OR (95% CI) per 5 points on PCL-SP value
‘When I notice my heart beating rapidly during physical activity, it reminds me of my heart event’1.53 (1.30–1.85)<0.0012.02 (1.49–2.99)<0.001
‘When I become short of breath during physical activity, it reminds me I’m at risk of having another heart event’1.46 (1.25–1.76)<0.0011.83 (1.41–2.53)<0.001
‘It scares me when my heart beats rapidly during physical activity’1.37 (1.19–1.61)<0.0011.73 (1.30–2.52)0.001
‘I sometimes avoid physical activity because I’m afraid it will cause me to have a heart event’1.32 (1.14–1.53)<0.0011.35 (1.10–1.73)0.008
Aversive cognitions about physical activityUnadjusted OR (95% CI) per 5 points on PCL-SP valueAdjusteda OR (95% CI) per 5 points on PCL-SP value
‘When I notice my heart beating rapidly during physical activity, it reminds me of my heart event’1.53 (1.30–1.85)<0.0012.02 (1.49–2.99)<0.001
‘When I become short of breath during physical activity, it reminds me I’m at risk of having another heart event’1.46 (1.25–1.76)<0.0011.83 (1.41–2.53)<0.001
‘It scares me when my heart beats rapidly during physical activity’1.37 (1.19–1.61)<0.0011.73 (1.30–2.52)0.001
‘I sometimes avoid physical activity because I’m afraid it will cause me to have a heart event’1.32 (1.14–1.53)<0.0011.35 (1.10–1.73)0.008

CI: confidence interval; PCL-S: post-traumatic stress disorder checklist for acute coronary syndrome; PTSD: post-traumatic stress disorder; OR: odds ratio.

Logistic regression model adjusted for age, gender, race/ethnicity, education, partner status, depression, GRACE risk score, Charlson comorbidity index, history of coronary heart disease, and acute coronary syndrome diagnosis.

Table 1.
Open in new tab

Association of PTSD symptoms with aversive cognitions about physical activity (n = 132).

Aversive cognitions about physical activityUnadjusted OR (95% CI) per 5 points on PCL-SP valueAdjusteda OR (95% CI) per 5 points on PCL-SP value
‘When I notice my heart beating rapidly during physical activity, it reminds me of my heart event’1.53 (1.30–1.85)<0.0012.02 (1.49–2.99)<0.001
‘When I become short of breath during physical activity, it reminds me I’m at risk of having another heart event’1.46 (1.25–1.76)<0.0011.83 (1.41–2.53)<0.001
‘It scares me when my heart beats rapidly during physical activity’1.37 (1.19–1.61)<0.0011.73 (1.30–2.52)0.001
‘I sometimes avoid physical activity because I’m afraid it will cause me to have a heart event’1.32 (1.14–1.53)<0.0011.35 (1.10–1.73)0.008
Aversive cognitions about physical activityUnadjusted OR (95% CI) per 5 points on PCL-SP valueAdjusteda OR (95% CI) per 5 points on PCL-SP value
‘When I notice my heart beating rapidly during physical activity, it reminds me of my heart event’1.53 (1.30–1.85)<0.0012.02 (1.49–2.99)<0.001
‘When I become short of breath during physical activity, it reminds me I’m at risk of having another heart event’1.46 (1.25–1.76)<0.0011.83 (1.41–2.53)<0.001
‘It scares me when my heart beats rapidly during physical activity’1.37 (1.19–1.61)<0.0011.73 (1.30–2.52)0.001
‘I sometimes avoid physical activity because I’m afraid it will cause me to have a heart event’1.32 (1.14–1.53)<0.0011.35 (1.10–1.73)0.008

CI: confidence interval; PCL-S: post-traumatic stress disorder checklist for acute coronary syndrome; PTSD: post-traumatic stress disorder; OR: odds ratio.

Logistic regression model adjusted for age, gender, race/ethnicity, education, partner status, depression, GRACE risk score, Charlson comorbidity index, history of coronary heart disease, and acute coronary syndrome diagnosis.

This study is the first to demonstrate an association between PTSD symptoms after suspected ACS and aversive cognitions about physical activity. We found that patients with elevated PTSD symptoms after a suspected ACS event were more likely to report that physical sensations during physical activity (e.g. rapid heartbeat, shortness of breath) scared them or reminded them of their traumatic event/future risk and were more likely to report avoidance of physical activity because of this fear. These results support the hypothesis that physical activity can serve as a trigger for the distressing re-experiencing that defines PTSD, and suggest that exercise avoidance may be an underlying mechanism by which PTSD worsens prognosis in ACS patients.

Author contribution

RM, IMK, DE and KMD contributed to the conception or design of the work. GS and KMD contributed to the acquisition, analysis, or interpretation of data for the work. RM and KMD drafted the manuscript. GS, IMK and DE critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work ensuring integrity and accuracy.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by R01-HL117832, R01-HL123368 and R01-HL134985 from the National Heart, Lung, and Blood Institute at the National Institutes of Health.

References

1

Edmondson
D
,
Richardson
S
,
Falzon
L
et al.  
Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review
.
PLOS ONE
 
2012
;
7
:
e38915
–
e38915
.

Google Scholar

Crossref
Search ADS
PubMed

 
2

Anderson
JL
,
Adams
CD
,
Antman
EM
et al.  
2011 ACCF/AHA Focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
.
Circulation
 
2011
;
123
:
e426
–
e579
.

Google Scholar

PubMed
OpenURL Placeholder Text

 
3

American Psychiatric Association
.
Diagnostic and statistical manual of mental disorders: DSM-5
,
Arlington, VA
:
American Psychiatric Association
,
2013
.

Google Scholar

OpenURL Placeholder Text

4

Edmondson
D
.
An enduring somatic threat model of posttraumatic stress disorder due to acute life-threatening medical events
.
Soc Pers Psychol Compass
 
2014
;
8
:
118
–
134
.

Google Scholar

Crossref
Search ADS

 
5

Meli L, Alcántara C, Sumner JA, et al. Enduring somatic threat perceptions and post-traumatic stress disorder symptoms in survivors of cardiac events. J Health Psychol. Epub ahead of print 1 April 2017. DOI: 10.1177/1359105317705982
.

6

Chang
BP
,
Sumner
JA
,
Haerizadeh
M
et al.  
Perceived clinician–patient communication in the emergency department and subsequent post-traumatic stress symptoms in patients evaluated for acute coronary syndrome
.
Emerg Med J
 
2016
;
33
:
626
–
631
.

Google Scholar

Crossref
Search ADS
PubMed

 
7

Bliese
PD
,
Wright
KM
,
Adler
AB
et al.  
Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat
.
J Consult Clin Psychol
 
2008
;
76
:
272
–
281
.

Google Scholar

Crossref
Search ADS
PubMed

 
8

Blanchard
EB
,
Jones-Alexander
J
,
Buckley
TC
et al.  
Psychometric properties of the PTSD Checklist (PCL)
.
Behav Res Ther
 
1996
;
34
:
669
–
673
.

Google Scholar

Crossref
Search ADS
PubMed

 
9

Weathers FW, Litz BT, Herman DS, et al. The PTSD Checklist: reliability, validity, and diagnostic utility. In: Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX, USA, October 1993
.

10

Peterson
R
,
Reiss
S
.
Anxiety sensitivity index manual
, 2nd ed.
Worthington, OH
:
International Diagnostic Systems
,
1992
.

Google Scholar

OpenURL Placeholder Text

 
© The European Society of Cardiology 2018
This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://dbpia.nl.go.kr/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Issue Section:
Physical activity > Letter to the editor
Download all slides

Comments

0 Comments
Comments (0)
Submit a comment
You have entered an invalid code
Thank you for submitting a comment on this article. Your comment will be reviewed and published at the journal's discretion. Please check for further notifications by email.