Post-traumatic stress disorder (PTSD) is a prevalent disorder among female veterans in the United States and is linked with an increased risk of having ischemic heart disease, even among relatively young women.

These are the main findings of a study presented in a virtual session as part of the American College of Cardiology World Congress of Cardiology, which ended this week after being shifted to an online format due to the COVID-19 pandemic.

“PTSD is becoming more and more prevalent,” presenter Ramin Ebrahimi, MD, of the Veterans Affairs (VA) Greater Los Angeles Healthcare System and UCLA, told Elsevier’s PracticeUpdate. “In addition, over the past two decades there have been many studies reporting more ischemic heart disease in patients with PTSD. Since PTSD is very prevalent in our veterans, and as cardiovascular disease (CVD) still remains the leading cause of death in the United States, it was important to do this research.”

For this cross-sectional analysis, Dr. Ebrahimi and colleagues used data from the VA Department nationwide corporate data warehouse to identify the 835,197 female veterans who visited any of the VA medical centers between fiscal years 2000 and 2017. The women were identified as having PTSD or ischemic heart disease using International Classification of Disease codes and medical records. Ischemic heart disease was defined as the presence of a diagnosis of coronary artery disease, unstable angina, and/or myocardial infarction.

This study is the largest of its kind exploring the relationship between PTSD and CVD among women. “Women in general have been underrepresented in most cardiovascular research,” said Dr. Ebrahimi. “As it pertains to PTSD and cardiovascular disorders, the data in women are very limited. As a result, our team felt studying this subject in women veterans is an important and timely effort.”

The relationship between PTSD and ischemic heart disease was explored in unadjusted form as well as after adjusting for age, traditional ischemic heart disease risk factors (ie, diabetes, hypertension, hyperlipidemia, and smoking), obesity and chronic kidney disease, female-specific risk factors (ie, gestational diabetes and hypertension and placental syndromes), psychiatric and neuroendocrine disorders, as well as alcohol and illicit drug dependence.

Overall, the women’s average age was 50.4 years and 151,144 (18.1%) had PTSD. Women with PTSD had an increased risk of ischemic heart disease, compared with those who did not have PTSD, with a hazard ratio of 1.20 (95% confidence interval 1.16–1.23; P < .0001). The hazard ratio remained significant even after adjusting for age (1.95, 95% confidence interval 1.89–2.01; P < .0001), ischemic heart disease risk factors (1.59, 95% confidence interval 1.54–1.64; P < .0001), obesity and chronic kidney disease (1.48, 95% confidence interval 1.43–1.53; P < .0001), female specific risk factors (1.48, 95% confidence interval 1.43–1.53; P < .0001) as well as psychiatric/neuroendocrine disorders and alcohol and illicit drug dependence (1.21, 95% confidence interval 1.16–1.25; P < .0001).

Dr. Ebrahimi noted that ischemic heart disease was seen even among women with PTSD who were less than 40 years of age.

“At this time, we do not understand the exact mechanism by which PTSD is associated with increased ischemic heart disease,” he said. “However, many potential mechanisms have been proposed. Some of these include increased levels of the stress hormone cortisol, inflammation, coagulation disorders, endocrine disorders such as thyroid or adrenal disorders that may affect heart rate or blood pressure, or other metabolic factors such as glucose or lipids.”

“Our results may have clinical implications for earlier and more routine screening for ischemic heart disease in women veterans with PTSD and potentially women in general,” concluded Dr. Ebrahimi. “Our team currently is working on better understanding potential mechanisms relating to the increased PTSD-CVD association.”