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Results From the Prospective Living With an Implanted Cardioverter-Defibrillator Study

Karl-Heinz Ladwig, PhD, MD; Jens Baumert, PhD; Birgitt Marten-Mittag, PhD; Christof Kolb, MD; Bernhard Zrenner, MD; Claus Schmitt, MD

Arch Gen Psychiatry. 2008;65(11):1324-1330.

Context  Cardiac disease and treatment with an implantable cardioverter-defibrillator (ICD) may be psychologically traumatic. Posttraumatic stress disorder (PTSD) is generally overlooked in cardiac patients, and no study to date (to our knowledge) has evaluated the effect of PTSD symptoms on the prognosis in patients with ICDs.

Objective  To test whether PTSD symptoms at baseline predict long-term mortality risk in patients with ICDs.

Design  Prospective cohort study with a mean follow-up period of 5.1 years, accounting for 743 person-years observed.

Setting  Data were derived from the Living With an Implanted Cardioverter-Defibrillator-Study, which initially included 211 patients with ICDs routinely attending the German Heart Center Munich outpatient clinic.

Participants  The Impact of Event Scale–Revised was used in 147 patients (125 men and 22 women) who qualified for the "A" criterion of PTSD (survival of a life-threatening event). Thirty-eight patients scoring in the upper quartile of the scale constituted the PTSD index group.

Main Outcome Measures  Mortality risk per 1000 person-years as assessed by Cox proportional hazards regression analysis based on an appropriate model fit (area under the curve, >0.80).

Results  Index patients experienced more anxiety and depression, had more cardiac symptoms, but showed no differences in left ventricular ejection fraction status or extent of ICD discharges compared with non–index patients. Forty-five patients (30.6%) died during the follow-up period. The relative mortality risk (multivariate adjusted for age, sex, diabetes mellitus, left ventricular ejection fraction, β-blocker prescription, prior resuscitation, ICD shocks received, depression, and anxiety) hazard ratio was 3.45 (95% confidence interval, 1.57-7.60; P = .002) for the PTSD group. Compared with 55 fatal events per 1000 person-years in patients without PTSD, the long-term absolute mortality risk accounted for 80 fatal events per 1000 person-years in patients with PTSD.

Conclusion  The adverse effect of PTSD symptoms on the long-term mortality risk in ICD-treated cardiac event survivors, independent of disease severity, supports the need for routinely applied interdisciplinary psychosocial aftercare.

Author Affiliations: Department of Psychosomatic Medicine and Psychotherapy, Technische Universitaet Muenchen (Drs Ladwig and Marten-Mittag), and German Heart Center Munich, Technical University of Munich (Drs Kolb, Zrenner, and Schmitt), Munich, and Institute of Epidemiology, Helmholtz Zentrum National Research Center for Environmental Health, Neuherberg (Drs Ladwig and Baumert), Germany.

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