Original Research

An Increased Risk of Stroke Among Panic Disorder Patients: A 3-Year Follow-up Study
Yi-Hua Chen, PhD1; Chaur-Jong Hu, MD2,3; Hsin-Chien Lee, MD, MPH2,4; Herng-Ching Lin, PhD5
Objective: To explore whether panic disorder (PD) increases the risk for stroke, using a nationwide, population-based dataset. Methods: Our study used data from Taiwans National Health Insurance Research Database. The study cohort included patients who received ambulatory psychiatric care for PD between 2002 and 2003, inclusive (n = 3891). We selected our comparison cohort by randomly recruiting enrollees (n = 19 455) matched with the study group by sex and age. Each patient was tracked for 3 years, from their index ambulatory care visit until the end of 2006, to identify whether or not a patient had a stroke during the follow-up period. Cox proportional hazard regressions were performed as a means of computing the 3-year survival rate, adjusting for potential confounding factors. Results: Among the total sample, 2029 patients (8.7%) experienced a stroke during the 3-year follow-up period, including 647 from the study cohort (16.6% of the PD patients) and 1382 (7.1%) from the comparison cohort. After adjusting for the patients sex, age, monthly income, level of urbanization, and comorbid medical disorders, the hazard of stroke occurring during the 3-year follow-up period was 2.37 (P < 0.001) times greater for patients with PD than for patients in the comparison cohort. In further analyses, stratified by medical diseases and age, the significant risk of PD on subsequent stroke persisted. Conclusions: We conclude that PD is an independent risk factor for stroke. For patients with PD, aggressive treatment of PD may be considered as part of stroke prevention. Can J Psychiatry. 2010;55(1):4349.

Clinical Implications We found that about 1 in 6 PD patients (16.6%) experienced a stroke within 3 years, stressing the significant need for possible intervention. After adjusting for potential confounders, the hazard of stroke occurring during the 3-year follow-up period was 2.37 (95% CI 2.12 to 2.67, P < 0.001) times greater for PD patients than for patients in the comparison cohort. Limitations PD diagnoses, which rely on administrative claims data reported by hospitals, may be less accurate than diagnoses made according to a standardized procedure. Some important variables such as cigarette smoking, obesity, and body mass index, which are likely to be associated with stroke, were not available in the National Health Insurance Research Database.

Key Words: panic disorder, stroke, cardiovascular disease

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common anxiety disorder, PD affects up to 5% of the population at some point in life.1 A dramatic rise in panic attacks from 5.3% to 12.7% has been detected in recent decades.2 Diagnosis is based on recurrent unexpected panic attacks, which consist of sudden onset of intense fear or discomfort associated with several cognitive and somatic symptoms. Many PD symptoms mimic features of CVDs (for example, sweating, palpitations, paresthesia, chest pain, hot flashes, shortness of breath, and choking sensation), and can therefore be difficult to differentiate. Panic attacks usually are accompanied by sympathetic nervous system arousal, and the resulting effects on cardiovascular regulation, such as increased heart rate and blood pressure, imply risk for CVD, including stroke.36 Compelling evidence shows that PD is commonly present with CVD, especially cardiovascular death. Higher than expected risk of cardiovascularcerebrovascular mortality has been observed among patients with PD or paniclike anxiety both in retrospective79 and prospective studies.10,11 More recently, the hazard ratio among postmenopausal women for PD associated with end point coronary heart disease or stroke combined was found to be 3.08 (95% CI 1.60 to 5.94).12 Although an association between CVD and PD has been observed, the real relation of PD to CVD remains unclear. Previous studies about whether PD confers risk for CVD or stroke had small sample sizes with restricted statistical power, patients selected from specific settings such as cardiac or psychiatric clinics, and depended on patients self-reported cardiovascularcerebrovascular condition. No prior study has specifically examined the association between PD and stroke using thorough medical assessments in a population-based study. Our study was designed to use a nationwide, population-based dataset to explore whether PD increases the risk for stroke during a 3-year follow-up period.

ambulatory care claims data from Taiwans NHI program, a single-payer system that finances health care for all Taiwanese citizens, offering unrestricted access to any health care provider of the patients choice. There are currently more than 21 million enrollees in the NHI program. Therefore, the NHIRD is one of the largest such datasets in the world. As such, it offers a unique opportunity to identify the risk of stroke among patients with PD. As the NHIRD consists of de-identified secondary data released to the public for research purposes, our study was exempt from full review by the Internal Review Board. Study Sample Our study includes a study cohort and a comparison cohort. The study cohort consists of patients who received ambulatory psychiatric care, with a principal diagnosis of PD (ICD-9-CM code 300.01), between January 2002 and December 2003. To ensure the validity of the PD diagnoses, we required that all study cohort patients had at least 2 consensus PD diagnoses after the index ambulatory care visit. We excluded patients who were hospitalized or received ambulatory care treatment for any type of mental illness (ICD-9-CM codes 290.XX319.XX) during the previous 5-year period. We also excluded patients aged 17 years and younger, to limit the study sample to the adult population. Ultimately, our study sample included 3891 patients with PD. Our comparison cohort was extracted from a database released by the Taiwan NHRI in 2008. This database consists of 1 073 891 random subjects, about 5% of all enrollees in the NHI program. It was created by the Taiwan NHRI using a systematic sampling method to randomly extract a representative database from the entire database. There are no statistically significant differences in age, sex, and medical costs between the sample group and all enrollees. We excluded patients diagnosed with any type of mental disorder. We then created our comparison cohort by randomly selecting 19 455 enrollees (5 for every PD patient) matched with the study group by sex and age (34 years and younger, 35 to 44 years, 45 to 54 years, 55 to 64 years, and 65 years and older). Each patient was tracked for 3 years from their index ambulatory care visit in the 2-year period from 2002 to 2003 up to the end of 2006 to identify whether or not a stroke (ICD-9-CM codes 430.XX438.XX) occurred during the follow-up period. To calculate the stroke-free survival time after the index ambulatory care visit during a 3-year period, the data was also linked with a death certificate data from Taiwan, with cases censored if a person died of nonstroke causes during that time. Among the patients who died from nonstroke causes (n = 411), 93 (2.4% of the PD patients) were from the study cohort and 318 (1.6%) were from the comparison cohort. The regression model adjusted for sociodemographic characteristics and comorbid medical disorders (hypertension,
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Methods
Database Our study used data from the NHIRD in Taiwan, covering the years 1995 to 2006. The dataset includes all inpatient and
Abbreviations used in this article
CVD ICD-9-CM NHI NHIB NHIRD NHRI NT$ PD cardiovascular disease International Classification of Diseases, Ninth Revision, Clinical Modification National Health Insurance NHI Bureau NHI Research Database National Health Research Institutes Taiwanese dollar panic disorder

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An Increased Risk of Stroke Among Panic Disorder Patients: A 3-Year Follow-up Study

Table 1 Demographic characteristics and comorbid medical disorders for patients with PD and comparison group patients in Taiwan, from 2002 to 2003 (n = 23 346)
PD n (%) Comparison group n (%)

Variable Sex Male Female Age, years 34 35 to 44 45 to 54 55 to 64 65 Hypertension Yes No Diabetes Yes No Hyperlipidemia Yes No Renal disease Yes No Urbanization level 1 2 3 4 5
b a

P >0.99

1474 (37.9) 2417 (62.1)

7370 (37.5) 12 085 (62.1) >0.99

708 (18.2) 1201 (30.9) 1034 (26.6) 456 (11.7) 492 (12.6)

3540 (18.2) 6005 (30.9) 5170 (26.6) 2280 (11.7) 2460 (12.6) <0.001

diabetes, hyperlipidemia, and renal disease) at the time of the index ambulatory care visit. Sociodemographic characteristics included sex, age, level of urbanization, and geographic location of the community in which the patient resided (Northern, Central, Eastern, and Southern Taiwan), and monthly income (0, NT$1 to NT$15 840, NT$15 841 to NT$25 000, and NT$25 001 or more) as variables. Urbanization levels are divided into 5 strata, based on prior studies in Taiwan, with level 1 referring to the most urbanized and level 5 referring to the least urbanized communities. We selected NT$15 840 as the first income level cut-off point because this is the government-stipulated minimum wage for full-time employees in Taiwan. Statistical Analysis The SAS statistical software, Version 8.2 (SAS Institute, Inc, Carey, NC), was used to perform the analyses in this study. Pearson chi-square tests were performed to examine the differences between the 2 cohorts in terms of sociodemographic characteristics and select comorbid medical disorders. The 3-year stroke-free survival rate was then estimated using the log-rank test to examine differences in the risk of stroke between the 2 cohorts. Cox proportional hazards regression model analsyses were also carried out as a means of computing the 3-year survival rate, adjusting for the variables mentioned above. Finally, we present hazard ratios along with 95% confidence intervals, using a significance level of 0.05.

1661 (42.7) 2230 (57.3)

5039 (25.9) 14 416 (74.1) <0.001

778 (20.0) 3113 (80.0)

2432 (12.5) 17 023 (87.5) <0.001

1297 (33.3) 2594 (66.7)

3619 (18.6) 15 836 (81.4) <0.001

Results
Table 1 shows the distribution of demographic characteristics and select comorbid medical disorders for the 2 cohorts. As expected, most of the sampled patients were women (62.1%) and aged 43 years and younger (49.1%). Patients with PD were more likely to have comorbidities such as hypertension (P < 0.001), diabetes (P < 0.001), hyperlipidemia (P < 0.001), and renal disease (P < 0.001) at the time of the index ambulatory care visit, compared with the comparison cohort. In addition, there were also significant differences in these 2 cohorts for monthly incomes and the urbanization level of the community where the patient resided (all P values < 0.001). Among the total sample of patients (n = 23 346), 2029 patients (8.7%) suffered a stroke during the 3-year follow-up period, including 647 from the study cohort (16.6% of the patients with PD) and 1382 (7.1%) from the comparison cohort. The log-rank test showed that patients with PD had significantly lower 3-year stroke-free survival rates than patients in the comparison cohort (P < 0.001). The results of the Kaplan-Meier method of survival analysis are presented in Figure 1. Table 2 describes the adjusted hazard ratios for stroke by cohort. After adjusting for the patients sex, age, monthly income, level of urbanization, and comorbid medical disorders, the hazard of stroke occurring during the 3-year followup period was 2.37 (95% CI 2.12 to 2.67, P < 0.001) times

314 (8.1) 3577 (91.9)

1051 (5.4) 18 404 (94.6) <0.001

1260 (32.4) 1148 (29.5) 481 (12.4) 561 (14.4) 441 (11.3)

6187 (31.8) 5486 (28.2) 2996 (15.4) 2549 (13.1) 2237 (11.6) <0.001

Monthly income, NT$ 0 1 to 15 840 15 841 to 25 000 25 001

a b

878 (22.6) 620 (15.9) 1583 (40.7) 810 (20.8)

4358 (22.4) 2140 (11.0) 8113 (41.7) 4844 (24.9)

Most urbanized Least urbanized

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Original Research

Figure 1 Stroke-free survival rates for patients with PD and patients in a comparison cohort in Taiwan

Comparison rate

_____ comparison cohort -------- panic disorder Time elapsed since index hospitalization (days)

greater for patients with PD than for patients in the comparison cohort. As expected, the adjusted hazard of stroke increased with patients age. It also increased in the presence of medical comorbidities such as hypertension (HR = 2.89; 95% CI 2.57 to 3.25, P < 0.001), diabetes (HR = 1.48; 95% CI 1.31 to 1.67, P < 0.001), hyperlipidemia (HR = 1.27; 95% CI 1.13 to 1.67, P < 0.001), and renal disease (HR = 1.36; 95% CI 1.17 to 1.60, P < 0.001). Table 3 reveals results from further analyses stratified by medical risk factors (that is, hypertension, diabetes, hyperlipidemia, and renal disease) and by age. For patients with hypertension, those with PD aged 44 years and younger and 45 years and older all had increased risks of subsequent stroke (adjusted HR = 1.87 and 1.75, respectively, both Ps < 0.001), compared with non-PD patients. For patients without hypertension, the adjusted hazard ratios were 4.91 and 2.29 for those aged 44 years and younger and 45 years and older, respectively (both Ps < 0.001). A similar trend was observed for diabetes, hyperlipidemia, and renal disease (all Ps < 0.001). The risk of PD on subsequent strokes persisted among those with and without these medical diseases and among patients aged 44 years and younger and 45 years and older.

monthly income, level of urbanization, and comorbid medical disorders, PD patients were independently associated with a 2.37-fold increased risk of following stroke throughout the follow-up. Previous studies have noted an association between PD and cardiovascularcerebrovascular illnesses. In a study on former inpatients with PD (n = 113), Coryell et al7 reported that men with PD were twice as likely to die from CVD as expected in the 35 years following their index admission. Coryell et al replicated the study in outpatients with PD and found a similar, though nonsignificant, trend probably owing to the small sample size.8 Cardiovascular morbidity may therefore contribute to excess mortality among PD patients.13 Using a community survey sample, Weissman et al9 displayed an excess in risk of self-reported stroke among people with lifetime diagnoses of PD, compared with those with other psychiatric disorders or no psychiatric disorders. More recently, a prospective study conducted by Smoller et al12 showed an increased risk of the combined end point of coronary heart disease or stroke, but not stroke alone (adjusted HR = 1.98; 95% CI 0.75 to 5.24) among postmenopausal women with a 6-month history of panic attacks. Our study then demonstrated that PD was specifically related to an increased risk of subsequent stroke over 3 years in a population-based analysis. The risk remained after adjustment for conventional risk factors including hypertension, diabetes, hyperlipidemia, renal disease, and aging.14 In further stratified analyses, the significant risk of PD on subsequent stroke incidences persisted, for patients with and without medical disease (that is, hypertension, diabetes, hyperlipidemia, and renal disease) and both for younger and
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Discussion
To our knowledge, this is the first large-scale populationbased study to identify PD as an independent risk factor for subsequent stroke diagnosis. We found that during the 3-year follow-up period, 16.6% of the PD patients from the study cohort experienced a stroke, compared with 7.1% from the comparison cohort. After adjusting for patients sex, age,
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An Increased Risk of Stroke Among Panic Disorder Patients: A 3-Year Follow-up Study

Table 2 Adjusted hazard ratio for stroke during the 3-year follow-up period for patients with PD and comparison group patients in Taiwan (n = 23 346)
Variable Cohort PD Comparison groupa Sex Male Female Age, years 34a 35 to 44 45 to 54 55 to 64 65 Hypertension Yes No
a a

for older people. These results emphasized PD as an independent risk factor for the following occurrence of stroke. Several potential mechanisms may help explain the link between PD to stroke. First, PD may be linked with thromboembolism (that is, loosening of a blood clot and obstructing the blood flow of the circulatory system) and hemorrhage (usually a rupture of an artery in the brain or intracerebral bleeds during an episode of hypertension), 2 major mechanisms for stroke. Kahn et al15,16 found increases of cardiac left ventricular chamber size among patients with PD. The left ventricle enlargement may elevate the risk of thrombus generation and thus raise the threat of ensuing strokes. Conversely, empirical evidence has identified an association between PD and hypertension.9,17 Hypertension may intensify the risk of subsequent hemorrhagic strokes. Second, the activation of the sympathetic nervous system in PD is considered to be important.18 Panic attacks usually are accompanied by high sympathetic tone and resulting increased heart rate and blood pressure, decreased heart rate variability, and even cardiac arrhythmia, all of which may indicate risk of CVD, including stroke.36 The results linking PD with stoke provide further evidence of the sympathetic hyperactivity hypothesis.19,20 Third, psychological distress may cause deleterious effects on cardiovascular conditions and consequently trigger CVD events.21 Recurrent episodes of panic attacks may be considered a repeated psychological stress reaction that is associated with CVD, including stroke. Lastly, the excess risk of CVD or stroke among PD patients may be indirectly attributed to higher rates of negative health behaviours. For example, elevated serum cholesterol, probably owing to inadequate diet, has been consistently reported among PD patients.22,23 Patients with PD may also be less prudent in their physical activity and smoking behaviours.24,25 All these risk factors could imperil PD patients for further stroke risk. Other findings in our study deserve more consideration. In our panic cohort, the rates of hypertension, diabetes, hyperlipidemia, and renal disease were significantly higher, compared with those in the comparison cohort. A possible causal relation of uncertain direction between these medical diseases and PD may be suggested for further examination. Comorbid presence of PD with cardiac, respiratory, gastrointestinal, and neurological diseases has been frequently documented.26 Our findings support that PD patients commonly suffer from physical disorders, although renal disease has rarely been mentioned in this context before.27 Again, the sympathetic hyperactivity hypothesis is worth considering. Moreover, the age distribution of the PD patients merits attention. In our study, about one-half of the PD patients were aged 44 years and younger, while the other one-half were 45 years and older. The onset of PD generally appears before the mid-30s.1 Because people with any psychiatric disorder diagnosis in the preceding 5 years were excluded, our sample might have comprised some cases of first-onset PD.

HR (95% CI)

2.37 (2.12 to 2.67) 1.00

<0.001

1.17 (1.05 to 1.30) 1.00

0.003

1.00 1.39 (1.06 to 1.82) 2.67 (2.06 to 3.45) 4.58 (3.51 to 5.97) 9.45 (7.29 to 12.25) 0.02 <0.001 <0.001 <0.001

2.89 (2.57 to 3.25) 1.00

<0.001

Diabetes Yes Noa Hyperlipidemia Yes No

a

1.48 (1.31 to 1.67) 1.00

<0.001

1.27 (1.13 to 1.67) 1.00

<0.001

Renal disease Yes Noa Monthly income, NT$ 0a 1 to 15 840 15 841 to 25 000 25 001 Urbanization level 1a 2 3 4 5
a b

1.36 (1.17 to 1.60) 1.00

<0.001

1.00 1.23 (1.05 to 1.44) 0.93 (0.81 to 1.06) 0.77 (0.65 to 0.92) 0.01 0.25 0.003

1.00 1.07 (0.94 to 1.23) 0.98 (0.84 to 1.16) 0.99 (0.84 to 1.17) 0.29 0.87 0.89 0.88

1.01 (0.85 to 1.20)

Reference group Least urbanized

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Table 3 Adjusted hazard ratio for stroke during the 3-year follow-up period for patients with PD and comparison group patients by medical disorder and patient age in years
Cohorta Yes, HR (95% CI)a Disorder Hypertension Hyperlipidemia Diabetes Renal disease
a

No, HR (95% CI)a 44 years 4.91 (3.646.62) 4.81 (3.636.38) 5.29 (4.086.87) 3.61 (2.794.67) 45 years 2.29 (1.772.95) 2.29 (1.932.71) 2.47 (2.132.87) 1.87 (1.642.14)

44 years 1.87 (1.222.86) 2.52 (1.584.02) 1.81 (1.023.43) 3.56 (1.1910.60)

45 years 1.75 (1.522.01) 1.94 (1.632.31) 1.83 (1.492.25) 1.85 (1.322.60)

The comparison group is the reference (1.00) for each. All HRs were calculated adjusting for patients sex, monthly income, level of urbanization, and comorbid medical disorders.

Meanwhile, only 30% of patients remit without subsequent relapse in the follow-up investigation.1,28 We might also have recruited recurrent PD cases in the analyses with older age. Our studys findings need to be interpreted within the context of 3 limitations. First, PD diagnoses, which rely on administrative claims data reported by hospitals, may be less accurate than diagnoses made according to a standardized procedure. However, the NHIB randomly samples a fixed percentage of claims from every hospital each year to verify diagnosis validity and quality of care through chart review by an independent group of doctors. Fines for fraud are 100 times the amount of the false claim charged to the NHIB. In addition, to ensure the validity of the PD diagnoses, we confirmed that all of the study cohort patients had at least 2 consensus PD diagnoses after the index ambulatory care visit. Second, the stroke diagnoses could be less than accurate, which might have compromised the findings. However, virtually all hospitals in Taiwan capable of admitting stroke patients are equipped with magnetic resonance imaging or computed tomography, which considerably increases the validity of stroke diagnosis. Finally, some important variables such as cigarette smoking, obesity, and body mass index, which are likely to be associated with stroke, were not available in the NHIRD. Our study revealed that women in their middle years, aged 35 to 54 years, are the population most susceptible to PD, results compatible with those from a nationwide survey in the United States.29 The middle-aged population essentially should not be the one at highest risk for stroke. However, about 1 in 6 PD patients (16.6%) experiences a stroke within 3 years, stressing the significant need for possible intervention. As PD has been identified as an independent risk factor for stroke, cognitive interventions aimed at teaching patients to more realistically evaluate their symptoms and to avoid directing attention to them may be challenged.1 However, our findings might still be too preliminary to advise PD patients about their stroke risk, because patients may interpret their symptoms
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catastrophically and experience worse prognosis. Psychiatrists, mental health professionals, and neurologists should be aware of the potential risk of stroke among PD patients and keep monitoring patients cardiovascularcerebrovascular conditions. Aggressive treatment for PD may be considered for preventing future stroke. Replication of studies to confirm PD, per se, as a risk factor for stroke is imperative, both scientifically (that is, to identify the potential causal link) and clinically (that is, to apply to patients management). Precise mechanisms relating PD and stroke need further identification. Future research is also required to investigate whether PD treatment may reduce the subsequent risk of stroke.
Acknowledgements This study is based in part on data from the NHIRD provided by the NHIB, Department of Health, Taiwan, and managed by the NHRI. The interpretation and conclusions contained herein do not represent those of the NHIB, Department of Health, or the NHRI. No funding was provided for this research.

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9. Weissman MM, Markowitz JS, Ouellette R, et al. Panic disorder and cardiovascular/cerebrovascular problems: results from a community survey. Am J Psychiatry. 1990;147(11):1504 1508. 10. Haines AP, Imeson JD, Meade TW. Phobic anxiety and ischaemic heart disease. Br Med J (Clin Res Ed). 1987;295(6593):297299. 11. Kawachi I, Colditz GA, Ascherio A, et al. Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation. 1994;89(5):19921997. 12. Smoller JW, Pollack MH, Wassertheil-Smoller S, et al. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the womens health initiative observational study. Arch Gen Psychiatry. 2007;64(10):11531160. 13. Coryell W. Panic disorder and mortality. Psychiatr Clin North Am. 1988;11(2):433440. 14. Donnan GA, Fisher M, Macleod M, et al. Stroke. Lancet. 2008;371(9624):16121623. 15. Kahn JP, Drusin RE, Klein DF. Idiopathic cardiomyopathy and panic disorder: clinical association in cardiac transplant candidates. Am J Psychiatry. 1987;144(10):13271330. 16. Kahn JP, Gorman JM, King DL, et al. Cardiac left ventricular hypertrophy and chamber dilatation in panic disorder patients: implications for idiopathic dilated cardiomyopathy. Psychiatry Res. 1990;32(1):5561. 17. Davies SJ, Ghahramani P, Jackson PR, et al. Association of panic disorder and panic attacks with hypertension. Am J Med. 1999;107(4):310316. 18. Esler M, Kaye D. Sympathetic nervous system activation in essential hypertension, cardiac failure and psychosomatic heart disease. J Cardiovasc Pharmacol. 2000;35(7 Suppl 4):S1S7. 19. Hamlin CL, Lydiard RB, Martin D, et al. Urinary excretion of noradrenaline metabolite decreased in panic disorder. Lancet. 1983;2(8352):740741. 20. Seier FE, Kellner M, Yassouridis A, et al. Autonomic reactivity and hormonal secretion in lactate-induced panic attacks. Am J Physiology. 1997;272(6 Pt 2):H2630H2638. 21. Dimsdale JE. Psychological stress and cardiovascular disease. J Am Coll Cardiol. 2008;51(13):12371246. 22. Bajwa WK, Asnis GM, Sanderson WC, et al. High cholesterol levels in patients with panic disorder. Am J Psychiatry. 1992;149(3):376378. 23. Yamada K, Tsutsumi T, Fujii I. Serum cholesterol levels in patients with panic disorders: a comparison with major depression and schizophrenia. Psychiatry Clin Neurosci. 1997;51(1):3134.

24. Amering M, Bankier B, Berger P, et al. Panic disorder and cigarette smoking behavior. Compr Psychiatry. 1999;40(1):3538. 25. Kaiya H, Umekage T, Harada S, et al. Factors associated with the development of panic attack and panic disorder: survey in the Japanese population. Psychiatry Clin Neurosci. 2005;59(2):177182. 26. Zaubler TS, Katon W. Panic disorder and medical comorbidity: a review of the medical and psychiatric literature. Bull Menninger Clin. 1996;60(2 Suppl A):A12A38. 27. Agargun MY, Dulger H, Inci R, et al. Serum lipid concentrations in obsessivecompulsive disorder patients with and without panic attacks. Can J Psychiatry. 2004;49(11):776778. 28. Katschnig H, Amering M. The long-term course of panic disorder and its predictors. J Clin Psychopharmacol. 1998;18(6 Suppl 2):6S11S. 29. Kessler RC, Wang PS. The descriptive epidemiology of commonly occurring mental disorders in the United States. Annu Rev Public Health. 2008;29:115129.

Manuscript received January 2009, revised, and accepted April 2009. 1 Associate Professor, School of Public Health, Taipei Medical University, Taipei, Taiwan. 2 Assistant Professor, College of Medicine, Taipei Medical University, Taipei, Taiwan. 3 Neurologist, Department of Neurology, Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan. 4 Psychiatrist, Department of Psychiatry, Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan. 5 Professor, School of Health Care Administration, Taipei Medical University, Taipei, Taiwan. Address for correspondence: Dr H-C Lin, School of Health Care Administration, Taipei Medical University, 250 Wu-Hsing St, Taipei 110, Taiwan; henry11111@tmu.edu.tw

Rsum : Un risque accru daccident vasculaire crbral chez les patients souffrant de trouble panique : une tude de suivi de 3 ans
Objectif : Rechercher si le trouble panique (TP) accrot le risque daccident vasculaire crbral (AVC), laide dun ensemble de donnes nationales dans la population. Mthodes : Notre tude a utilis les donnes de la base de donnes nationale de recherche en assurance-sant de Tawan. La cohorte de ltude comprenait des patients ayant reu des soins psychiatriques ambulatoires pour le TP entre 2002 et 2003, inclusivement (n = 3891). Nous avons slectionn notre cohorte de comparaison en recrutant au hasard des participants (n = 19 455) jumels au groupe de ltude selon le sexe et lge. Chaque patient a t suivi durant 3 ans, depuis leur premire consultation en soins ambulatoires jusqu la fin de 2006, afin didentifier si un patient avait eu ou non un AVC durant la priode de suivi. Des rgressions des hasards proportionnels de Cox ont t effectues afin de calculer le taux de survie sur 3 ans, avec ajustement pour des facteurs confusionnels potentiels. Rsultats : Sur lchantillon total, 2029 patients (8,7 %) ont eu un AVC durant la priode de suivi de 3 ans, dont 647 de la cohorte de ltude (16,6 % des patients du TP) et 1382 (7,1 %) de la cohorte de comparaison. Aprs ajustement pour le sexe, lge, le revenu mensuel, le niveau durbanisation, et les troubles mdicaux comorbides des patients, le risque de survenue dun AVC durant la priode de suivi de 3 ans tait 2,37 (P < 0,001) fois plus grand pour les patients souffrant de TP que pour les patients de la cohorte de comparaison. Dans dautres analyses, stratifies selon les maladies somatiques et lge, le risque significatif du TP sur les AVC subsquents persistait. Conclusions : Nous concluons que le TP est un facteur de risque indpendant pour un accident vasculaire crbral. Pour les patients souffrant du TP, le traitement vigoureux du TP peut tre envisag dans le cadre de la prvention de lAVC.

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