The Most Vicious Cycle of All: Cardiac PTSD

Just surviving a major cardiac event is an achievement, but of course getting through whatever initial resuscitation and procedures necessary are merely the first steps.

As a patient embarks on their rehabilitation journey, one incredibly dangerous setback cardiologists must be on the lookout for is cardiac posttraumatic stress disorder (PTSD). This remarkably common complication — according to a 2004 study published in Critical Care Medicine, as many as 27% of those who survive cardiac events may develop PTSD — can not only cause noncompliance with medication and other ongoing treatment modalities but also put the patient at an increased risk for a second cardiac event.

“In the aftermath of cardiac arrest or a heart attack, one of the most overlooked aspects of recovery is the emotional toll it takes, said Srihari S. Naidu, MD, a professor of medicine at New York Medical College and director of the Cardiac Cath Labs at the Westchester Medical Center Health Network, both in Valhalla, New York. “The experience can be deeply traumatic, not just for the patient, but for their loved ones as well. Despite this, mental health remains one of the least systematically addressed components of cardiac care.”

One problem, Naidu said, is that we “still, we lack standardized approaches to routinely screen, diagnose, and treat PTSD in this vulnerable population.”

Indeed, the American Heart Association identified this as a problem in its 2020 scientific statement, Sudden Cardiac Arrest Survivorship. In this publication, the association said the coordination of multidisciplinary care, to include emotional care, must start as early as within the ICU, but that it needs to continue throughout the recovery period.

“Without a coordinated plan during hospitalization to assess both short- and long-term recovery needs, we risk missing the broader picture,” said Naidu, who is also the president of the Society for Cardiovascular Angiography and Interventions. “In my experience, the outpatient clinic visit is often the first, and sometimes the only, opportunity to uncover these issues, which may manifest as anxiety or persistent thoughts about the event, or a variety of unrelated symptoms.”

James Jackson, MD, director of Behavioral Health and professor of medicine and psychiatry at Vanderbilt University in Nashville, Tennessee, said the symptoms are all united by one thing: The fact that the patient has the source of their trauma with them at all times.

“If you’re carrying your heart around with you and the heart is the source of the trauma, you’re constantly reminded, right? And if your cardiac event developed out of the blue, the concern is it could develop out of the blue again, right? So you’re carrying this trauma around with you. It’s a constant reminder,” he said. “The trauma is not parked somewhere in the rear view. The trauma is sort of in the present and even in the future.”

Symptom-wise, this trauma manifests itself in a variety of ways and can often go overlooked due to the focus on the physical recovery, Naidu said.

“During follow-up, subtle cues begin to emerge; patients who seem emotionally distant, who have trouble sleeping, or who avoid talking about what happened (can be red flags),” he said. “PTSD doesn’t always present dramatically.” 

Sometimes, Naidu said, it’s the patient who suddenly bursts into tears when recalling the event. Other times, it’s the one who avoids follow-ups, skips cardiac rehab, or steers clear of anything that reminds them of the hospital. Early symptoms may include hypervigilance, nightmares, intrusive memories, emotional numbness, and avoidance.

The Cycle Folds Onto Itself

When you break it down and look at triggering factors, it’s not hard to understand how PTSD becomes a self-fulfilling prophecy.

“Often with patients in a cardiac context, they get quite anxious. Their heart starts beating fast, and then they really worry. And so their response to that is, I’m going to withdraw. I’m going to disengage,” Jackson said.

While physical activity or exercise often helps reduce stress, patients are often short of breath and are reminded how it felt when they were having the attack.

“And so if they start to exercise, it’s all well and good,” Jackson said. “But as soon as they get slightly short of breath, even if they’re fine physiologically, as soon as they get short of breath, they’re going to shut that down. And this is just one example, but it becomes a very isolating sort of process.”

Patients left in this sustained crisis state experience a significantly diminished overall quality of life, and a study led by Antonia Seligowski and published in the March 2024 issue of Brain, Behavior, and Immunity found that PTSD after cardiac arrest significantly increases the risks for both major adverse cardiovascular events and all-cause mortality within just 1 year of discharge.

This is supported by the findings of Donald Edmondson, MD, associate professor of behavioral medicine in medicine and psychiatry at Columbia University Irving Medical Center, New York City, both in his 2013 study published in the American Heart Journal and in research he has done since.

“Over the years now, we’ve studied cardiac patients, both acute coronary syndrome, so myocardial infarction, as well as cardiac arrest and stroke,” Edmondson said. “What we see is that between 15 and 30% of patients will screen positive for PTSD due to that cardiac event 1 month later. Those who screen positive for PTSD are at least at doubled risk, if not greater, for having another cardiac event or dying within the year after that first cardiac event.”

These outcomes highlight how critical it is to address PTSD early and effectively, Naidu said.

“As cardiologists, we often focus on optimizing medications, procedures, and physical rehabilitation, but without integrating behavioral support, we’re missing a major part of the healing process,” he said.

PTSD and cardiovascular disease have a well-documented relationship: PTSD can worsen cardiovascular risk, and in turn, living with heart disease can amplify psychological stress.

Jackson said that there are behavioral health approaches at work in other areas that may be useful for cardiac events that are not sudden onset.

“There’s a general sort of a movement afoot called prehab,” Jackson said. “The general idea about prehab would be, ‘Hey, you’re going to have this surgery. We think that it’s going to knock your brain down. So we’re going to try to do some brain training with you before the surgery, and we think that in doing that, we’re going to build your reserve up.”

Is There a Type?

Although a 2022 study led by Sophia Armand and published in the Journal of Cardiovascular Nursing showed that younger age, female sex, and high levels of acute stress at the time of the event to be significant risk factors for developing PTSD after cardiac arrest. There’s no one overarching “profile” in terms of who’s likely to develop PTSD after any cardiac event. Naidu has his hunches, though.

“I would say that I suspect cardiac arrest is more frequently associated with PTSD than other types of cardiac events. Compared to conditions like myocardial infarction or unstable angina, the psychological impact of cardiac arrest, particularly when complicated by anoxic brain injury, tends to be more profound,” Naidu said, cautioning that individual risk factors should be weighed in every case. “Anoxic injury significantly increases the risk of depression, anxiety, and PTSD, often for an uncertain duration.”

At Columbia, Edmondson said there are two indicators that together predict a high risk for a cardiac patient developing PTSD.

“They tend to pay close attention to their cardiac sensations and catastrophize them,” Edmondson said of the patients who go on to develop PTSD. “Initially, in the ER [emergency room], they’re extremely distressed. Then, post event, they’ll say over the past 4 weeks, when I feel my heart beating fast, I worry that I’m having another heart attack. Or if I feel short of breath, I worry that I’m going to die.” 

“Having those two predictors together, so initial high distress in the emergency department and this sort of high, what we call interoceptive bias, those two things together place people at high risk for developing PTSD at that 1-month period (after their cardiac event).”

Regardless, more research must be done on this extremely risky and highly debilitating mental health issue that’s so deeply entwined with its cardiac trigger.

“More focused studies are needed to better understand the timing, risk factors, and mechanisms behind these symptoms, and to develop standardized strategies for early screening, intervention, and long-term psychological support,” said Naidu. “An urgent need exists to screen for and treat PTSD, not just for mental health but to help prevent repeat hospitalizations and improve long-term cardiovascular outcomes.”