Psychiatric disorders diagnosed in the aftermath of a traumatic event were associated with higher odds of subsequent major adverse cardiac and cerebrovascular events.

Results of a large Danish registry study showed alcohol use disorder (AUD) was the leading psychiatric predictor in both men and women. Depressive disorders, posttraumatic stress disorder (PTSD)/stress-related disorders, brain-related or physiologic conditions, and delirium were also among the top predictors.

“Experiencing traumatic events can significantly affect mental health as well as cardiovascular health,” lead author Jennifer A. Sumner, PhD, associate professor in the Department of Psychology at the University of California, Los Angeles, said in a news release.

“Although most work to date has focused on PTSD and cardiovascular health, our research suggests that we should think about a wide range of mental health consequences when looking at cardiovascular disease risk after trauma,” Sumner added. 

The study was published online on September 2 in the Journal of the American Heart Association.

Looking Beyond PTSD

Research on posttraumatic psychopathology and cardiovascular disease (CVD) has largely focused on PTSD, leaving the cardiovascular risks associated with other psychiatric disorders that emerge after trauma poorly characterized.

To examine these associations, the researchers conducted a matched case-control study nested within a cohort of adults in Denmark who experienced a traumatic event between 1995 and 2018.

Such events included fires or explosions, transportation accidents, serious medical complications or injuries, traumatic brain injury, physical assault, stillbirth or pregnancy-related trauma, and suicide of a family member.

Among 219,866 adults, 43,994 subsequently experienced a major adverse cardiac or cerebrovascular event (MACCE), defined as nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or cardiovascular death.

Each case was matched with four trauma-exposed control individuals who had not experienced a MACCE, based on sex, age, year of trauma, and the date of the cardiovascular event.

The researchers identified psychiatric disorders diagnosed within 3 years after trauma and before the cardiovascular event, then used sex-stratified machine-learning models to identify the most important psychiatric predictors of subsequent MACCE.

The models evaluated a broad range of conditions, including substance use, depressive, bipolar, anxiety, stress-related, psychotic, and personality disorders.

“This study is unique in that it covers a wide range of traumatic experiences and considers a variety of mental health conditions that can start after these events as potential predictors of cardiovascular disease,” Sumner said.

Top Psychiatric Predictors

AUD emerged as the most important psychiatric predictor of MACCE in both men and women. Among men, its importance in the machine-learning model was about 10-fold greater than that of depressive episodes, the second-ranked predictor. Among women, AUD also ranked first, but depressive episodes were a much closer second.

After adjustment for sociodemographic factors, AUD was associated with 64% higher odds of MACCE among men and 85% higher odds among women in the testing samples. Depressive episodes were associated with 51% and 78% higher odds of MACCE among men and women, respectively.

PTSD/stress-related disorders also ranked among the leading predictors. In adjusted analyses of the testing samples, the association was not statistically significant in men (odds ratio [OR], 1.20; 95% CI, 0.88-1.64) but was significant in women (OR, 1.91; 95% CI, 1.41-2.59).

Other prominent predictors included recurrent depression, schizophrenia, anxiety disorders, bipolar disorder, personality disorders, nonsubstance-induced delirium, and disorders attributable to brain damage or physical disease. 

Some sex-specific differences also emerged. Cannabis- and opioid-related substance use disorders ranked among the most important predictors only in men, whereas persistent mood and delusional disorders and sedative-related substance use disorders ranked among the leading predictors only in women.

Implications and Limitations

Taken together, the findings suggest that psychiatric disorders beyond PTSD may also be relevant to cardiovascular risk after trauma, the researchers noted. However, they cautioned that these diagnoses should be viewed as risk markers rather than independent or causal CVD risk factors.

The observed associations may reflect a combination of behavioral pathways, including smoking, physical inactivity, poor diet, sleep disruption, poor adherence to medical care, and biological mechanisms such as autonomic and hypothalamic-pituitary-adrenal axis dysregulation and chronic systemic inflammation.

The researchers characterized the findings as hypothesis-generating. Traditional cardiometabolic risk factors, including hypertension, hyperlipidemia, and diabetes, were intentionally excluded from the machine-learning models, and lifestyle and clinical cardiovascular risk factors were not modeled.

The researchers characterized the findings as hypothesis-generating, noting that the models were designed to identify psychiatric predictors rather than optimize CVD risk prediction. 

Traditional cardiometabolic risk factors, including hypertension, hyperlipidemia, and diabetes, were therefore intentionally excluded, and lifestyle and clinical cardiovascular risk factors were not modeled.

The investigators were also unable to determine whether associations differed between coronary and cerebrovascular outcomes. The findings may also have limited generalizability beyond Denmark, which has universal healthcare and differs from many countries in social determinants of health.

“Traumatic experiences which lead to mental health disorders can have lasting effects on the risk of developing heart disease,” Glenn N. Levine, MD, who was not involved in the study, said in the news release.

“By recognizing trauma, seeking mental health support, and managing cardiovascular risk factors, we may help mitigate this risk,” added Levine, who is a professor of medicine at Baylor College of Medicine and cardiology section chief at the Michael E. DeBakey VA Medical Center, both in Houston.

This study had no commercial funding. Author disclosures are available in the original publication.