PTSD Increases the Risk of Incident Ischemic Heart Disease in Women Veterans
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking.
Objective
To determine whether PTSD is associated with incident IHD in women veterans.
Design, Setting, and Participants
In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020.
Exposures
PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters.
Main Outcomes and Measures
Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes.
Results
A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38).
Conclusions and Relevance
This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.
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Additional Info
Disclosure statements are available on the authors' profiles:
Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans
JAMA Cardiol 2021 Mar 17;[EPub Ahead of Print], R Ebrahimi, KE Lynch, JC Beckham, PA Dennis, B Viernes, CH Tseng, ALW Shroyer, JA SumnerFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Women Veterans, PTSD, and Increased Ischemic Heart Disease Risk: How Best to Translate This to Young Community Women?
In this study of almost 400,000 women veterans, the authors identify posttraumatic stress disorder (PTSD) as significantly associated with an increased risk of developing incident ischemic heart disease, particularly among women veterans younger than 40 years of age at baseline. We learn that women veterans are younger and more racially and ethnically diverse than their male peers, and they have an increased prevalence of traditional cardiovascular risk factors and mental health disorders compared with civilian women and male veterans.1
Of concern is that cardiovascular mortality has increased in recent years among young women in the community, erasing the progress of prior years. Young women of racial and ethnic minorities are most adversely impacted.
Psychosocial issues, particularly depression, preferentially disadvantage women, with psychological factors and emotional stress also predictive of early-onset myocardial infarction, particularly in younger women.2,3 Mental stress has been documented to induce changes of myocardial ischemia in young patients with recent myocardial infarction. Yet psychosocial risk factors are not included as risk enhancers in the 2019 ACC/AHA Guideline for Primary Prevention of Cardiovascular Disease.4
PTSD is associated with a number of behavioral risk factors for ischemic heart disease, including unhealthy diet, obesity, smoking, and physical inactivity; additionally, disruptions in a number of neuroendocrine pathways could lead to deleterious effects on the immune, metabolic, and cardiovascular systems. Further, PTSD is often coexistent with other psychiatric conditions that impart increased ischemic heart disease risk. The authors advocate for a more intense study of PTSD in women veterans. My call to action would be to concomitantly evaluate PTSD in community women, particularly those of younger age and racial and ethnic minorities, a vulnerable population. The resultant data should determine whether psychosocial risk factors, including depression, stress, and PTSD, would warrant listing as risk enhancers for the prevention of ischemic heart disease.
References
US women are twice as likely as men to be diagnosed with PTSD, and female veterans experience PTSD at a higher rate than community peers. Previous studies have verified a significant association between PTSD and ischemic heart disease (IHD) in men but similar studies of women are not common. This study clearly indicates that such research is imperative.
Using a retrospective longitudinal cohort, the researchers examined VA medical records of nearly 400,000 female veterans without and with PTSD. After controlling for traditional risk factors, they found a significant association between a diagnosis of PTSD and subsequent IHD (HR, 1.44). A significant association was found for female veterans 40 years and younger (HR, 1.72), black female veterans (HR, 1.49), and Hispanic/Latino female veterans (HR, 1.50). Female veterans with PTSD in the 60+ group had the lowest hazard ratio (1.24), suggesting that IHD risk increases for all female veterans.
There is a tendency to view PTSD symptoms as primarily psychological when, in reality, the disorder involves a complex interaction of psychological and physiological reactions. Traumatic events trigger physiological reactions, including hypervigilance, heightened reactivity, insomnia, irritability, and physical agitation, all of which are associated, long term, with IHD. Other sustained responses affecting heart health include inactivity, withdrawal, underutilization of healthcare, unhealthy behaviors (eg, smoking), and substance abuse.
That a relationship between PTSD and IHD exists should not be a surprise. That it could be so pronounced among younger female veterans with PTSD is unexpected and should alert clinicians to more aggressively monitor IHD risk factors among women sooner than is currently recommended. Greater sensitivity is also needed in understanding gender differences due to differences in trauma type (intimate partner violence, sexual trauma) and subsequent reactions. For example, substance abuse in this cohort of women with PTSD was especially low.
Although the criteria used to identify veterans with PTSD were solid, the study design didn’t distinguish the types of trauma experienced or PTSD chronicity. The impact of mental health treatment wasn’t measured, including the use of psychiatric medications, which can affect IHD.
Some useful resources about IHD for female patients with (and without) PTSD are available at the websites of the American Heart Association (Go Red for Women), the CDC, and the Society of Behavioral Medicine.