Chronic Conditions Also Associated With Past Combat Experience

Annette M. Boyle

MINNEAPOLIS — Serious health conditions linked to post-traumatic stress disorder (PTSD) continue to mount. Researchers recently uncovered a significant link between the condition and the risk of developing heart failure.

PTSD already has been associated with higher rates of cardiovascular, nervous, digestive, musculoskeletal and respiratory diseases. Many of the studies, including this latest, also have demonstrated higher risks with combat experience, even without the development of PTSD.

Between 1999 and 2009, the number of VA patients diagnosed with PTSD tripled, reaching 446,045 veterans. At the same time, heart failure has become the leading reason for admission to VHA hospitals. Several studies have shown a positive association between PTSD and coronary artery disease, which is known to be a significant risk factor for heart failure.

A research team reviewed the outpatient medical records of 8,248 veterans between the ages of 45 and 89 who had more than one outpatient visit to the VA Pacific Islands Health Care System between Jan. 1, 2002, and Dec. 31, 2004. Patients were followed until Dec. 31, 2012, and results were published this spring in the American Journal of Public Health.1

Their large-scale longitudinal study found a significant association between PTSD and incident heart failure.

“According to our findings, PTSD increases the risk of developing heart failure by 47%, independent of combat service,” said lead author Samit Roy, MSPH, research methodology fellow in cardiovascular disease at Lillehei Clinical Research Unit of Department of Medicine at the University of Minnesota.

The reverse was also true: Combat service was a strong predictor of heart failure independent of PTSD, with veterans who had served in active combat zones having five times the risk of heart failure of those who had not deployed to a combat region during military service. The researchers did not “quantify the exposure to various combat-related events during deployment, such as the number of active engagements in hostile fire with the enemy,” Roy told U.S. Medicine, so the study did not assess the impact of combat exposure specifically.

In keeping with previous studies, the researchers found that age, gender, hypertension, diabetes and obesity were also important factors in predicting heart failure.

About 21% of the study group had a diagnosis of PTSD. Of the 371 individuals diagnosed with heart failure during the study period, 287 had previously been diagnosed with PTSD. Only 84 cases of heart failure occurred among veterans who did not have PTSD.

While the precise nature of association between PTSD and heart failure remains murky, the researchers posited that PTSD, like other forms of stress or anxiety, might damage the heart over time. Possible mechanisms include autonomic nervous system dysfunction, inflammation, hypercoagulability, co-occurring metabolic syndrome, altered neurochemistry and cardiac hyperreactivity.

“There are many theories as to how exactly PTSD contributes to heart disease,” said senior author Alyssa Mansfield, PHD, MPH, an epidemiologist with the VA Pacific Islands Health Care System and an assistant adjunct professor of epidemiology at the University of Hawaii. “Overall, the evidence to date seems to point in the direction of a causal relationship.”

A lack of data prohibited the authors from delving further into the relationship between PTSD and heart failure or examining the association of PTSD and heart disease in women or racial, ethnic or period-of-service subgroups.

In addition, the VA Pacific Islands Health Care System lacks an inpatient VAMC, and veterans receive inpatient care at contracted military treatment facilities or community hospitals. As a result, the study relied on outpatient data, which may have resulted in an underreporting of heart failure, as the researchers could not determine the extent to which hospitalized heart failure occurred during the study period.

The study builds on an increasing body of literature that points to a relationship between mental illness and physical comorbidity, which has important clinical and public health implications for veterans with PTSD. The authors noted that epidemiological studies have consistently demonstrated a significant prospective relationship between both depression and anxiety-related disorders and cardiac events, though more research is needed to clarify the specific mechanisms.

A greater understanding of the relationship between mental health and physical illness is fundamental to the provision of the highest quality of care for veterans, according to the researchers.

“Given the ongoing involvement of U.S. military personnel in combat operations, the high prevalence of PTSD in veterans, and the increasing incidence of heart failure in the United States, outpatient care must include both mental health and chronic disease management,” they concluded. “Our findings provide support for the redoubling of heart failure prevention and treatment efforts among U.S. veterans with PTSD.”

Study authors suggested that primary care physicians and mental health professionals can work together to improve the health of veterans with PTSD by treating the disorder, taking steps to reduce other factors that contribute to heart disease and looking for signs of early-stage heart failure.

At the same time, educating veterans about the link between PTSD and heart failure may provide the additional motivation needed to engage in treatment for their PTSD.

“Our hope is this research will be used to inform healthcare providers of the association between PTSD and heart failure,” Roy said, “which may be used in creating and implementing targeted screenings, interventions or treatment programs.”


1 Roy SS, Foraker RE, Girton RA, Mansfield AJ. Posttraumatic stress disorder and incident heart failure among a community-based sample of US veterans. Am J Public Health. 2015 Apr;105(4):757-63.