Meta-Analysis of Perceived Stress and Its Association With Incident Coronary Heart Disease

Most studies examining potential associations between psychological factors and cardiovascular outcomes have focused on depression or anxiety. The effect of perceived stress on incident coronary heart disease (CHD) has yet to be reviewed systematically. We conducted a systematic review and meta-analysis of the association between perceived stress and incident CHD. Ovid, MEDLINE, and PsycINFO were searched as data sources. Prospective observational cohort studies were selected that measured self-reported perceived stress and assessed incident CHD at ≥6 months. We extracted study characteristics and estimates of the risk of incident CHD associated with high perceived stress versus low perceived stress. We identified 23 potentially relevant articles, of which 6 met our criteria (n = 118,696). Included studies measured perceived stress with validated measurements and nonvalidated simple self-report surveys. Incident CHD was defined as new diagnosis of, hospitalization for, or mortality secondary to CHD. Meta-analysis yielded an aggregate risk ratio of 1.27 (95% confidence interval 1.12 to 1.45) for the magnitude of the relation between high perceived stress and incident CHD. In conclusion, this meta-analysis suggests that high perceived stress is associated with a moderately increased risk of incident CHD

Prevalence of PTSD in Survivors of Stroke and Transient Ischemic Attack: A Meta-Analytic Review

Background and Purpose Posttraumatic stress disorder (PTSD) is common in survivors of acute life-threatening illness, but little is known about the burden of PTSD in survivors of stroke and transient ischemic attack (TIA). This study estimated the prevalence of stroke or TIA-induced posttraumatic stress disorder (PTSD) using systematic review and meta-analysis. Methods Potentially relevant peer-reviewed journal articles were identified by searching the Ovid MEDLINE, PsycINFO, PILOTS Database, The Cochrane Library and Scopus from inception to January 2013; all searches were conducted on January 31, 2013. Observational cohort studies that assessed PTSD with specific reference to a stroke or TIA that occurred at least 1 month prior to the PTSD assessment were included. PTSD rates and characteristics of the study and sample were abstracted from all included studies. The coding of all articles included demographics, sample size, study country, and method and timing of PTSD assessment. Results Nine studies (N = 1,138) met our inclusion criteria. PTSD rates varied significantly across studies by timing of PTSD assessment (i.e., within 1 year of stroke/TIA versus greater than 1 year post-stroke/TIA; 55% of heterogeneity explained; Q1 = 10.30; P = .001). Using a random effects model, the estimated rate of PTSD following stroke or TIA was 23% (95% CI, 16%–33%) within 1 year of the stroke or TIA and 11% (95% CI, 8%–14%) after 1 year. Conclusions Although PTSD is commonly thought to be triggered by external events such as combat or sexual assault, these results suggest that 1 in 4 stroke or TIA survivors develop significant PTSD symptoms due to the stroke or TIA. Screening for PTSD in a large population-based prospective cohort study with cardiovascular outcome assessments is needed to yield definitive prevalence, and determine whether stroke or TIA-induced PTSD is a risk factor for subsequent cardiovascular events or mortality

Relationship between premature ventricular complexes and depressive symptoms in non-ST-elevation acute coronary syndrome

Aims: Depression is a recognized risk marker for mortality among acute coronary syndrome (ACS) patients. We hypothesized that ventricular arrhythmia detected by inpatient telemetry monitoring is more frequent among ACS patients with elevated depressive symptoms compared to those without depressive symptoms. Methods and results: We analysed data from patients enrolled in a prospective observational study of depression in ACS. Telemetry recordings during the index admission (average recording 21.3±3.0 hours) were analysed for frequent premature ventricular complexes (PVCs), defined as ≥10 per hour. The self-report Beck Depression Inventory (BDI) was used to assess depressive symptoms. Among 200 ACS patients, frequent PVCs were observed in 29% of patients with moderate depressive symptoms (BDI ≥10), 27% of those with mild symptoms (BDI 5–9), and only 11% of those with no/minimal symptoms (p=0.02). Log-transformed PVCs per hour were associated with depressive symptom category (p=0.008). In a multivariable logistic regression model that included age, gender, left ventricular ejection fraction, cardiovascular risk score, heart rate, and QT interval, mild symptoms (OR 3.02, 95% 0.97–9.43, p=0.058) and moderate-severe symptoms (OR 3.94, 95% CI 1.27–12.22, p=0.018) were associated with frequent PVCs. Conclusions: In this sample of ACS patients, depressive symptoms were independently associated with frequent PVCs during inpatient telemetry monitoring

Posttraumatic Stress Disorder Prevalence and Risk of Recurrence in Acute Coronary Syndrome Patients: A Meta-analytic Review

BACKGROUND:Acute coronary syndromes (ACS; myocardial infarction or unstable angina) can induce posttraumatic stress disorder (PTSD), and ACS-induced PTSD may increase patients' risk for subsequent cardiac events and mortality. OBJECTIVE:To determine the prevalence of PTSD induced by ACS and to quantify the association between ACS-induced PTSD and adverse clinical outcomes using systematic review and meta-analysis. DATA SOURCES:Articles were identified by searching Ovid MEDLINE, PsycINFO, and Scopus, and through manual search of reference lists. METHODOLOGY/PRINCIPAL FINDINGS:Observational cohort studies that assessed PTSD with specific reference to an ACS event at least 1 month prior. We extracted estimates of the prevalence of ACS-induced PTSD and associations with clinical outcomes, as well as study characteristics. We identified 56 potentially relevant articles, 24 of which met our criteria (N = 2383). Meta-analysis yielded an aggregated prevalence estimate of 12% (95% confidence interval [CI], 9%-16%) for clinically significant symptoms of ACS-induced PTSD in a random effects model. Individual study prevalence estimates varied widely (0%-32%), with significant heterogeneity in estimates explained by the use of a screening instrument (prevalence estimate was 16% [95% CI, 13%-20%] in 16 studies) vs a clinical diagnostic interview (prevalence estimate was 4% [95% CI, 3%-5%] in 8 studies). The aggregated point estimate for the magnitude of the relationship between ACS-induced PTSD and clinical outcomes (ie, mortality and/or ACS recurrence) across the 3 studies that met our criteria (N = 609) suggested a doubling of risk (risk ratio, 2.00; 95% CI, 1.69-2.37) in ACS patients with clinically significant PTSD symptoms relative to patients without PTSD symptoms. CONCLUSIONS/SIGNIFICANCE:This meta-analysis suggests that clinically significant PTSD symptoms induced by ACS are moderately prevalent and are associated with increased risk for recurrent cardiac events and mortality. Further tests of the association of ACS-induced PTSD and clinical outcomes are needed

Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS One

Abstract Background: Acute coronary syndromes (ACS; myocardial infarction or unstable angina) can induce posttraumatic stress disorder (PTSD), and ACS-induced PTSD may increase patients' risk for subsequent cardiac events and mortality. Objective: To determine the prevalence of PTSD induced by ACS and to quantify the association between ACS-induced PTSD and adverse clinical outcomes using systematic review and meta-analysis. Data Sources: Articles were identified by searching Ovid MEDLINE, PsycINFO, and Scopus, and through manual search of reference lists

Correction: Posttraumatic Stress Disorder Prevalence and Risk of Recurrence in Acute Coronary Syndrome Patients: A Meta-analytic Review.

[This corrects the article DOI: 10.1371/journal.pone.0038915.]

Association of ACS-induced PTSD with adverse clinical outcome.

<p>Note: The size of the box associated with each study’s estimate represents the precision of the estimate, and the line represents the confidence interval around the estimate.</p

Search strategy flowchart.

<p>Search strategy flowchart.</p

Characteristics of Studies on the Prevalence of ACS-Induced PTSD.

<p>Abbreviations: ACS, acute coronary syndrome; ADIS-IV, Anxiety Disorder Interview Schedule for <i>DSM-IV</i><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Guler1" target="_blank">[11]</a>; CAPS, Clinician Administered PTSD Scale <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Blake1" target="_blank">[62]</a>; DTS, Davidson Trauma Scale <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Davidson2" target="_blank">[63]</a>; IES, Impact of Events Scale <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Horowitz1" target="_blank">[64]</a>; IES-R, Impact of Events Scale–Revised <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Weiss1" target="_blank">[65]</a>; NR, not reported; PDS, Posttraumatic Stress Diagnostic Scale <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Foa1" target="_blank">[66]</a>; PSS-SR, PTSD Symptom Scale–Self-Report Version <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Foa2" target="_blank">[67]</a>; PTSD, posttraumatic stress disorder; RI, Reaction Index <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-Frederick1" target="_blank">[68]</a>; SCID, Structured Clinical Interview for <i>DSM-IV</i><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038915#pone.0038915-First1" target="_blank">[69]</a>;</p>a<p>Value reported for full sample, including participants who did not complete the study.</p