Symptoms of posttraumatic stress and death anxiety in persons with HIV and medication adherence difficulties

The present study examined the frequency and correlates of self-reported symptoms of posttraumatic stress among patients with HIV and medication adherence problems. Self-report data revealed that more than half of participants met diagnostic criteria for posttraumatic stress disorder (PTSD) according to the Posttraumatic Diagnostic Scale PDS. Death anxiety was associated with overall PTSD symptom severity scores as well as severity scores for reexperiencing, avoidance, and arousal symptoms. The association between death anxiety and total PTSD severity, reexperiencing and avoidance symptom scores remained after controlling for depression and satisfaction with social support. Anxiety, as manifested by PTSD symptoms should be routinely assessed among patients with HIV, and variables such as death anxiety, social support, and depression are appropriate targets for mental health interventions.     

Effects of five parent-and-child risk factors on salivary cortisol levels and symptoms of posttraumatic stress disorder in school-age, critically ill children: Pilot study

Objective

We examined the contributions of risk factors to the psychological and neuroendocrine status of children admitted to a pediatric intensive care unit (PICU), and explored the feasibility of a full-scale study of these risk factors.

Methods

A prospective, correlational design was used. Risk factors included parental stress, parental anxiety, child anxiety, severity of the child's illness, and invasive procedures administered to the child. Outcomes variables were pediatric posttraumatic stress disorder (PTSD) symptoms and salivary cortisol levels. Measures were taken at 3 time points over 3 months.

Results

The mothers' state anxiety significantly increased over time, whereas the children's PTSD symptoms decreased. Most children with average or high anxiety demonstrated varying degrees of PTSD symptomatology, whereas children with low anxiety exhibited doubtful or mild symptoms of PTSD. As the severity of PTSD symptoms increased over time, the level of salivary cortisol decreased at two weeks and three months after hospital discharge.

Conclusions

Predicted trends in data were found and warrant further investigation, using a similar methodology in a full-scale study with an emphasis on recruiting the most seriously ill children.     

Posttraumatic stress disorder in first-time myocardial infarction patients

OBJECTIVES: The objectives of this study were to investigate the prevalence of posttraumatic stress disorder in patients with a first myocardial infarction compared with a random sample of healthy controls and to determine variables associated with the disorder. DESIGN: A questionnaire was distributed to 112 consecutive patients 4 to 6 weeks after infarction and to 115 healthy controls selected randomly from the general population. Objective clinical measures were obtained from the patients' medical records. RESULTS: Twenty-five (22%) patients qualified for a diagnosis of posttraumatic stress disorder (PTSD) compared with 8 (7%) controls with patients being more than a three-fold (OR: 3.84; 95% CI: 1.65 to 8.94) risk of having the disorder. When adjusting for other variables, the risk was reduced to above a two-fold risk (OR: 2.71; 95% CI: 0.99-7.41). In patients and controls, depression and neuroticism were associated with a diagnosis of PTSD adjusting for other variables. In patients, anxiety was associated with a diagnosis of PTSD adjusting for other variables. Left ventricular ejection fraction and symptoms of angina pectoris were not related to a diagnosis of PTSD in the patient group. CONCLUSIONS: Given that previous research has shown that persons with PTSD are at increased risk of cardiovascular diseases, cardiac patients with the disorder may be at a higher risk of recurrent cardiac events. Although longitudinal studies are needed to confirm such a relationship, this disorder should not be overlooked because of its potential role in reinfarctions and mortality.     

Income and social support related with mental health during COVID-19 outbreak in China

To investigate psychological response of Chinese public during the regular prevention and control of Corona Virus Disease 2019 (COVID-19), and explore the relationship among income loss, social support and mental health.Five hundred twenty-six participants were randomly selected by snowball sampling method. Chinese version of Perceived Psychological Stress Scale, Perceived Social Support Scale, self-rating anxiety scale, and the PTSD Checklist for DSM-5 were used to measure the levels of psychological stress, social support, anxiety, and post-traumatic stress disorder (PTSD) symptoms. Demographic variables, income loss and income satisfaction during the outbreak period were also collected.The prevalence rate of anxiety, PTSD symptoms and stress problems were 19.8%, 23.8%, and 24.7% respectively. Multiple Regression Analysis illustrated that social support associated with stress, anxiety and PTSD after controlling demographic variables; for non-student samples, stress, anxiety, and PTSD were corelated with change in income and social support.During the regular prevention and control of COVID-19, social support might help reducing stress, anxiety, and PTSD symptoms. In addition to social support, change of income level was also an important factor for mental health. This study suggested the importance of maintaining a steady income after acute outbreak of COVID-19.     

Functional disability and post-traumatic stress disorder in survivors of mechanical ventilation: a cross-sectional study in Guangzhou,China

BackgroundCritical illness is associated with cognitive, physical, and psychological impairments; however, evidence of the severity and frequency of impairments in Chinese survivors of mechanical ventilation in an intensive care unit (ICU) remains limited. Our aim was to investigate the incidence and severity of impairments in Chinese survivors of mechanical ventilation in ICU and to explore risk factors influencing specific impairments.MethodsPatients discharged alive after mechanical ventilation in a large general ICU for ≥2 days were enrolled in this single-center cross-sectional study. Survivors were evaluated using measures of functional disability (Activity of Daily Living Scale), and post-traumatic stress disorder (PTSD, The Impact of Event Scale-Revised) via telephone interview. Multivariable analysis was conducted.ResultsData were obtained from 130 consenting survivors. At follow-up (mean: 19.64 months), among those in part-time or full-time employment prior to admission, only 45.1% had returned to work. Further, 29.2% of survivors had clear disabilities affecting daily living. Deficits in activities of daily living (ADL) were mainly characterized by impairment of instrumental ADL. Predictors of ADL in mechanically ventilated survivors included age, ICU admission diagnosis, and Acute Physiology And Chronic Health Evaluation II (APACHE II) score, which accounted for 33.5% of total variance. Furthermore, 17.7% of participants had symptoms consistent with PTSD. ICU length of stay was the only predictor of PTSD, and accounted for 7.5% of total variance.ConclusionsICU survivors of mechanical ventilation in China face negative impacts on employment, and commonly have ADL impairment and PTSD. Age, ICU admission diagnosis, and APACHE II score were key factors influencing ADL, while ICU length of stay was the only factor affecting PTSD. These findings suggest that some survivors who have had certain exposures may warrant closer follow-up, and systematic interventions for these high-risk survivors should be developed in China.     

Alcohol use, mental health status and psychological well-being 2 years after the World Trade Center attacks in New York City

Over the past 30 years, studies have shown that survivors of community-wide disasters suffer from a variety of physical and mental health problems. Researchers also have documented increased substance use in the aftermath of these disasters. In the present study, we examined the relationship between alcohol use and mental health status within the context of the terrorist attacks on the World Trade Center in New York City (NYC). The data for the present report come from a 2-wave panel study of adults living in NYC on the day of the attacks. Wave 1 (W1) and Wave 2 (W2) interviews occurred one year and two years after the attacks, respectively. Overall, 2,368 individuals completed the W1 survey (cooperation rate, 63%) and 1,681 completed the W2 survey (re-interview rate, 71%). The alcohol use variables examined were binge drinking, alcohol dependence, increased days drinking, and increased drinks per day. The outcomes examined included measures of posttraumatic stress disorder (PTSD), major depression, BSI-18-Global Severity and measures of SF12-mental and physical health status. After controlling for demographic, stress, and resource factors, multivariate logistic regressions indicated that all alcohol measures were related to one or more of these outcomes. In particular, binge drinking was related to partial PTSD, while alcohol dependence was associated subsyndromal PTSD, severity of PTSD, depression, BSI-18 global severity, and SF-12 poor mental health status. Increased post-disaster drinking was positively associated with subsyndromal PTSD and negatively associated with SF-12 physical health. We discuss reasons for these results and the negative consequences that heavy alcohol use may have on the postdisaster recovery process.     

Alcohol Use,Mental Health Status and Psychological Well-being 2 Years After the World Trade Center Attacks in New York City

Over the past 30 years, studies have shown that survivors of community-wide disasters suffer from a variety of physical and mental health problems. Researchers also have documented increased substance use in the aftermath of these disasters. In the present study, we examined the relationship between alcohol use and mental health status within the context of the terrorist attacks on the World Trade Center in New York City (NYC). The data for the present report come from a 2-wave panel study of adults living in NYC on the day of the attacks. Wave 1 (W1) and Wave 2 (W2) interviews occurred one year and two years after the attacks, respectively. Overall, 2,368 individuals completed the W1 survey (cooperation rate, 63%) and 1,681 completed the W2 survey (re-interview rate, 71%). The alcohol use variables examined were binge drinking, alcohol dependence, increased days drinking, and increased drinks per day. The outcomes examined included measures of posttraumatic stress disorder (PTSD), major depression, BSI-18-Global Severity and measures of SF12-mental and physical health status. After controlling for demographic, stress, and resource factors, multivariate logistic regressions indicated that all alcohol measures were related to one or more of these outcomes. In particular, binge drinking was related to partial PTSD, while alcohol dependence was associated subsyndromal PTSD, severity of PTSD, depression, BSI-18 global severity, and SF-12 poor mental health status. Increased post-disaster drinking was positively associated with subsyndromal PTSD and negatively associated with SF-12 physical health. We discuss reasons for these results and the negative consequences that heavy alcohol use may have on the postdisaster recovery process.     

Psycho-emotional Manifestations of Valvular Heart Diseases: Prospective Assessment in Mitral Regurgitation

Objective

To define the prevalence and consequences of post-traumatic stress disorder (PTSD) as an emotional response to cardiac diseases in patients with mitral regurgitation.

Methods

We prospectively enrolled 186 patients with moderate or severe organic mitral regurgitation, presenting class I (absent) or II (minimal) dyspnea, who were compared with 80 controls of similar age (38 with completely normal cardiac function; 42 with mild mitral-valve prolapse; all with no, or at most mild, mitral regurgitation). Mitral-regurgitation severity and consequences were comprehensively measured, simultaneously with PTSD, anxiety, and depression.

Results

PTSD prevalence was higher in mitral-regurgitation patients vs controls (23% vs 9%, P <.01). Although mitral-regurgitation objective severity (regurgitant volume 77.8 ± 28.9 vs 79.0 ± 27.5 mL, P = .8) and objective consequences (left-atrial volume 59.1 ± 20.9 vs 54.02 ± 15.6 mL, P = .1; right-ventricular systolic pressure 34.1 ± 11.4 vs 32.9 ± 7.2 mm Hg, P = .6) were similar with and without PTSD (all P ≥.1), patients with PTSD were more symptomatic (class II 74 vs 38%; fatigue 71% vs 38%, both P <.0001) and had higher anxiety and depressions scores (P <.0001).

Conclusions

PTSD is prevalent in organic moderate or severe mitral-regurgitation patients but is not determined by objective mitral-regurgitation severity or consequences. PTSD is linked to anxiety and depression and to symptoms usually considered cardiac, such as dyspnea. Thus, PTSD and psycho-emotional manifestations, linked to symptoms, represent important responses to chronic-valve disease that may affect clinical outcomes.     

Prediction of psychiatric morbidity in severely injured accident victims at one-year follow-up

The objective of this study was to assess the prevalence of posttraumatic stress disorder (PTSD) and symptoms of depression and anxiety in severely injured accident victims 1 yr posttrauma and to predict psychiatric morbidity by means of variables assessed shortly after the accident. The sample consisted of 106 consecutive patients with accidental injuries (mean Injury Severity Score = 21.9, mean Glasgow Coma Scale score = 14.4) admitted to the intensive care unit of a University Hospital. Patients with severe head injuries, suicide attempters, and victims of physical assault were excluded. At 1-yr follow-up, two patients (1.9%) had PTSD, and 13 (12.3%) had subsyndromal PTSD. Eighteen patients (17%) had clinically relevant symptoms of anxiety, and nine (8.5%) were depressed. Overall, 27 patients (25.5%) showed some form of psychiatric morbidity (full or subsyndromal PTSD and/or anxiety and/or depression). Logistic regression analysis, using 1-yr psychiatric morbidity status as the dependent variable, allowed correct classification of 83.8% of patients 12 mo postaccident (specificity 91.8%, sensitivity 61.5%). Biographical risk factors and a sense of death threat contributed significantly to the predictive model. We conclude that a substantial proportion of severely injured accident victims develop some form of psychiatric morbidity that can be predicted to some degree by mainly psychosocial variables.     

Predictors of neurocognitive outcomes on antiretroviral therapy after cryptococcal meningitis: a prospective cohort study

Cryptococcal meningitis is the most common cause of adult meningitis in Africa, yet neurocognitive outcomes are unknown. We investigated the incidence and predictors of neurologic impairment among cryptococcal survivors. HIV-infected, antiretroviral-naive Ugandans with cryptococcal meningitis underwent standardized neuropsychological testing at 1, 3, 6, and 12 months. A quantitative neurocognitive performance z-score (QNPZ) was calculated based on population z-scores from HIV-negative Ugandans (n?=?100). Comparison was made with an HIV-infected, non-meningitis cohort (n?=?110). Among 78 cryptococcal meningitis survivors with median CD4 count of 13 cells/μL (interquartile range: 6–44), decreased global cognitive function occurred through 12 months compared with the HIV-infected, non-cryptococcosis cohort (QNPZ-6 at 12 months, P?=?0.036). Tests of performance in eight cognitive domains was impaired 1 month after cryptococcal diagnosis; however, cryptococcal meningitis survivors improved their global neurocognitive function over 12 months with residual impairment (mean z-scores?<?-1), only in domains of motor speed, gross motor and executive function at 12 months. There was no evidence that neurocognitive outcome was associated with initial demographics, HIV parameters, or meningitis severity. Paradoxically, persons with sterile CSF cultures after 14 days of induction amphotericin therapy had worse neurocognitive outcomes than those still culture-positive at 14 days (P?=?0.002). Cryptococcal meningitis survivors have significant short-term neurocognitive impairment with marked improvement over the first 12 months. Few characteristics related to severity of cryptococcosis, including Cryptococcus burden, were associated with neurocognitive outcome.     

Traumatic Dissociation as a Predictor of Posttraumatic Stress Disorder in South African Female Rape Survivors

Women survivors of rape are at an increased risk for posttraumatic stress disorder (PTSD). Traumatic dissociation has been identified as a precursor of PTSD. This study assessed the predictive potential of traumatic dissociation in PTSD and depression development.The study followed a longitudinal, prospective design. Ninety-seven female rape survivors were recruited from 2 clinics in Cape Town, South Africa. Clinical interviews and symptom status assessments of the participants were completed to measure dissociation, childhood traumas, resilience, depression, and PTSD.Traumatic dissociation was a significant predictor of PTSD and depression. The linear combination of prior dissociation, current dissociation, and resilience significantly explained 20.7% of the variance in PTSD. Dissociation mediated the relationship between resilience and PTSD.As traumatic dissociation significantly predicts PTSD, its early identification and management may reduce the risk of developing PTSD. Interventions focused on promoting resilience may also be successful in reducing the risk of dissociation following rape.     

Relationship of quality of life and perceived control with posttraumatic stress disorder symptoms 3 to 6 months after myocardial infarction

PURPOSE: This study examined whether psychological variables were associated with posttraumatic stress disorder (PTSD) symptoms 3 to 6 months after myocardial infarction. METHODS: The sample included 52 patients with myocardial infarction. A structured interview was used to obtain information about PTSD symptoms, quality of life, and ratings of perceived control, danger, and predictability, as well as information about stressful events that occurred during hospitalization. RESULTS: Four patients (7.7%) met criteria for the diagnosis of PTSD. Elevated PTSD scores were associated with poorer quality of life (r = -0.32 to -0.79). Lower perceived control was associated with higher PTSD symptom scores (r = -0.30 to -0.52). Finally, PTSD scores were significantly correlated with the number of times patients were readmitted to the hospital (r = 0.35-0.57). CONCLUSIONS: Approximately 8% of patients experienced PTSD 3 to 6 months following MI. Increasing levels of PTSD symptoms were correlated with poorer quality of life. Perceived lack of control during the MI and multiple hospitalizations may be related to the severity of PTSD symptoms.     

Clinical Correlates of HIV-Associated Neurocognitive Disorders in South Africa

Human immunodeficiency virus-associated neurocognitive disorders (HAND) occurs globally and across different genetic clades of the virus. However, few studies have examined HAND in South Africa, despite the prevalence of HIV in this region of the world, and the predominance of clade C. The present study examined the relationship between a number of demographic and clinical variables in a sample of 536 patients attending HIV clinics in South Africa. HAND was present in 23.5% of the sample and was associated with older age, a low educational level among those with post-traumatic stress disorder (PTSD) and alcohol abuse among those with many months since diagnosis. These results suggest that HAND is common among patients in South Africa, and is associated with clinical variables such as PTSD and alcohol abuse. This underlines the impact of HIV on the nervous system and the importance of screening for co morbid mental health conditions.     

Posttraumatic stress disorder: clinical features, pathophysiology, and treatment

Posttraumatic stress disorder (PSTD), classified as an anxiety disorder, has become increasingly important because of wars overseas, natural disasters, and domestic violence. After trauma exposes the victim to actual or threatened death or serious injury, 3 dimensions of PTSD unfold: (1) reexperiencing the event with distressing recollections, dreams, flashbacks, and/or psychologic and physical distress; (2) persistent avoidance of stimuli that might invite memories or experiences of the trauma; and (3) increased arousal. Traumatic events sufficient to produce PTSD in susceptible subjects may reach a lifetime prevalence of 50% to 90%. The actual lifetime prevalence of PTSD among US citizens is approximately 8%, with the clinical course driven by pathophysiologic changes in the amygdala and hippocampus. Comorbid depression and other anxiety disorders are common. General principles of treatment include the immediate management of PTSD symptoms and signs; management of any trauma-related comorbid conditions; nonpharmacologic interventions including cognitive behavioral treatment; and psychopharmacologic agents including antidepressants (selective serotonin reuptake inhibitors most commonly), antianxiety medications, mood stabilizing drugs, and antipsychotics. This review of PTSD will provide the reader with a clearer understanding of this condition, an increased capacity to recognize and treat this syndrome, and a greater appreciation for the role of the internist in PTSD.     

Prevalence of post-traumatic stress disorder in fibromyalgia patients: overlapping syndromes or post-traumatic fibromyalgia syndrome?

OBJECTIVES: The primary aim of this study was to assess the frequency of post-traumatic stress disorder (PTSD) in patients with the fibromyalgia syndrome (FMS). The influence of gender on measures of PTSD in fibromyalgia (FM) patients also was examined. METHODS: Seventy-seven consecutive patients (40 women and 37 men) who fulfilled the criteria for FM were asked to complete questionnaires measuring the prevalence and severity of symptoms of PTSD, anxiety, and depression. The subjects were divided in 2 groups based on the presence or absence of PTSD symptoms. RESULTS: In this study, 57% of the FM sample had clinically significant levels of PTSD symptoms. The FM patients with PTSD reported significantly greater levels of avoidance, hyperarousal, reexperiencing, anxiety, and depression than did the patients without clinically significant levels of PTSD symptoms. The prevalence of PTSD among the FM patients in this study was significantly higher than in the general population. Women with FM and PTSD reported a greater number of past traumatic events than did their male counterparts. CONCLUSIONS: The results represent the first comprehensive study applying structured clinical assessment of trauma exposure and PTSD to a group of FM patients. This study shows a significant overlap between FM and PTSD, according to the currently accepted diagnostic criteria for each.     

肺癌患者易患创伤后应激障碍且多合并其他精神疾病

目的：研究肺癌患者创伤后应激障碍（PTSD）的影响因素，并分析其与抑郁症、焦虑症及心理弹性之间的相关性。方法：选取肺癌患者224例，调查患者一般资料，PTSD诊断工具采用PTSD检测量表平民版（PCL-C），抑郁症诊断通过汉密尔顿抑郁量表（HAMD），焦虑症诊断应用汉密尔顿焦虑量表（HAMA），心理弹性评估采用中文版心理弹性量表（CD-RISC），分析224例肺癌患者PTSD的影响因素，并分别分析PTSD与抑郁症、焦虑症、心理弹性之间的相关性。结果：肺癌患者PTSD的发病率为19%(43/224)。女性、病程＜6个月，合并抑郁症、焦虑症是肺癌患者PTSD发病的危险因素，高水平心理弹性是PTSD发病的保护因素(P均<0.05)。合并抑郁症、焦虑症与PTSD的发病呈正相关（r=0.621、0.483,P均<0.05）；心理弹性水平与PTSD、抑郁症及焦虑症的发病情况呈负相关（r=-0.332,-0.416,-0.485,P均<0.05）。结论：肺癌患者在诊断之后易发生PTSD，且多合并其他心理疾病，应及时全程给予有效的防治措施。     

Common mental health problems and antiretroviral therapy adherence

This paper reviews the literature on various mental health problems and their impact on adherence to antiretroviral therapy (ART). Depression, anxiety disorders, and disorders related to substance abuse were identified as key role-players influencing adherence. The severity of symptoms related to these disorders was found to be inversely related to ART adherence, with the possible exception of post-traumatic stress disorder (PTSD). PTSD was found to have both positive and negative implications for adherence, with severity of symptoms ranging from health-protective concern to disabling distress. Possible solutions aimed at addressing the adverse effects of mental health problems on adherence are discussed. Routine screening in ART settings is suggested in settings where follow-up of positive screen scores are possible, along with the necessary interventions to resolve the disorder of concern. Suggested interventions include utilising psychotherapeutic treatment, both in isolation and in conjunction with medication, to address mental health problems. Furthermore, finding effective ways of marshalling social support is recommended for ensuring optimal adherence, and possibly mitigating the adverse effects of mental health problems. Further research is needed to find feasible ways of identifying, assessing and treating patients with mental health problems in resource-constrained settings where HIV prevalence is highest.     

Post-traumatic stress disorder symptoms after veno-arterial extracorporeal membrane oxygenator support

BackgroundPost-traumatic stress disorder (PTSD) is a common long-term outcome after intensive care of critical illness.ObjectivesAssess the prevalence and factors associated to PTSD after veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support.MethodsRetrospective analysis of admission data and cross-sectional assessment of PTSD symptoms in adult survivors from admission requiring VA-ECMO support in a referral hospital. People were screened through abbreviated Impact of Event Scale-6 (IES-6).ResultsOut of 135 VA-ECMO implants performed from 2013 to 2020, 48 (35.6%) patients survived the admission. After a median follow-up of 31.4 [36] months, 34 survivors responded the questionnaire. All patients required sedation and invasive mechanical ventilation. Up to 29.4% of patients had PTSD symptoms. Patients with altered IES-6 items had passed a longer time since admission in ICCU (44±15 vs 30±20 months, p = 0.034). No baseline characteristic or admission-related variables were correlated with IES-6 except the lower time under mechanical ventilation (6.5 [8.5] vs. 8.5 [21] days, p = 0.044).ConclusionsSurvivors from admission requiring VA-ECMO support show high prevalence of PTSD symptoms, appearing more frequently when more time has elapsed since admission. Special attention should be paid to psychological symptoms after VA-ECMO support.     

Which came first: the readiness or the change? Longitudinal relationships between readiness to change and drinking among college drinkers

Aims Although readiness to change (RTC) is cited as a key mechanism underlying drinking behavior change, empirical evidence supporting RTC as a predictor of college drinking has been mixed. Considering methodological limitations of previous studies, the current aim was to conduct a more comprehensive test of longitudinal relationships between readiness to change and college drinking. Design In this correlational, longitudinal study, we used a series of cross‐lagged path analyses to test associations between RTC and college drinking outcomes over a 2‐year period. Setting Data collection was conducted via online surveys on a university campus in the US Pacific Northwest. Participants Participants (n = 818; 58% women) were college students who reported at least one heavy‐drinking episode in the past month and participated in a randomized controlled trial of personalized normative feedback interventions. Measurements Drinking quantity–frequency items and the Rutgers Alcohol Problem Index assessed drinking outcomes. The Readiness to Change Questionnaire assessed RTC. Findings For drinking‐related problems, the best‐fitting model included cross‐lagged paths between RTC and subsequent drinking‐related problems. For drinking quantity–frequency, best‐fitting models also included the cross‐lagged paths between drinking quantity–frequency and subsequent RTC. Higher RTC almost uniformly predicted higher subsequent levels of drinking and greater experience of drinking‐related problems, and drinking quantity–frequency variables were primarily positive predictors of subsequent RTC. Conclusions Contrary to previous assumptions, ‘the Readiness to Change Questionnaire’ does not appear to be predictive of lower levels of subsequent drinking.     

Relative value of clinical variables, bicycle ergometry, rest radionuclide ventriculography and 24 hour ambulatory electrocardiographic monitoring at discharge to predict 1 year survival after myocardial infarction

The relative value of predischarge clinical variables, bicycle ergometry, radionuclide ventriculography and 24 hour ambulatory electrocardiographic monitoring for predicting survival during the first year in 351 hospital survivors of acute myocardial infarction was assessed. Discriminant function analysis showed that in patients eligible for stress testing the extent of blood pressure increase during exercise slightly improved the predictive accuracy beyond that of simple clinical variables (history of previous myocardial infarction, persistent heart failure after the acute phase of infarction and use of digitalis at discharge), whereas radionuclide ventriculography and 24 hour electrocardiographic monitoring did not. The predictive value for mortality was 12% with clinical variables alone and 15% with the stress test added. Radionuclide ventriculography and 24 hour electrocardiographic monitoring were slightly additive to clinical information in the whole group of patients independent of the eligibility for stress testing (predictive value for mortality 24% with clinical variables alone and 26% with radionuclide ejection fraction and 24 hour electrocardiographic monitoring added). It is concluded that the appropriate use of simple clinical variables and stress testing is sufficient for risk stratification in postinfarction patients, whereas radionuclide ventriculography and 24 hour electrocardiographic monitoring should be limited to patients not eligible for stress testing.