PTSD, Medication Adherence, and Prognosis after Acute Coronary Syndromes

描述(由申请人提供)：这项辅助研究的目标是确定急性冠脉综合征(ACS)后的干预目标，该目标可能会降低因ACS而发展为创伤后应激障碍(PTSD)的患者再次发生心脏事件的风险和死亡率。在每年在急性冠脉综合征中幸存下来的近200万美国人中，约有12%患有创伤后应激障碍。与没有发生创伤后应激障碍的急性冠脉综合征幸存者相比，患有创伤后应激障碍的患者发生心血管事件复发和死亡率的风险是后者的两倍。导致急性冠脉综合征的创伤后应激障碍和不良心血管预后之间的联系机制尚不清楚。因此，有必要进行研究，评估解释创伤后应激障碍与预后之间关系的机制。创伤后应激障碍的一个特点是避免暴露在创伤事件的提醒中。这导致了一种假设，即患有创伤后应激障碍的急性冠脉综合征幸存者将很难坚持使用作为创伤性心脏事件提醒的药物。为了支持这一假设，我们已经表明，患有创伤后应激障碍的中风幸存者报告不遵守他们的药物的可能性是前者的三倍。然而，到目前为止，还没有人评估急性冠脉综合征引起的创伤后应激障碍是否与服药依从性差有关。如果急性冠脉综合征引起的创伤后应激障碍导致对心脏保护药物的依从性差，那么药物依从性可能是改善患有创伤后应激障碍的急性冠脉综合征幸存者预后的一个重要目标。NHLBI资助的研究“急诊室中社会人际因素对创伤后应激障碍/心脏结局的影响”为检验这些假说提供了一个独特的机会。这项家长研究将招募1741名急性冠脉综合征患者，他们最初出现在急诊室(ER)，并被跟踪12个月，以确定1)哪些ER因素对急性冠脉综合征后创伤后应激障碍的发展起作用，以及2)在急性冠脉综合征事件发生后1个月由急性冠脉综合征引起的创伤后应激障碍与预后之间的关系。在这项辅助研究中，我们建议使用金标准方法--电子监测，额外测量急性冠脉综合征后6个月内阿司匹林的依从性。我们还将对参与者进行调查，以了解为什么急性冠脉综合征引起的创伤后应激障碍与不良的用药依从性有关。最后，我们将测试在控制用药依从性后，急性冠脉综合征引起的创伤后应激障碍和急性冠脉综合征复发/死亡率之间的关联是否会减少。本研究的结果将有助于理解急性冠脉综合征所致的创伤后应激障碍导致不良预后的机制，并将为改善患有创伤后应激障碍的急性冠脉综合征幸存者的预后确定一个特定的靶点。

DESCRIPTION (provided by applicant): The goal of this ancillary study is to identify a target for intervention after an acute coronary syndrome (ACS) that may decrease risk for recurrent cardiac events and mortality among patients who develop posttraumatic stress disorder (PTSD) due to the ACS. Approximately 12% of the nearly 2 million Americans who survive an ACS each year develop PTSD. Compared to ACS survivors who do not develop PTSD, those with PTSD have double the risk of recurrent cardiovascular events and mortality. The mechanisms underlying the association between ACS-induced PTSD and poor cardiovascular prognosis remain unknown. As a result, there is need for studies that assess mechanisms explaining the association between PTSD and prognosis. A hallmark of PTSD is avoidance of exposure to reminders of the traumatic event. This has led to the hypothesis that ACS-survivors with PTSD will poorly adhere to medications that serve as reminders of the traumatic cardiac event. In support of this hypothesis, we have shown that stroke survivors with PTSD are three times as likely to report being non-adherent to their medications. Yet, thus far, no one has assessed whether ACS-induced PTSD is associated with poor medication adherence. If ACS-induced PTSD results in poor adherence to cardioprotective medications, then medication adherence may represent an important target for improving prognosis in ACS-survivors with PTSD. The NHLBI-funded study "Impact of Social-Interpersonal Factors in the ER on PTSD/Cardiac Outcomes" provides a unique opportunity to test these hypotheses. This parent study will enroll a cohort of 1,741 ACS patients who initially present to the emergency room (ER) and are followed for 12 months to determine 1) which ER factors contribute to the development of PTSD after ACS and 2) the association between ACS- induced PTSD at 1 month and prognosis 1 year after the index ACS event. In this ancillary study, we propose to additionally measure adherence to aspirin in the six months after ACS using the gold-standard approach - electronic monitoring. We will also survey participants to understand why ACS-induced PTSD is associated with poor medication adherence. Finally, we will test whether the association between ACS-induced PTSD and ACS recurrence/mortality will be diminished after controlling for medication adherence. The results from this study will contribute to the understanding of the mechanisms by which ACS-induced PTSD leads to poor prognosis and will identify a specific target for interventions to improve prognosis in ACS survivors with PTSD.