Clinical Topics

PTSD Alone Doesn’t Increase Cardiovascular Risk in Veterans

by Brenda Mooney

April 8, 2019

Study Urges Close Monitoring of Physical, Psychological Co-Morbidities

ST. LOUIS—Even though veterans diagnosed with post-traumatic stress disorder are 41% more likely to developing cardiovascular disease than those without, PTSD alone doesn’t fully explain the higher risk, according to a study.

Instead, researchers suggest that a combination of physical disorders, psychiatric disorders and smoking—all more common in patients with PTSD—share the blame.

The study in the Journal of the American Heart Association, the Open Access Journal of the American Heart Association/American Stroke Association, looked at whether one condition, or a combination of heart disease risk factors often identified in patients with PTSD, can explain the association between CVD and the traumatic stress condition.

To reach that conclusion, Saint Louis University School of Medicine-led researchers reviewed electronic health records of 2,519 VA patients diagnosed with PTSD and 1,659 without PTSD. Participants were aged 30-70, 87% male and 60% white. Participants had no record of cardiovascular disease diagnoses for at least a year prior to the study and were followed for at least three years.

Results indicated that, among VA patients, those diagnosed with PTSD were 41% more likely to develop circulatory and heart disease than those without PTSD. The study also found that smoking, depression, other anxiety disorders, sleep disorders, Type 2 diabetes, obesity, high blood pressure and elevated cholesterol all were significantly more prevalent among patients with PTSD than those without.

Yet, researchers weren’t able to pinpoint a single comorbid condition that explained the association between PTSD and incident cardiovascular disease. In fact, after adjusting for a combination of physical and psychiatric disorders, smoking, sleep disorder, substance use disorders, PTSD was not associated with new cases of cardiovascular disease.

“This suggests there is no single comorbidity or behavior that explains the link between PTSD and cardiovascular disease,” explained lead author Jeffrey Scherrer, Ph.D., professor and director, Division of Research in the Department of Family and Community Medicine at the Saint Louis University School of Medicine in Missouri. “Instead, a combination of physical disorders, psychiatric disorders and smoking—that are more common in patients with PTSD vs. without PTSD—appear to explain the association between PTSD and developing cardiovascular disease.”

Results might not be generalizable to patients older than 70 or to nonveteran populations, researchers cautioned. The authors added that their study did not measure lifetime cardiovascular disease risk and that a long-term study might have different results.

“For veterans, and likely nonveterans, heart disease prevention efforts should focus on helping patients reduce weight, control high blood pressure, cholesterol, Type 2 diabetes, depression, anxiety disorders, sleep problems, substance abuse and smoking,” Scherrer said. “That is a long list, and for patients with many of these conditions it is challenging, yet important, to manage all of them.”

“Recognizing that PTSD does not preordain cardiovascular disease may empower patients to seek care to prevent and/or manage CVD risk factors,” he added.

The study included participation from the San Francisco and Cincinnati VAMCs, as well as the National Center for PTSD.

Clinical Implications

In terms of clinical implications, study authors suggest that longer duration of exposure to CVD risk factors, such as smoking, among patients with PTSD might increase the risk of cardiac events. On the other hand, early detection and effective management of hypertension, Type 2 diabetes mellitus, depression, anxiety, sleep disorders and other CVD risk factors could help mitigate the elevated risk.

Background information in the article pointed out that PTSD is associated with a range of biological, psychological, and behavioral correlates that could help explain the association between PTSD and CVD. Those include:

  • PTSD can result in hypothalamic–pituitary–adrenal axis dysfunction, increased inflammation and abnormal cortisol regulation, which increases risk of hypertension, diabetes mellitus and CVD similar to the process observed in patients with depression.
  • Poor coping strategies involve heavy smoking, excessive alcohol use and illicit drug use, which might contribute to increased risk of CVD.
  • Depression and other anxiety disorders are frequently comorbid with PTSD, and depression and some anxiety disorders have been identified as CVD risk factors.

Researchers reported that younger patients were more likely to have PTSD (P<0.0001), while white race was less common and black race was more common among patients with the condition.

Significantly more common among PTSD patients were depression, other anxiety disorder, sleep disorders and substance use disorder, according to the study. But so were T2DM, obesity, hypertension and hyperlipidemia, researchers pointed out, adding that significantly higher average body mass index was observed in patients with PTSD and the percent of patients with a body mass index of 30 or higher was significantly higher in those with vs. without PTSD. Those with PTSD diagnoses also were much more likely to be current smokers.

The study found that, during follow‐up, 782 patients developed CVD. Of these cases, 10.5% were incident hypertensive heart disease diagnoses, 6.8% myocardial infarction, 29.8% ischemic heart disease, 4.2% diseases of pulmonary circulation and 56.0% “other” heart disease diagnoses. Multiple components of incident CVD were identified in 6.4% of the patients.

“In a large sample of VHA patients, we observed that patients diagnosed with PTSD from Sept. 30, 2008, to October 1, 2012, and followed up through 2015, were 41% more likely than those without PTSD to develop CVD,” study authors wrote. “Physical comorbidities partially explained this association. After adjusting for these conditions, the magnitude of the association between PTSD and incident CVD was reduced by 44% but remained statistically significant (HR=1.23; 95% CI: 1.06–1.44).”

The researchers recommended closer monitoring of physical and psychiatric disorders might be warranted in PTSD patients, as well as a smoking cessation program.

“Additionally, PTSD itself can be effectively treated and further research is needed to determine whether PTSD remission is associated with fewer comorbidities and lower CVD risk,” they concluded. “Recognizing that PTSD does not preordain CVD may empower patients to seek care to prevent and/or manage CVD risk factors. Patients without PTSD are also at risk of CVD if they smoke, have a sleep disorder, depression, or metabolic disease. In both patient populations, the risk of CVD can be mitigated with health behavior change and effective chronic disease management.”

Scherrer JF, Salas J, Cohen BE, Schnurr PP, et. Al. Comorbid Conditions Explain the Association Between Posttraumatic Stress Disorder and Incident Cardiovascular Disease. J Am Heart Assoc. 2019 Feb 19;8(4):e011133. doi: 10.1161/JAHA.118.011133. PubMed PMID: 30755078.

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