A study using data from Veterans Health Administration (VHA) electronic medical records shows a significant association between posttraumatic stress disorder (PTSD) among female veterans and an increased risk for incident ischemic heart disease (IHD).
The increased risk for IHD was highest among women younger than 40 with PTSD, and among racial and ethnic minorities.
“These women have been emerging as important targets for cardiovascular prevention, and our study suggests that PTSD may be an important psychosocial risk factor for IHD in these individuals,” the researchers, with lead author Ramin Ebrahimi, MD, Department of Medicine, Cardiology Section, Veterans Affairs Greater Los Angeles Health Care System, conclude. “With the number of women veterans growing, it is critical to appreciate the healthcare needs of this relatively young and diverse patient population.”
Their results also have “important implications for earlier and more aggressive IHD risk assessment, monitoring and management in vulnerable women veterans,” they add. “Indeed, our findings support recent calls for cardiovascular risk screening in younger individuals and for the need to harness a broad range of clinicians who routinely treat younger women to maximize prevention efforts.”
The article was published online in JAMA Cardiology on March 17.
Increasing Number of VHA Users
“As an interventional cardiologist and the director of the cardiac catheterization laboratory, I noticed a significant number of the patients referred to the cath lab carried a diagnosis of post-traumatic stress disorder,” Ebrahimi told theheart.org | Medscape Cardiology. “This intrigued me and started my journey into trying to understand how psychiatric disorders in general, and PTSD, may impact/interact with cardiovascular disorders,” he added.
The number of women veterans in the military has been increasing, and they now make up about 10% of the 20 million American veterans; that number is projected to exceed 2.2 million in the next 20 years, the authors write. Women veterans are also the fastest growing group of users of the VHA, they add.
IHD is the leading cause of death in women in the United States, despite the advancements in prevention and treatment. Although women are twice as likely to develop PTSD as men, and it is even more likely in women veterans, much of the research has predominately been on male veterans, the authors write.
For this retrospective study, which used data from the VHA Corporate Data Warehouse, the authors examined a cohort of women veterans who were 18 years or older who had used the VHA healthcare system between January 1, 2000 and December 31, 2017.
Of the 828,997 women veterans, 151,030 had PTSD and 677,967 did not. Women excluded from the study were those who did not have any clinical encounters after their index visit, participants who had a diagnosis of IHD at or before the index visit, and those with incident IHD within 90 days of the index visit, allowing time between a PTSD diagnosis and IHD.
Propensity score matching on age at index visit, the number of previous visits, and the presence of traditional and female-specific cardiovascular risk factors, as well as 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. A total of 132,923 women with PTSD and 265,846 women without PTSD were included, and data were analyzed from October 1, 2018, to October 30, 2020.
IHD was defined as new-onset coronary artery disease, angina, or myocardial infarction-based ICD-9 and ICD-10 diagnostic codes. Age, race, and ethnicity were self-reported.
The analytic sample consisted of relatively young women veterans (mean [SD] age at baseline, 40.1 [12.2] years) of various races (White, 57.6%; Black, 29.8%) and ethnicities, the authors report.
Of the 9940 women who experienced incident IHD during follow-up, 5559 did not have PTSD (2.1%) and 4381 had PTSD (3.3%). PTSD was significantly associated with an increased risk for IHD. Over the median follow-up of 4.9 years, women veterans with PTSD had a 44% higher rate of developing incident IHD than the women veterans without PTSD (hazard ratio [HR], 1.44; 95% CI, 1.38 – 1.50).
In addition, those with PTSD who developed IHD were younger at diagnosis (mean [SD] age, 55.5 [9.7]) than patients without PTSD (mean [SD] age, 57.8 [10.7]). Effect sizes were largest in the group younger than 40 years (HR, 1.72; 95% CI, 1.55 – 1.90) and decreased for older participants (HR for those ≥60 years, 1.24; 95% CI, 1.12 – 1.38)
The authors found a 49% to 66% increase in risk for IHD associated with PTSD in Black women (HR, 1.49; 95% CI, 1.38 – 1.62) and those identified as non-White and non-Black (HR, 1.66; 95%, 1.33 – 2.08).
Women of all ethnic groups with PTSD were at higher risk of developing IHD, but this was especially true for Hispanic/Latina women (HR, 1.50; 95% CI 1.22 – 1.84), they note.
The authors reported some limitations to their findings. The analytic sample could result in a lower ascertainment of certain conditions, such as psychiatric disorders, they write. Substance disorders were low in this study, possibly because of the younger age of women veterans in the sample. Because this study used VHA electronic medical records data, medical care outside of the VHA that was not paid for by the VHA could not be considered.
In addition, although this study used a large sample of women veterans, the findings can not be generalized to women veterans outside of the VHA system, nonveteran women, or men, the researchers write.
A Call to Action
In an accompanying comment, Beth E. Cohen, MD, University of California, San Francisco, and the San Francisco Veterans Affairs Health Care System, points out that the physical implications for psychosocial conditions, including depression and PTSD, have been recognized for quite some time. For example, results of the INTERHEART case–control study of 30,000 people showed stress, depression, and stressful life events accounted for one-third the population-attributable risk for myocardial infarction.
As was also noted by Ebrahimi and colleagues, much of the current research has been on male veterans, yet types of trauma differ among genders; women experience higher rates of military sexual trauma but lower rates of combat trauma than male veterans, Cohen writes. The PTSD symptoms, trajectory, and biological effects can differ for women and men, as can the pathogenesis, presentation, and outcomes of cardiovascular disease (CVD).
These findings, she said, “are an important extension of the prior literature and represent the largest study in women veterans to date. Although methods differ across studies, the magnitude of risk associated with PTSD was consistent with that found in prior studies of male veterans and nonveteran samples.”
The assessment of age-specific risk is also a strength of the study, “and has implications for clinical practice, because PTSD-associated risk was greatest in a younger group in whom CVD may be overlooked.”
Cohen addressed the limitations outlined by the authors, including ascertainment bias, severity of PTSD symptoms, and their chronicity, but added that “even in the context of these limitations, this study illustrates the importance of PTSD to the health of women veterans and the additional work needed to reduce their CVD risk.”
Clinical questions remain, she added. Screens for PTSD are widely used in the VHA, yet no studies have examined whether screening or early detection decrease CVD risk. Additionally, no evidence suggests that screening for or treatment of PTSD improve cardiovascular outcomes.
“Given the challenges of answering these questions in observational studies, it will be important to incorporate measures of CVD risk and outcomes in trials of behavioral and medical therapies for patients with PTSD,” she writes.
She adds that collaborations among multidisciplinary patient care teams will be important. “The findings of this study represent a call to action for this important work to understand the cardiovascular effects of PTSD and improve the health and wellbeing of women veterans,” Cohen concludes.
This research was supported by Investigator-Initiated Research Award from the Department of Defense US Army Medical Research and Material Command Congressionally Directed Medical Research Programs (Ebrahimi) and in part by grant from the VA Informatics and Computing Infrastructure (VINCI) and the Offices of Research and Development at the Northport, Durham, and Greater Los Angeles Veterans Affairs Medical Centers. Ebrahimi reported receiving grants from Department of Defense during the conduct of the study. Disclosures for other authors are available in the paper. Cohen reports no disclosure.
JAMA Cardiol. Published online March 17, 2021. Abstract, Editorial
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