The link between mental illness and heart health is well-established, with various studies showing that depression, anxiety, and chronic stress may increase the risk for cardiovascular disease (CVD).1,2 In addition, several research studies have demonstrated an increased risk for CVD and CV events in individuals with posttraumatic stress disorder (PTSD).3

Among these findings, a 2018 cohort study of first responders in the World Trade Center attack identified PTSD as a risk factor for myocardial infarction (hazard ratio [HR], 2.22; 95% CI, 1.30-3.82) and stroke (HR, 2.51; 95% CI, 1.39-4.57), independent of depression.4 Further, in a meta-analysis of 9 studies (N=151,144), researchers found a HR of 1.46 (95% CI, 0.26-1.69; P <.0005) for the association between PTSD and coronary heart disease.5

Emerging research continues to shed light on the connection between PTSD and heart disease in various populations. “While the initial studies showing this association were cross-sectional, recent retrospective longitudinal studies provided similar results,” said Ramin Ebrahimi, MD, professor of medicine in the department of cardiology at the University of California, Los Angeles, School of Medicine, and director of interventional cardiovascular research at the Veterans Affairs (VA) Greater Los Angeles Healthcare System. Dr Ebrahimi also noted that most of the previous research conducted in this area has been limited to men.


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For example, in a study sample of 138,341 veterans (aged 55 years and older; approximately; 96% men), those with PTSD had an increased risk for CVD (45%), congestive heart failure (26%), myocardial infarction (49%), and peripheral vascular disease (35%) compared to veterans without PTSD.6 Although newer studies have linked PTSD symptoms to CVD in community-based women, there is limited evidence regarding this association in women veterans.7

Dr Ebrahimi and colleagues aimed to address this gap in a retrospective, longitudinal cohort study of 132,923 women veterans with a current or previous PTSD diagnosis who were matched 1:2 to 265,846 women veterans with no previous PTSD diagnosis.8 “Our project represents the largest and most comprehensive study to investigate the association of PTSD with ischemic heart disease in women veterans,” he told us in an interview.

The results, published in March 2021 in JAMA Cardiology, revealed a significant association between PTSD and an increased risk of developing ischemic heart disease, with a hazard ratio of 1.44 (95% CI, 1.38-1.50). This risk was higher in younger participants, with the largest effect sizes observed for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) compared with those 60 years and older (HR, 1.24; 95% CI, 1.12-1.38), and in racial and ethnic minorities compared with non-Hispanic White women.8

The associations were significant even after accounting for various confounders including traditional CVD risk factors, such as diabetes and hypertension, female-specific risk factors, such as gestational diabetes and preeclampsia, psychologic disorders and substance abuse, neuroendocrine disorders, and chronic kidney disease.8

Results from these studies point to the potential need for earlier and more aggressive assessment of CVD risk in women with PTSD, according to Dr Ebrahimi. Overall, topics warranting further research in this area include nontraditional mechanisms driving the PTSD-CVD association, relevant genetic markers, as well as gender and ethnic differences, and the impact of therapy on CVD outcomes.

We learned more about the link between PTSD and CVD in an interview with Beth Cohen, MD, MA, professor of medicine at the University of California, San Francisco, School of Medicine, staff physician at the San Francisco VA Medical Center, and principal investigator of the Mind Your Heart Study, a prospective cohort study examining the impact of PTSD on CV health.9

What does the existing evidence suggest about associations between PTSD and CVD, and what can the findings by your research team add to our understanding of this connection?

Numerous studies have found that patients with PTSD are at increased risk of developing CVD, including ischemic heart disease, heart failure, and cerebrovascular disease. Earlier studies of PTSD and CVD were limited by the use of patient self-report or administrative data to classify CVD outcomes. However, more recent studies have confirmed the association with carefully adjudicated CVD events. Work by our group and others has also used objective measures to assess CVD and CV risk, including exercise treadmill testing, myocardial perfusion on nuclear imaging, and assessment of coronary artery calcification.

What are believed to be the mechanisms driving this connection?

The mechanisms linking PTSD to CVD are believed to be a combination of biological, behavioral, and psychosocial factors. We know that patients with PTSD have alterations in autonomic nervous system function and elevations in inflammation that can contribute to CVD. Patients with PTSD are also more likely to have lower physical activity and higher rates of tobacco and substance use. In addition, there may be psychosocial factors, such as comorbid mental disorders, lower socioeconomic status, and reduced social support, which further increase CVD risk.

What are the relevant clinical recommendations for clinicians in terms of screening and treatment of PTSD?

Clinical studies have not addressed whether more aggressive screening or treatment of patients with PTSD will impact their CVD risk. So, for now, clinicians should focus on making sure patients are engaged in treatment for PTSD. There are numerous challenges for patients in accessing evidence-based care and overcoming the stigma of seeking help, so providers have a very important role in encouraging them to get care and strategizing to overcome barriers.

In addition, although we know that traditional CVD risk factors don’t fully explain the increased risk we see in patients with PTSD, screening for and treating them based on current guidelines are important.

What are some key remaining research needs in this area?

Although many studies have found links between PTSD and CVD, we still need carefully designed, prospective studies with multiple measures of PTSD, potential confounders and mechanisms, and CVD outcomes, to better assess the causal link and identify mechanisms that can be targets for treatments.

In addition, though this question has been studied in multiple populations, including veterans, nonveterans, and women, studies have been limited in terms of racial and ethnic diversity.

Finally, we need clinical trials to examine the impact of PTSD treatment on CVD outcomes to determine whether differential screening in patients with PTSD can further reduce CVD risk.

References

  1. Satyjeet F, Naz S, Kumar V, et al. Psychological stress as a risk factor for cardiovascular disease: a case-control study. Cureus. 2020;12(10):e10757. doi:10.7759/cureus.10757
  2. Jackson CA, Sudlow CLM, Mishra GD. Psychological distress and risk of myocardial infarction and stroke in the 45 and up study. Circ Cardiovasc Qual Outcomes. 2018;11(9):e004500. doi:10.1161/CIRCOUTCOMES.117.004500
  3. O’Donnell CJ, Schwartz Longacre L, Cohen BE, et al. Posttraumatic stress disorder and cardiovascular disease: state of the science, knowledge gaps, and research opportunities. Published online July 14, 2021. JAMA Cardiol. doi:10.1001/jamacardio.2021.2530
  4. 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. doi:10.1161/CIRCOUTCOMES.117.004572
  5. Akosile W, Colquhoun D, Young R, Lawford B, Voisey J. The association between post-traumatic stress disorder and coronary artery disease: a meta-analysis. Australas Psychiatry. 2018;26(5):524-530. doi:10.1177/1039856218789779
  6. Beristianos MH, Yaffe K, Cohen B, Byers AL. PTSD and risk of incident cardiovascular disease in aging veterans. Am J Geriatr Psychiatry. 2016;24(3):192-200. doi:10.1016/j.jagp.2014.12.003
  7. Cohen BE. Exploring posttraumatic stress disorder as a cardiovascular risk factor in women veterans: the heart of the matter. JAMA Cardiol. 2021;6(6):651-652. doi:10.1001/jamacardio.2021.0236
  8. Ebrahimi R, Lynch KE, Beckham JC, et al. Association of posttraumatic stress disorder and incident ischemic heart disease in women veterans. JAMA Cardiol. 2021;6(6):642-651. doi:10.1001/jamacardio.2021.0227
  9. UCSF—The Mind Your Heart Study. Publications. Accessed August 11, 2021. https://mindyourheartstudy.ucsf.edu/publications