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

Abstract

ABSTRACTImportancePosttraumatic 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.ObjectiveTo 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 participantsUsing 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 (n=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 measuresICD-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.ResultsPTSD 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 relevancePTSD 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.