PHILADELPHIA, PA – Adults with congenital heart disease (ACHD) may be at increased risk for posttraumatic stress disorder (PTSD), new research suggests[1].

In the study of 134 outpatients with ACHD, 21% had global PTSD symptoms and 11% had symptoms directly related to their cardiac condition, as measured with two validated mental health scales.

The strongest factors associated with PTSD were having comorbid depressive symptoms (P<0.001) and an earlier year for their most recent cardiac surgery (P<0.03).

"The high prevalence of PTSD in this complex group of patients has important implications for the medical and psychosocial management of this growing population," write Lisa X Deng (Children's Hospital of Philadelphia Cardiology Division, PA) and colleagues.

They add that although the PTSD prevalence they found was "several times higher than the 3.5% observed in the general population," it's comparable to pediatric congenital heart disease (12%–29%) and adults with acquired heart disease (12%–38%).

The findings were published online December 13, 2015 in the American Journal of Cardiology.

PTSD Checklist

The investigators note that although past research has shown a link between PTSD and adverse outcomes in cardiac patients, including increased mortality, this is one of the first studies to examine the disorder in those with ACHD.

They enrolled 134 outpatients (54% women; mean age 34.6 years) from an ACHD-focused clinic between August and December 2013. All patients were instructed to fill out the Impact of Event Scale-Revised (IES-R), PTSD Checklist-Civilian Version (PCL-C), and depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), as well as a background survey.

Among the patient population, 89% had undergone prior cardiac surgery, interventional catheterization, or an electrophysiology procedure. In addition, 57% reported going through 106 "medically traumatic events." This included those surrounding cardiac surgery (36 events), other CV episodes (43 events), and noncardiac circumstances such as car accidents or cancer (27 events).

Global PTSD criteria on the PCL-C, as defined by a score of at least 44, was found for 21% of participants (mean score 55.3). However, "only one patient had a formal clinical diagnosis of PTSD documented in their medical chart and only 11 . . . were receiving mental-health treatment," report the researchers.

In this group, PTSD was significantly associated with high scores on the HADS-D (odd ratio [OR] 1.5; 95% CI 1.2–1.9) and with earlier year of most recent cardiac surgery (OR 0.94; 95% CI 0.9–1.0).

The investigators write that "advances in anesthetic and perioperative management may explain this association of PTSD with early era of surgical repair," or it could be that "traumatic stressors may produce chronic, lasting effects." Another possibility is that more recent procedures could help patients to reinterpret and downgrade the impact of earlier processes, they add.

No significant associations with PTSD were found for ACHD severity, total number of interventional procedures, or history of stroke/ischemic attack.

Event-Related PTSD

In patients who filled out the IES-R, 11% had a total score of at least 33, signifying that event-related PTSD was likely. The mean score for the PTSD subgroup was 54.5.

As with the PCL-C analyses, the strongest factors associated with PTSD among the IES-R completers were depressive symptoms on the HADS-D (OR 1.6; 95% CI 1.2–2.3, P=0.004) and year of most recent cardiac surgery (OR 0.9; 95% CI 0.8–1.0, P=0.009).

The investigators write that the difference in prevalence found between the two PTSD measures "suggests that clinicians should not assume that [ACHD] represents the only traumatic events perceived by patients."

Study limitations cited included the small sample size, it was conducted at only one center, both PTSD and depressive symptoms were assessed by patient report, duration and progression of PTSD symptoms were not measured, and information about nonmedical traumatic events was not collected.

"Larger prospective studies of ACHD patients are needed to investigate the predictors and trajectory of PTSD in this population and to determine the optimal screening and treatment paradigm in this complex group," conclude the researchers.

The study was funded by a grant from Big Hearts to Little Hearts. The study authors report no relevant financial relationships.