PTSD, Comorbidities, Gender, and Increased Risk of Cardiovascular Disease in a Large Military Cohort

Overview

Journal medRxiv

Date 2024 May 3

PMID 38699311

Authors

David S Krantz

Frances H Gabbay

Elizabeth A Belleau

Pablo A Aliaga

Gary H Wynn

Murray B Stein

Robert J Ursano

James A Naifeh

Affiliations

Soon will be listed here.

Abstract

Importance: Posttraumatic stress disorder (PTSD) is a prevalent mental health problem that increases risk of cardiovascular disease (CVD). It is not known whether gender or comorbidities modify associations between PTSD and CVD.

Objective: To assess risk of hypertension and atherosclerotic CVD (ASCVD) associated with PTSD in a predominantly young military population, and determine if gender or PTSD comorbidities modify these associations.

Design Setting And Participants: Using administrative medical records, this longitudinal, retrospective cohort study assessed relationships of PTSD, gender, comorbidities (metabolic risk factors [MRF], behavioral risk factors [BRF], depression, and sleep disorders) to subsequent hypertension and ASCVD among 863,993 active-duty U.S. Army enlisted soldiers (86.2% male; 93.7% <age 40). Using discrete-time survival analysis, person-months with an initial hypertension diagnosis (=49,656) were compared to an equal-probability control sample. Separate analyses compared person-months with ASCVD (n=2,427) to an equal-probability control sample.

Main Outcomes And Measures: ICD-9-CM diagnoses of hypertension, ASCVD (coronary artery disease, myocardial infarction, stroke, heart failure), PTSD, MRF (Type 2 diabetes, obesity), BRF (tobacco/alcohol use disorders), depression, and sleep disorders.

Results: PTSD was associated with subsequent hypertension (OR=3.0 [95% CI=2.9-3.1]), and ASCVD (OR=2.7 [95% CI=2.2-3.3]). These associations remained significant but were attenuated after adjusting for comorbidities and sociodemographic/service-related variables (Hypertension: OR=1.9 [95% CI=1.8-2.0]; ASCVD: OR=1.4 [95% CI=1.2-1.8]). For hypertension, gender and each comorbidity were significant explanatory variables in multivariable models, and there were significant PTSD interactions with gender, MRF, depression, and sleep disorders. Stratifying separately by gender and presence of each comorbidity, PTSD-hypertension associations were stronger among men, those without MRF, without depression, and without sleep disorders. Standardized risk estimates indicated that predicted hypertension rates for those with vs. without PTSD were higher for men, and for those with vs. without MRF, depression, and sleep disorders. For ASCVD, comorbidities, but not gender, were independent predictors, and associations between PTSD and ASCVD were not modified by gender or comorbidities.

Conclusions And Relevance: PTSD and comorbidities are independent risk factors for hypertension and ASVD in younger individuals, and gender and comorbid conditions modify PTSD relationships with hypertension. These findings suggest that CVD preventive interventions address PTSD and medical and behavioral comorbidities.

References

Iorga A, Cunningham C, Moazeni S, Ruffenach G, Umar S, Eghbali M . The protective role of estrogen and estrogen receptors in cardiovascular disease and the controversial use of estrogen therapy. Biol Sex Differ. 2017; 8(1):33. PMC: 5655818. DOI: 10.1186/s13293-017-0152-8. View

Lewis T . Trauma and Posttraumatic Stress Disorder: Emerging Risk Factors for Cardiovascular Disease in Women?. Circulation. 2015; 132(4):227-9. DOI: 10.1161/CIRCULATIONAHA.115.017432. View

Resnick E, Mallampalli M, Carter C . Current challenges in female veterans' health. J Womens Health (Larchmt). 2012; 21(9):895-900. PMC: 3430482. DOI: 10.1089/jwh.2012.3644. View

Naifeh J, Colpe L, Aliaga P, Sampson N, Heeringa S, Stein M . Barriers to Initiating and Continuing Mental Health Treatment Among Soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Mil Med. 2016; 181(9):1021-32. PMC: 5120390. DOI: 10.7205/MILMED-D-15-00211. View

Remch M, Laskaris Z, Flory J, Mora-McLaughlin C, Morabia A . Post-Traumatic Stress Disorder and Cardiovascular Diseases: A Cohort Study of Men and Women Involved in Cleaning the Debris of the World Trade Center Complex. Circ Cardiovasc Qual Outcomes. 2018; 11(7):e004572. PMC: 6044466. DOI: 10.1161/CIRCOUTCOMES.117.004572. View

Ursano R, Colpe L, Heeringa S, Kessler R, Schoenbaum M, Stein M . The Army study to assess risk and resilience in servicemembers (Army STARRS). Psychiatry. 2014; 77(2):107-19. PMC: 4075436. DOI: 10.1521/psyc.2014.77.2.107. View

Olff M, Langeland W, Draijer N, Gersons B . Gender differences in posttraumatic stress disorder. Psychol Bull. 2007; 133(2):183-204. DOI: 10.1037/0033-2909.133.2.183. View

Bourassa K, Hendrickson R, Reger G, Norr A . Posttraumatic Stress Disorder Treatment Effects on Cardiovascular Physiology: A Systematic Review and Agenda for Future Research. J Trauma Stress. 2020; 34(2):384-393. PMC: 8035275. DOI: 10.1002/jts.22637. View

Koenen K, Sumner J, Gilsanz P, Glymour M, Ratanatharathorn A, Rimm E . Post-traumatic stress disorder and cardiometabolic disease: improving causal inference to inform practice. Psychol Med. 2016; 47(2):209-225. PMC: 5214599. DOI: 10.1017/S0033291716002294. View

10.

Edmondson D, von Kanel R . Post-traumatic stress disorder and cardiovascular disease. Lancet Psychiatry. 2017; 4(4):320-329. PMC: 5499153. DOI: 10.1016/S2215-0366(16)30377-7. View

11.

Freedland K, Carney R . Depression as a risk factor for adverse outcomes in coronary heart disease. BMC Med. 2013; 11:131. PMC: 3658994. DOI: 10.1186/1741-7015-11-131. View

12.

Wisco B, Nomamiukor F, Marx B, Krystal J, Southwick S, Pietrzak R . Posttraumatic Stress Disorder in US Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study. J Clin Psychiatry. 2022; 83(2). DOI: 10.4088/JCP.20m14029. View

13.

Kubzansky L, Koenen K, Jones C, Eaton W . A prospective study of posttraumatic stress disorder symptoms and coronary heart disease in women. Health Psychol. 2009; 28(1):125-30. PMC: 2757327. DOI: 10.1037/0278-6133.28.1.125. View

14.

Farr O, Sloan D, Keane T, Mantzoros C . Stress- and PTSD-associated obesity and metabolic dysfunction: a growing problem requiring further research and novel treatments. Metabolism. 2014; 63(12):1463-8. PMC: 4459590. DOI: 10.1016/j.metabol.2014.08.009. View

15.

Naifeh J, Mash H, Stein M, Fullerton C, Kessler R, Ursano R . The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): progress toward understanding suicide among soldiers. Mol Psychiatry. 2018; 24(1):34-48. PMC: 6756108. DOI: 10.1038/s41380-018-0197-z. View

16.

Kessler R, Sonnega A, Bromet E, Hughes M, Nelson C . Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995; 52(12):1048-60. DOI: 10.1001/archpsyc.1995.03950240066012. View

17.

Hernesniemi J, Tynkkynen J, Havulinna A, Oksala N, Vartiainen E, Laatikainen T . Significant interactions between traditional risk factors affect cardiovascular risk prediction in healthy general population. Ann Med. 2014; 47(1):53-60. DOI: 10.3109/07853890.2014.970570. View

18.

Edmondson D, Kronish I, Shaffer J, Falzon L, Burg M . Posttraumatic stress disorder and risk for coronary heart disease: a meta-analytic review. Am Heart J. 2013; 166(5):806-14. PMC: 3815706. DOI: 10.1016/j.ahj.2013.07.031. View

19.

McFarlane A . Post-traumatic stress disorder is a systemic illness, not a mental disorder: is Cartesian dualism dead?. Med J Aust. 2017; 206(6):248-249. DOI: 10.5694/mja17.00048. View

20.

Turner J, Neylan T, Schiller N, Li Y, Cohen B . Objective evidence of myocardial ischemia in patients with posttraumatic stress disorder. Biol Psychiatry. 2013; 74(11):861-6. PMC: 4005370. DOI: 10.1016/j.biopsych.2013.07.012. View