Post-traumatic stress disorder and cardiovascular disease link: time to identify specific pathways and interventions

Cardiovascular impact of post-traumatic stress disorder: A systematic review and meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is increasingly recognized for its effects beyond mental health, with emerging evidence suggesting a significant association with cardiovascular diseases (CVD). This systematic review and meta-analysis aimed to synthesize available evidence on the association between PTSD and various cardiovascular outcomes.

METHODS

We conducted a comprehensive literature search in databases until March 15, 2024. Studies were included if they were observational in design and assessed the association between PTSD and cardiovascular outcomes. Data were extracted on study characteristics, participant demographics, PTSD assessment, cardiovascular outcomes, and effect estimates. Meta-analyses were performed using random-effects models, and heterogeneity was assessed using the I² statistic. All statistical analyses were conducted using R software version 4.3.

RESULTS

Twenty studies met the inclusion criteria, encompassing a total of over 335,000 participants. The pooled analyses demonstrated a statistically significant increased risk of any CVD (HR = 1.417, 95 % CI: 1.313-1.522), MI (HR = 1.415, 95 % CI: 1.331-1.500), and stroke (HR = 2.074, 95 % CI: 1.165-2.982) associated with PTSD. Substantial heterogeneity was observed across the studies for stroke and MACE, and evidence of publication bias was noted.

CONCLUSION

This meta-analysis confirms a significant association between PTSD and an increased risk of several cardiovascular outcomes, indicating the importance of integrating cardiovascular risk management with psychiatric care for PTSD patients to mitigate the heightened risk of CVDs. Future research should focus on exploring the underlying mechanisms and potential interventions to manage both PTSD and its associated cardiovascular risks effectively.

PTSD improvement and incident cardiovascular disease in more than 1000 veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiovascular disease (CVD). Whether clinically meaningful PTSD improvement is associated with lowering CVD risk is unknown.

METHODS

Eligible patients (n = 1079), were 30-70 years old, diagnosed with PTSD and used Veterans Health Affairs PTSD specialty clinics. Patients had a PTSD Checklist score (PCL) ≥ 50 between Fiscal Year (FY) 2008 and FY2012 and a second PCL score within 12 months and at least 8 weeks after the first PCL ≥ 50. Clinically meaningful PTSD improvement was defined by ≥20 point PCL decrease between the first and second PCL score. Patients were free of CVD diagnoses for 1 year prior to index. Index date was 12 months following the first PCL. Follow-up continued to FY2015. Cox proportional hazard models estimated the association between clinically meaningful PTSD improvement and incident CVD and incident ischemic heart disease (IHD). Sensitivity analysis stratified by age group (30-49 vs. 50-70 years) and depression. Confounding was controlled using propensity scores and inverse probability of exposure weighting.

RESULTS

Patients were 48.9 ± 10.9 years of age on average, 83.3% male, 60.1% white, and 29.5% black. After controlling for confounding, patients with vs. without PTSD improvement did not differ in CVD risk (HR = 1.08; 95%CI: 0.72-1.63). Results did not change after stratifying by age group or depression status. Results were similar for incident IHD.

CONCLUSIONS

Over a 2-7 year follow-up, we did not find an association between clinically meaningful PTSD improvement and incident CVD. Additional research is needed using longer follow-up.

Comorbid Conditions Explain the Association Between Posttraumatic Stress Disorder and Incident Cardiovascular Disease

Background Posttraumatic stress disorder ( PTSD ) is associated with risk of cardiovascular disease ( CVD ). Biopsychosocial factors associated with PTSD likely account for some or all of this association. We determined whether 1, or a combination of comorbid conditions explained the association between PTSD and incident CVD . Methods and Results Eligible patients used 1 of 5 Veterans Health Affairs medical centers distributed across the United States. Data were obtained from electronic health records. At index date, 2519 Veterans Health Affairs ( VA ) patients, 30 to 70 years of age, had PTSD diagnoses and 1659 did not. Patients had no CVD diagnoses for 12 months before index date. Patients could enter the cohort between 2008 and 2012 with follow-up until 2015. Age-adjusted Cox proportional hazard models were computed before and after adjusting for comorbidities. Patients were middle aged (mean=50.1 years, SD ±11.0), mostly male (87.0%), and 60% were white. The age-adjusted association between PTSD and incident CVD was significant (hazard ratio=1.41; 95% CI : 1.21-1.63). After adjustment for metabolic conditions, the association between PTSD and incident CVD was attenuated but remained significant (hazard ratio=1.23; 95% CI : 1.06-1.44). After additional adjustment for smoking, sleep disorder, substance use disorder, anxiety disorders, and depression, PTSD was not associated with incident CVD (hazard ratio=0.96; 95% CI : 0.81-1.15). Conclusions PTSD is not an independent risk factor for CVD . Physical and psychiatric conditions and smoking that co-occur with PTSD explain why this patient population has an increased risk of CVD . Careful monitoring may limit exposure to CVD risk factors and subsequent incident CVD .

Predictors of Current DSM-5 PTSD Diagnosis and Symptom Severity Among Deployed Veterans: Significance of Predisposition, Stress Exposure, and Genetics

BACKGROUND

Previously we reported a genetic risk score significantly improved PTSD prediction among a trauma-exposed civilian population. In the current study, we sought to assess this prediction among a trauma-exposed military population.

METHODS

We examined current PTSD diagnosis and PTSD symptom severity among a random sample of 1042 community-based US military veterans. Main effects and interaction effects were assessed for PTSD genetic risk by trauma exposure using cross-product terms for PTSD x trauma exposures, including combat, lifetime trauma, and adverse childhood exposures. The PTSD risk variants studied were within genetic loci previously associated with PTSD, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variants, which were used to calculate a total PTSD genetic risk score (range=0-8, mean=3.6, SD=1.4).

RESULTS

Based on DSM-5 PTSD criteria, 7.1% of veterans (95% CI=5.6-8.8) met criteria for current PTSD. The PTSD genetic risk count was significantly higher among PTSD cases vs non-cases (3.92 vs 3.55, p=0.027). Since the PTSD genetic risk score was not significant in the PTSD diagnosis model, we assessed this association using PTSD symptom severity. Because these symptom data were skewed (mean=9.54, SD=12.71, range=0-76), we used negative binomial regression to assess this outcome. This symptom model included a PTSD genetic risk score, demographic factors, trauma exposures, current insomnia, current depression, concussion history, and attention-deficit disorder, expressed as incident rate ratios (IRR), which is an estimate of one-unit increase in PTSD severity, given other variables are held constant. Variables in the final model included age and sex (both p<0.001), PTSD genetic risk (IRR=1.02, p=0.028), warzone tours (IRR=0.94, p=0.003), childhood abuse (IRR=1.50, p<0.0001), current depression (IRR=1.89, p<0.0001), current insomnia (IRR=2.58, p<0.0001), low social support (IRR=1.19, p<0.0001), attention-deficit disorder (IRR=1.51, p<0.0001), agreeable personality (IRR=0.77, p<0.0001), and concussion (IRR=1.38, p<0.0001). Significant interactions were detected for combat and lifetime trauma exposure by PTSD genetic risk (both p<0.0001), suggesting that the impact of trauma exposures on PTSD severity was lower when the PTSD genetic risk was higher.

CONCLUSION

Both warzone and non-warzone factors predicted current PTSD symptoms among veterans, including a PTSD genetic risk score. Interaction effects were detected for combat exposure and lifetime trauma by genetic risk score for PTSD symptoms, suggesting that PTSD symptom manifestation was more dependent on PTSD risk variants than the level of trauma or combat exposure. This suggests that controlling for other factors, the absence of genetic risk variants may confer PTSD resilience. Further research is planned.

Future Research: Global Implications

Therapists trained to provide eye movement desensitization and reprocessing (EMDR) therapy have a global responsibility. This article summarizes the multiple impacts of high stress events, and their long-term effects on individuals, families, communities, and nations. While it is well documented that EMDR treatment will remediate the individual symptoms of posttraumatic stress, research is still needed to determine how far-reaching such outcomes are. Future studies should determine whether treatment reverses the neurobiological changes, cognitive deficits, and affective dysregulation, which are associated with exposure to traumatic events. Research should also investigate whether successful treatment decreases high-risk and/or perpetrator behavior, and whether these effects are translated into behavioral and attitudinal changes sufficient to bring an end to intergenerational trauma and ethnopolitical conflicts. It seems self-evident that the ideal way to address pressing societal needs, on both local and global levels, is by the integration of science and practice. The article also discusses the development of nonprofit EMDR humanitarian assistance programs, and their essential work in the alleviation of suffering around the world. In addition to recommending the examination of EMDR's efficacy in treating traumatization from direct, natural, structural, and cultural causes, this article advocates that research resources be dedicated for testing interventions in the areas of the world with the greatest needs. The alleviation of suffering is the duty of our profession.

Post-trauma cardiovascular risk factors and subclinical atherosclerosis in young adults following the war in Bosnia and Herzegovina

Background: Risk of cardiovascular disease (CVD) has been associated with stress from serving in a war, but it has not been established whether children who experience war-related stress are at increased CVD risk. Objective: This study aimed to compare CVD risk factors in young adults according to whether they experienced traumatic events as children during the 1990-1995 war in Bosnia and Herzegovina, and whether those exposed to trauma have evidence of subclinical atherosclerosis. Method: We examined 372 first-year medical students who were preschool children during the war (1990-1995) (average age 19.5 ± 1.7 years, 67% female) in 2007-2010. They completed the Semi-Structured Interview for Survivors of War. CVD risk factors and carotid intima-media thickness (CIMT) measurements were obtained and compared in individuals with and without trauma. We also examined whether increased CIMT was independently associated with trauma after adjustment for other risk factors. Results: From multiple logistic regression, only elevated triglycerides (> 1.7 mmol/l) were associated with a 5.2 greater odds of having experienced trauma. The mean CIMT of subjects with trauma was greater than that of non-trauma-exposed subjects (0.53 mm vs 0.50 mm, p = 0.07). Moreover, trauma was independently associated with higher CIMT (difference = 0.036 mm, p = 0.024) after adjustment for CVD risk factors. Conclusions: We show that most CVD risk factors are associated with post-war trauma in young adults, and, if present, such trauma is associated with higher triglycerides and higher levels of CIMT in multivariable analysis.

Latent profiles of early trauma & Type D personality: sex differences in cardiovascular risk markers

BACKGROUND

Both adverse early life-events and distressed personality are associated with an increased cardiovascular risk. As there is an important link between these psychological factors, we investigated how these might cluster in sex-specific psychological profiles. We further examined the association of these profiles with cardiovascular risk markers.

METHOD

446 women (mean age = 49.8 ± 17.9 years) and 431 men (mean age = 49.4 ± 17.5 years) from the Dutch general population completed questionnaires on demographics, adverse early life-events (ETI), Type D personality (DS14), anxiety (GAD-7) and depressive (PHQ-9) symptoms, and traditional cardiovascular risk markers.

RESULTS

A step-3 latent profile analysis identified three profiles in women (Reference, Type D & trauma, and Type D/no trauma) and four in men (Reference, Type D & trauma, Type D/no trauma, and Physical abuse). In women, the Type D/no trauma was associated with highest levels of emotional symptoms (OR = 2.47; 95% CI: 2.11-2.89), lipid abnormalities (OR = 3.69; 95% CI: 1.47-9.27), and increased levels of alcohol use (OR = 3.63; 95% CI: 1.42-9.30). The Type D & trauma profile was associated with increased levels of emotional symptoms (OR = 2.03; 95% CI: 1.70-2.42), highest levels of smoking (OR = 3.30; 95% CI: 1.21-8.97) and alcohol use (OR = 7.63; 95% CI: 2.86-20.33). Women in both profiles were older as compared to the Reference group (OR = 1.03; 95% CI: 1.01-1.05). In men, the Type D & trauma profile was associated with increased levels of emotional symptoms (OR = 1.11; 95% CI: 1.03-1.20). There were no significant differences between the profiles in lifestyle factors and cardiometabolic factors.

CONCLUSIONS

In women, the Type D/no trauma profile and the Type D & trauma profile were associated with a specific combination of cardiovascular risk markers. In men, the Type D & trauma profile was associated with an increased level of emotional symptoms.

Post-traumatic stress disorder symptom duration and remission in relation to cardiovascular disease risk among a large cohort of women

BACKGROUND

Prior studies suggest that post-traumatic stress disorder (PTSD) is associated with elevated cardiovascular disease (CVD) risk, but effects of duration and remission of PTSD symptoms have rarely been evaluated.

METHOD

We examined the association of time-updated PTSD symptom severity, remission and duration with incident CVD risk (552 confirmed myocardial infarctions or strokes) over 20 years in 49 859 women in the Nurses' Health Study II. Among women who reported trauma on the Brief Trauma Questionnaire, PTSD symptoms, assessed by a screener, were classified by symptom severity and chronicity: (a) no symptoms, (b) 1-3 ongoing, (c) 4-5 ongoing, (d) 6-7 ongoing, (e) 1-3 remitted, (f) 4-7 remitted symptoms. Inverse probability weighting was used to estimate marginal structural logistic regression models, adjusting for time-varying and time-invariant confounders.

RESULTS

Compared with women with no trauma exposure, women with trauma/no PTSD [odds ratio (OR) 1.30, 95% confidence interval (CI) 1.03-1.65] and women with trauma/6-7 symptoms (OR 1.69, 95% CI 1.08-2.63) had elevated risk of CVD; women with remitted symptoms did not have elevated CVD risk. Among women exposed to trauma, every 5 additional years of PTSD symptomology was associated with 9% higher CVD incidence compared with women with trauma/no PTSD.

CONCLUSIONS

The findings suggest that alleviating PTSD symptoms shortly after onset may attenuate CVD risk.

Comorbid diseases as risk factors for incident posttraumatic stress disorder (PTSD) in a large community cohort (KCIS no.PSY4)

Nature disasters and terrorist attacks have occurred globally in recent years. Posttraumatic stress disorder (PTSD) has gained increasing attention, but its incidence and comorbidities in the general population are different from those inside the disaster areas. The present study estimated incident PTSD and comorbid diseases for over a decade in a cohort from a community-based integrated screening program. Factors associated with the incidence of PTSD were analyzed using Cox regression models. PTSD incidence was estimated as 81 per 10⁵ person-years. Incidence was higher in females than in males and one-year increments in age lowered the risk for PTSD by 3%. Adjusting for other factors, cardiovascular heart disease (adjusted hazard ratio (aHR) = 1.45, 95% confidence interval (CI): 1.03–2.04), bipolar disorder (aHR = 1.86, 95% CI: 1.07–3.24) and major depressive disorder (aHR = 7.03, 95% CI: 5.02–9.85) all significantly increased 45%, 86% and 603%, respectively, the risk of developing PTSD. The low rate of people with incident PTSD receiving treatment in this community health screening population implies there is room for improvement in terms of early detection and intervention. Clinical preventive efforts may be made for patients seeking general medical help, especially those with cardiovascular disorders or mood disorders.

Risk for Incident Hypertension Associated With Posttraumatic Stress Disorder in Military Veterans and the Effect of Posttraumatic Stress Disorder Treatment

OBJECTIVE

Posttraumatic stress disorder (PTSD) increases cardiovascular disease and cardiovascular mortality risk. Neither the prospective relationship of PTSD to incident hypertension risk nor the effect of PTSD treatment on hypertension risk has been established.

METHODS

Data from a nationally representative sample of 194,319 veterans were drawn from the Veterans Administration (VA) roster of United States service men and women. This included veterans whose end of last deployment was from September 2001 to July 2010 and whose first VA medical visit was from October 1, 2001 to January 1, 2009. Incident hypertension was modeled as 3 events: (1) a new diagnosis of hypertension and/or (2) a new prescription for antihypertensive medication, and/or (3) a clinic blood pressure reading in the hypertensive range (≥140/90 mm Hg, systolic/diastolic). Posttraumatic stress disorder diagnosis was the main predictor. Posttraumatic stress disorder treatment was defined as (1) at least 8 individual psychotherapy sessions of 50 minutes or longer during any consecutive 6 months and/or (2) a prescription for selective serotonin reuptake inhibitor medication.

RESULTS

Over a median 2.4-year follow-up, the incident hypertension risk independently associated with PTSD ranged from hazard ratio (HR), 1.12 (95% confidence interval [CI], 1.08-1.17; p < .0001) to HR, 1.30 (95% CI, 1.26-1.34; p < .0001). The interaction of PTSD and treatment revealed that treatment reduced the PTSD-associated hypertension risk (e.g., from HR, 1.44 [95% CI, 1.38-1.50; p < .0001] for those untreated, to HR, 1.20 [95% CI, 1.15-1.25; p < .0001] for those treated).

CONCLUSIONS

These results indicate that reducing the long-term health impact of PTSD and the associated costs may require very early surveillance and treatment.

Predator-based psychosocial stress animal model of PTSD: Preclinical assessment of traumatic stress at cognitive, hormonal, pharmacological, cardiovascular and epigenetic levels of analysis

Research on post-traumatic stress disorder (PTSD) is faced with the challenge of understanding how a traumatic experience produces long-lasting detrimental effects on behavior and brain functioning, and more globally, how stress exacerbates somatic disorders, including cardiovascular disease. Moreover, the design of translational research needs to link animal models of PTSD to clinically relevant risk factors which address why only a subset of traumatized individuals develop persistent psychopathology. In this review, we have summarized our psychosocial stress rodent model of PTSD which is based on well-described PTSD-inducing risk factors, including a life-threatening experience, a sense of horror and uncontrollability, and insufficient social support. Specifically, our animal model of PTSD integrates acute episodes of inescapable exposure of immobilized rats to a predator with chronic daily social instability. This stress regimen produces PTSD-like effects in rats at behavioral, cognitive, physiological, pharmacological and epigenetic levels of analysis. We have discussed a recent extension of our animal model of PTSD in which stress exacerbated coronary pathology following an ischemic event, assessed in vitro. In addition, we have reviewed our research investigating pharmacological and non-pharmacological therapeutic strategies which may have value in clinical approaches toward the treatment of traumatized people. Overall, our translational approach bridges the gap between human and animal PTSD research to create a framework with which to enhance our understanding of the biological basis of trauma-induced pathology and to assess therapeutic approaches in the treatment of psychopathology.

PTSD and Risk of Incident Cardiovascular Disease in Aging Veterans

OBJECTIVES

To determine if late-life posttraumatic stress disorder (PTSD) is associated with cardiovascular disease in a sample of older veterans, and whether the association is independent of medical and psychiatric comorbities.

DESIGN

Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (2000-2011).

SETTING

VA medical centers in the United States.

PARTICIPANTS

A total of 138,341 veterans 55 years and older without cardiovascular disease at study baseline (2000-2003).

MEASUREMENTS

PTSD and cardiovascular disease (as defined by diagnoses of: cerebrovascular disease [CVD], congestive heart failure [CHF], myocardial infarction [MI], and peripheral vascular disease [PVD]) were identified by ICD-9 codes during study baseline (2000-2003) and follow-up (2004-2011), respectively.

RESULTS

3% of veterans (N = 4,041) had a baseline diagnosis of PTSD. Unadjusted increased risk of incidence of CVD was 80%, CHF was 56%, MI was 82%, and PVD was 60% in veterans with PTSD compared with those without PTSD. After adjustment for demographics, medical comorbidities, substance use, and psychiatric comorbidities, veterans with late-life PTSD were at a 45% increased risk for incident CVD, 26% increased risk for incident CHF, 49% increased risk for incident MI, and 35% increased risk for PVD compared with veterans without late-life PTSD.

CONCLUSIONS

Findings highlight the longitudinal impact of PTSD on increasing the incidence of cardiovascular disease in older adults. This study implies the need for greater monitoring and treatment of PTSD in older persons, particularly older veterans, to assist in preventing adverse outcomes, such as cardiovascular disease, over the long term.

Associations between stress disorders and cardiovascular disease events in the Danish population

OBJECTIVES

Post-traumatic stress disorder (PTSD) is a well-documented risk factor for cardiovascular disease (CVD). However, it is unknown whether another common stress disorder-adjustment disorder--is also associated with an increased risk of CVD and whether gender modifies these associations. The aim of this study was to examine the overall and gender-stratified associations between PTSD and adjustment disorder and 4 CVD events.

DESIGN

Prospective cohort study utilising Danish national registry data.

SETTING

The general population of Denmark.

PARTICIPANTS

PTSD (n=4724) and adjustment disorder (n=64,855) cohorts compared with the general population of Denmark from 1995 to 2011.

PRIMARY OUTCOME MEASURES

CVD events including myocardial infarction (MI), stroke, ischaemic stroke and venous thromboembolism (VTE). Standardised incidence rates and 95% CIs were calculated.

RESULTS

Associations were found between PTSD and all 4 CVD events ranging from 1.5 (95% CI 1.1 to 1.9) for MI to 2.1 (95% CI 1.7 to 2.7) for VTE. Associations that were similar in magnitude were also found for adjustment disorder and all 4 CVD events: 1.5 (95% CI 1.4 to 1.6) for MI to 1.9 (95% CI 1.8 to 2.0) for VTE. No gender differences were noted.

CONCLUSIONS

By expanding beyond PTSD and examining a second stress disorder-adjustment disorder-this study provides evidence that stress-related psychopathology is associated with CVD events. Further, limited evidence of gender differences in associations for either of the stress disorders and CVD was found.

Altered one-carbon metabolism in posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with increased morbidity and mortality through somatic conditions, particularly cardiovascular disease. The one-carbon metabolism in connection with the hypothalamic-pituitary-adrenal (HPA)-axis may be an important mediator of this increased cardiovascular risk.

METHODS

In a mixed-gender sample of 49 PTSD patients and 45 healthy controls we therefore investigated: (1) alterations in the one-carbon metabolism as reflected in fasting plasma concentrations of homocysteine, folate, vitamins B6 and B12, and (2) associations of these one-carbon metabolites with the HPA-axis hormones cortisol, dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S).

RESULTS

After correction for confounders, PTSD patients had significantly elevated homocysteine (z = 2.963, p = .003) compared to controls, but normal levels of folate, vitamin B6 and B12. Comorbid depression did not explain the observed higher homocysteine levels. Patients showed increased risk for moderate hyperhomocysteinemia (OR = 7.0, χ(2) = 7.436, p = .006). Additionally, homocysteine was associated with PTSD severity (z = 2.281, p = .005). Moreover, all HPA-axis hormones were associated with folate in both patients and controls (all p's ≤ .011), while DHEA-S influenced folate in patients (z = 2.089, p = .037).

LIMITATIONS

Our clinical sample is relatively small and therefore small-sized effects may have remained undetected.

CONCLUSIONS

Our study indicates that: (1) the one-carbon metabolism is altered in PTSD patients, (2) earlier findings of higher homocysteine in male PTSD patients are generalized to female patients, (3) homocysteine is negatively associated with PTSD severity, and (4) HPA-axis alterations are associated with the one-carbon metabolism. Longitudinal studies are needed to determine whether elevated homocysteine levels reflect preexisting risk factors and/or consequences of psychological trauma.

Risk of stroke among patients with post-traumatic stress disorder: nationwide longitudinal study

BACKGROUND

Previous evidence has shown positive associations between post-traumatic stress disorder (PTSD) and hypertension, dyslipidaemia and diabetes mellitus, which are all risk factors for stroke, but the role of PTSD in the subsequent development of stroke is still unknown.

AIMS

To investigate the temporal association between PTSD and the development of stroke.

METHOD

Identified from the Taiwan National Health Insurance Research Database, 5217 individuals aged ≥18 years, with PTSD but with no history of stroke, and 20 868 age- and gender-matched controls were enrolled between 2002 and 2009, and followed up until the end of 2011 to identify the development of stroke.

RESULTS

Individuals with PTSD had an increased risk of developing any stroke (hazard ratio (HR) 3.37, 95% CI 2.44-4.67) and ischaemic stroke (HR = 3.47, 95% CI 2.23-5.39) after adjusting for demographic data and medical comorbidities. Sensitivity tests showed consistent findings (any stroke HR = 3.02, 95% CI 2.13-4.28; ischaemic stroke HR = 2.89, 95% CI 1.79-4.66) after excluding the first year of observation.

CONCLUSIONS

Individuals with PTSD have an increased risk of developing any stroke and ischaemic stroke. Further studies are required to investigate the underlying mechanisms.

Sex-dependent effects of chronic psychosocial stress on myocardial sensitivity to ischemic injury

Individuals with post-traumatic stress disorder (PTSD) experience many debilitating symptoms, including intrusive memories, persistent anxiety and avoidance of trauma-related cues. PTSD also results in numerous physiological complications, including increased risk for cardiovascular disease (CVD). However, characterization of PTSD-induced cardiovascular alterations is lacking, especially in preclinical models of the disorder. Thus, we examined the impact of a psychosocial predator-based animal model of PTSD on myocardial sensitivity to ischemic injury. Male and female Sprague-Dawley rats were exposed to psychosocial stress or control conditions for 31 days. Stressed rats were given two cat exposures, separated by a period of 10 days, and were subjected to daily social instability throughout the paradigm. Control rats were handled daily for the duration of the experiment. Rats were tested on the elevated plus maze (EPM) on day 32, and hearts were isolated on day 33 and subjected to 20 min ischemia and 2 h reperfusion on a Langendorff isolated heart system. Stressed male and female rats gained less body weight relative to controls, but only stressed males exhibited increased anxiety on the EPM. Male, but not female, rats exposed to psychosocial stress exhibited significantly larger infarcts and attenuated post-ischemic recovery of contractile function compared to controls. Our data demonstrate that predator stress combined with daily social instability sex-dependently increases myocardial sensitivity to ischemic injury. Thus, this manipulation may be useful for studying potential mechanisms underlying cardiovascular alterations in PTSD, as well as sex differences in the cardiovascular stress response.

Posttraumatic stress disorder, combat exposure, and carotid intima-media thickness in male twins

Posttraumatic stress disorder (PTSD) is associated with an increased risk of ischemic heart disease, though the pathophysiologic mechanisms remain unclear. Carotid artery intima-media thickness (CIMT) is a measure of subclinical atherosclerosis. We examined whether PTSD and combat exposure were associated with CIMT in Vietnam War-era twins after controlling for shared genetic and childhood factors. Between 2002 and 2010, we studied 465 middle-aged twins from the Vietnam Era Twin Registry who were free from cardiovascular disease. PTSD was diagnosed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and CIMT was measured by ultrasound. Mixed-effects regression models were used to examine individual, between-pair, and within-pair associations. Approximately 13% of participants met the criteria for PTSD, and 45% served in the Vietnam Theater. PTSD was associated with 32.7 μm higher CIMT (95% confidence interval (CI): 0.9, 64.5) after adjustment for confounders. The average CIMT for the pair increased by 59.7 μm for each additional twin with PTSD (95% CI: 15.9, 104.2). We found no significant within-pair differences in CIMT when comparing PTSD-discordant co-twins. Results for combat exposure were similar, but its association with CIMT weakened after adjustment for PTSD (95% CI: 7.0, 45.3). Among Vietnam War-era veterans, combat exposure and PTSD are associated with CIMT, though the associations are largely mediated by shared childhood factors.

Screening for post-traumatic stress disorder after injury in the pediatric emergency department--a systematic review protocol

BACKGROUND

Pediatric injury is highly prevalent and has significant impact both physically and emotionally. The majority of pediatric injuries are treated in emergency departments (EDs), where treatment of physical injuries is the main focus. In addition to physical trauma, children often experience significant psychological trauma, and the development of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) is common. The consequences of failing to recognize and treat children with ASD and PTSD are significant and extend into adulthood. Currently, screening guidelines to identify children at risk for developing these stress disorders are not evident in the pediatric emergency setting. The goal of this systematic review is to summarize evidence on the psychometric properties, diagnostic accuracy, and clinical utility of screening tools that identify or predict PTSD secondary to physical injury in children. Specific research objectives are to: (1) identify, describe, and critically evaluate instruments available to screen for PTSD in children; (2) review and synthesize the test-performance characteristics of these tools; and (3) describe the clinical utility of these tools with focus on ED suitability.

METHODS

Computerized databases including MEDLINE, EMBASE, CINAHL, ISI Web of Science and PsycINFO will be searched in addition to conference proceedings, textbooks, and contact with experts. Search terms will include MeSH headings (post-traumatic stress or acute stress), (pediatric or children) and diagnosis. All articles will be screened by title/abstract and articles identified as potentially relevant will be retrieved in full text and assessed by two independent reviewers. Quality assessment will be determined using the QUADAS-2 tool. Screening tool characteristics, including type of instrument, number of items, administration time and training administrators level, will be extracted as well as gold standard diagnostic reference properties and any quantitative diagnostic data (specificity, positive and negative likelihood/odds ratios) where appropriate.

DISCUSSION

Identifying screening tools to recognize children at risk of developing stress disorders following trauma is essential in guiding early treatment and minimizing long-term sequelae of childhood stress disorders. This review aims to identify such screening tools in efforts to improve routine stress disorder screening in the pediatric ED setting.

TRIALS REGISTRATION

PROSPERO registration: CRD42013004893.

Posttraumatic stress disorder and risk for coronary heart disease: a meta-analytic review

OBJECTIVE

The aim of this study was to estimate the association of posttraumatic stress disorder (PTSD) with risk for incident coronary heart disease (CHD).

DESIGN

A systematic review and meta-analysis were used as study designs.

DATA SOURCES

Articles were identified by searching Ovid MEDLINE, PsycINFO, Scopus, Cochrane Library, PILOTS database, and PubMed Related Articles and through a manual search of reference lists (1948-present).

STUDY SELECTION

All studies that assessed PTSD in participants initially free of CHD and subsequently assessed CHD/cardiac-specific mortality were included.

DATA EXTRACTION

Two investigators independently extracted estimates of the association of PTSD with CHD, as well as study characteristics. Odds ratios were converted to hazard ratios (HRs), and a random-effects model was used to pool results. A secondary analysis including only studies that reported estimates adjusted for depression was conducted.

RESULTS

Six studies met our inclusion criteria (N = 402,274); 5 of these included depression as a covariate. The pooled HR for the magnitude of the relationship between PTSD and CHD was 1.55 (95% CI 1.34-1.79) before adjustment for depression. The pooled HR estimate for the 5 depression-adjusted estimates (N = 362,950) was 1.27 (95% CI 1.08-1.49).

CONCLUSION

Posttraumatic stress disorder is independently associated with increased risk for incident CHD, even after adjusting for depression and other covariates. It is common in both military veterans and civilian trauma survivors, and these results suggest that it may be a modifiable risk factor for CHD. Future research should identify the mechanisms of this association and determine whether PTSD treatment offsets CHD risk.

Association between posttraumatic stress disorder and inflammation: a twin study

The association of posttraumatic stress disorder (PTSD) with cardiovascular disease risk may be mediated by inflammation. Our objective was to examine the association between PTSD and measures of inflammation and to determine whether these associations are due to shared familial or genetic factors. We measured lifetime history of PTSD using the Structured Clinical Interview for DSM-IV in 238 male middle-aged military veteran twin pairs (476 individuals), selected from the Vietnam Era Twins Registry, who were free of cardiovascular disease at baseline. We assessed inflammation using levels of high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6), fibrinogen, white blood cells, vascular cell adhesion molecule-1, and intercellular adhesion molecule-1 (ICAM-1). Geometric mean levels and percent differences by PTSD were obtained from mixed-model linear regression analyses with adjustment for potential confounders. Within-pair analysis was conducted to adjust for shared family environment and genetics (monozygotic pairs). Overall, 12.4% of participants had a lifetime history of PTSD. Adjusted mean levels of hsCRP and ICAM-1 were significantly higher among those with vs. without PTSD [hsCRP: 1.75 vs. 1.31mg/l (33% difference); ICAM-1: 319 vs. 293ng/ml (9% difference)]. Adjustment for depression rendered the association of PTSD with hsCRP non-statistically significant. For IL-6, no consistent association was seen. Within-pair analysis produced associations that were similar in direction for all three markers but lesser in magnitude for hsCRP and IL-6. There was no evidence of interaction by zygosity. Elevated hsCRP and ICAM-1 are associated with PTSD, and these associations may be confounded by shared non-genetic, antecedent familial and environmental factors.

Potentially traumatic events and the risk of six physical health conditions in a population-based sample

BACKGROUND

Potentially traumatic events (PTEs) are common in the population, yet, the impact of total burden and specific types of PTEs on physical health has not been systematically investigated.

METHODS

Data were drawn from the Detroit Neighborhood Health Study, a community sample of predominately African Americans living in Detroit, Michigan, interviewed in 2008-2009 (N = 1,547) and in 2009-2010 (N = 1,054). Kaplan-Meier and Cox proportional hazards models were used.

RESULTS

Respondents with the highest levels of PTE exposure (8+ events) had an average age of adverse physical health condition diagnosis that was 15 years earlier than respondents with no exposure. There was a monotonic relation between number of PTEs and arthritis risk. Compared to those who reported no lifetime events, respondents with 1-2, 3-4, 5-7, and 8+ traumatic events had 1.06, 1.12, 1.73, and 2.44 times the hazard of arthritis. Assaultive violence (HR = 1.7; 95% CI 1.2-2.3) and other threats to physical integrity (HR = 1.5, 95% CI 1.1-2.1) were particularly strong risk factors for arthritis.

CONCLUSIONS

These results provide novel evidence linking PTEs, particularly those involving violence and threat to life, to elevated risk for arthritic conditions. Efforts to prevent or mitigate traumatic event exposures may have a broad range of benefits for health.

Posttraumatic stress disorder and cardiovascular disease

Posttraumatic stress disorder (PTSD) is an anxiety disorder initiated by exposure to a traumatic event and characterized by intrusive thoughts about the event, attempts to avoid reminders of the event, and physiological hyperarousal. In a number of large prospective observational studies, PTSD has been associated with incident cardiovascular disease (CVD) and mortality. Also, in recent years, a number of studies have shown that cardiovascular events can themselves cause PTSD in more than 1 in 8 patients with acute coronary syndrome. Further, a few small studies suggest that PTSD secondary to an acute CVD event then places patients at increased risk for subsequent CVD events and mortality. In this article, we review the evidence for a link between PTSD and CVD, and discuss potential mechanisms for that association as well as future directions for research.

Understanding the neurobiology of fear conditioning and emergence of posttraumatic stress disorder psychobiology: commentary on Blanchard et al

In this article, we discuss the historical evolution of posttraumatic stress disorder (PTSD) after the Vietnam War, with a focus on an article by Blanchard, Kolb, Prins, Gates, and McCoy (J Nerv Ment Dis 179:371-373, 1991) published in this Journal in 1991 entitled Changes in Plasma Norepinephrine to Combat-Related Stimuli Among Vietnam Veterans With Posttraumatic Stress Disorder. In this commentary, we discuss the significance of this brief article and the developments in the PTSD field before, during, and after the Blanchard publication. Within this context, we discuss the eventual recognition in both the clinical and scientific fields that PTSD had a major neurobiological foundation. Finally, we examine the key implication of these discoveries from an epidemiological, a clinical, and a public health perspective.