Military Veterans With PTSD Are at Risk for A-fib

BOSTON, MA—Posttraumatic stress disorder (PTSD) is an independent risk factor for A-fib in US military veterans, a new analysis shows.

After accounting for other known variables associated with the arrhythmia, PTSD was linked to a 13% greater relative risk of developing A-fib in subsequent years (HR 1.13; 95% CI 1.02-1.24), Lindsey Rosman, PhD (Yale School of Medicine and VA Connecticut Healthcare System), reported at the Heart Rhythm Society 2018 Scientific Sessions here.

Though the absolute difference in the percentage of patients who developed A-fib in the PTSD versus non-PTSD groups was small (0.28% vs 0.24%), Rosman described the heightened risk as “pretty substantial” when considering the young age of the population (mean age 30) and the fact that half of those who developed A-fib did not have any prior cardiovascular issues.

“That leads us to think that it’s possible that early detection and treatment of PTSD could attenuate risk for AF,” she said. “More research is obviously needed to look at—in a clinical trial scenario—whether treatment in fact does attenuate risk, but it’s possible.”

Spurred by evidence suggesting that acute stress and negative emotions trigger episodes of A-fib, Rosman and colleagues set out to evaluate whether a similar relationship would be found with exposure to prolonged and intense emotional stress in the form of PTSD. They looked at data on about 1 million veterans who first accessed care through the Veterans Health Administration between October 2001 and November 2014, excluding those with a history of A-fib or atrial flutter at baseline.

During a mean follow-up of 4.8 years, 2,491 patients (0.25%) were diagnosed with A-fib and 27.9% were diagnosed with PTSD. The association between the two conditions remained after adjustment for demographics, comorbid depression, lifestyle factors, and cardiovascular risk factors.

It’s possible that when looking at preventative efforts that would target this cohort, focusing on health and lifestyle behaviors may be more beneficial as opposed to focusing on underlying cardiovascular disease. Lindsey Rosman

Rosman said she was not surprised by the finding because previous studies have shown that changes in autonomic function occur in response to acute traumatic stressors, like the 9/11 terrorist attack. There is also evidence that PTSD can cause changes in the hypothalamic-pituitary-adrenal axis.

“There is a very strong biological underpinning for why chronic stress, and those prolonged autonomic changes could trigger AF,” Rosman said.

Paul Marvar, PhD (George Washington University, Washington, DC), agreed, saying that there is accumulating evidence that autonomic dysfunction links PTSD and A-fib. Trauma cues—a car backfiring, for example—set off a constellation of physiological changes in someone with PTSD, and “those exposures over time . . . could certainly contribute to altered cardiac activity,” he told TCTMD.

This study, Marvar said, “contributes to greater understanding of the link between posttraumatic stress disorder and cardiovascular disease development.”

He said that a number of clinical studies are ongoing to provide more definitive data on a causal link between PTSD and A-fib and to see whether treating PTSD will prevent A-fib and other cardiovascular diseases. The fact that this study identified a relationship between PTSD and A-fib in such a young population is noteworthy, Marvar added, because there would be greater opportunities to intervene on patients at this age to prevent more serious cardiovascular disease down the road.

Rosman noted that not much is known about young patients with A-fib and how best to manage them. There is some evidence to suggest that the risk factor profile differs in younger versus older A-fib populations, she said.

“It’s possible that when looking at preventative efforts that would target this cohort, focusing on health and lifestyle behaviors may be more beneficial as opposed to focusing on underlying cardiovascular disease,” she said.