Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women

doi:10.1161/CIRCULATIONAHA.114.014492

. 2015 Jul 28;132(4):251-9.

doi: 10.1161/CIRCULATIONAHA.114.014492. Epub 2015 Jun 29.

Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women

Affiliations

¹ From Department of Epidemiology, Columbia University Mailman School of Public Health, New York (J.A.S., M.S.V.E., M.C., S.F.S., K.C.K.); Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA (L.D.K., A.L.R., J.A.-B., K.C.K.); Department of Neurology, Columbia College of Physicians and Surgeons, New York (M.S.V.E.); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Q.C.); Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA (K.M.R.); Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.W.R.-E., D.S., E.B.R., K.C.K.); The Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA (J.W.R.-E.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.S.); Department of Nutrition, Harvard School of Public Health, Boston, MA (E.B.R.); and Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.B.R.). js4456@columbia.edu.
² From Department of Epidemiology, Columbia University Mailman School of Public Health, New York (J.A.S., M.S.V.E., M.C., S.F.S., K.C.K.); Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA (L.D.K., A.L.R., J.A.-B., K.C.K.); Department of Neurology, Columbia College of Physicians and Surgeons, New York (M.S.V.E.); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Q.C.); Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA (K.M.R.); Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.W.R.-E., D.S., E.B.R., K.C.K.); The Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA (J.W.R.-E.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.S.); Department of Nutrition, Harvard School of Public Health, Boston, MA (E.B.R.); and Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.B.R.).

PMID: 26124186
PMCID: PMC4519406
DOI: 10.1161/CIRCULATIONAHA.114.014492

Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women

Jennifer A Sumner et al. Circulation. 2015.

. 2015 Jul 28;132(4):251-9.

doi: 10.1161/CIRCULATIONAHA.114.014492. Epub 2015 Jun 29.

Affiliations

¹ From Department of Epidemiology, Columbia University Mailman School of Public Health, New York (J.A.S., M.S.V.E., M.C., S.F.S., K.C.K.); Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA (L.D.K., A.L.R., J.A.-B., K.C.K.); Department of Neurology, Columbia College of Physicians and Surgeons, New York (M.S.V.E.); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Q.C.); Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA (K.M.R.); Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.W.R.-E., D.S., E.B.R., K.C.K.); The Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA (J.W.R.-E.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.S.); Department of Nutrition, Harvard School of Public Health, Boston, MA (E.B.R.); and Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.B.R.). js4456@columbia.edu.
² From Department of Epidemiology, Columbia University Mailman School of Public Health, New York (J.A.S., M.S.V.E., M.C., S.F.S., K.C.K.); Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA (L.D.K., A.L.R., J.A.-B., K.C.K.); Department of Neurology, Columbia College of Physicians and Surgeons, New York (M.S.V.E.); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Q.C.); Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA (K.M.R.); Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.W.R.-E., D.S., E.B.R., K.C.K.); The Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA (J.W.R.-E.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.S.); Department of Nutrition, Harvard School of Public Health, Boston, MA (E.B.R.); and Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.B.R.).

PMID: 26124186
PMCID: PMC4519406
DOI: 10.1161/CIRCULATIONAHA.114.014492

Abstract

Background: Psychological stress is a proposed risk factor for cardiovascular disease (CVD), and posttraumatic stress disorder (PTSD), the sentinel stress-related mental disorder, occurs twice as frequently in women as men. However, whether PTSD contributes to CVD risk in women is not established.

Methods and results: We examined trauma exposure and PTSD symptoms in relation to incident CVD over a 20-year period in 49 978 women in the Nurses' Health Study II. Proportional hazards models estimated hazard ratios and 95% confidence intervals for CVD events confirmed by additional information or medical record review (n=548, including myocardial infarction [n=277] and stroke [n=271]). Trauma exposure and PTSD symptoms were assessed by using the Brief Trauma Questionnaire and a PTSD screen. In comparison with no trauma exposure, endorsing ≥4 PTSD symptoms was associated with increased CVD risk after adjusting for age, family history, and childhood factors (hazard ratio,1.60; 95% confidence interval, 1.20-2.13). Being trauma-exposed and endorsing no PTSD symptoms was associated with elevated CVD risk (hazard ratio, 1.45; 95% confidence interval, 1.15-1.83), although being trauma-exposed and endorsing 1 to 3 PTSD symptoms was not. After adjusting for adult health behaviors and medical risk factors, this pattern of findings was maintained. Health behaviors and medical risk factors accounted for 14% of the trauma/no symptoms-CVD association and 47% of the trauma/4+ symptoms-CVD association.

Conclusion: Trauma exposure and elevated PTSD symptoms may increase the risk of CVD in this population of women. These findings suggest that screening for CVD risk and reducing health risk behaviors in trauma-exposed women may be promising avenues for prevention and intervention.

Keywords: cardiovascular diseases; epidemiology; stress disorders, post-traumatic; women.

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Figures

**Figure 1**
Timeline of variables collected at biennial assessments. CVD=cardiovascular disease. BMI=body mass index. T2D=type 2 diabetes mellitus. HTN=hypertension. HT=hormone therapy. ADM=antidepressant medication. Response rates for the analytic sample are listed for each time point. Trauma/PTSD status was assigned for each year of the study and updated based on reported age of worst trauma (assessed with a supplemental questionnaire in 2008).

**Figure 2**
Flowchart of exclusions for deriving the final analytic sample.

See this image and copyright information in PMC

Comment in

Trauma and Posttraumatic Stress Disorder: Emerging Risk Factors for Cardiovascular Disease in Women?
Lewis TT. Lewis TT. Circulation. 2015 Jul 28;132(4):227-9. doi: 10.1161/CIRCULATIONAHA.115.017432. Epub 2015 Jun 29. Circulation. 2015. PMID: 26124184 No abstract available.
Letter by Durmaz et al Regarding Article, "Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women".
Durmaz O, Kucuk U, Olgun Kucuk H. Durmaz O, et al. Circulation. 2016 Feb 16;133(7):e400. doi: 10.1161/CIRCULATIONAHA.115.019196. Circulation. 2016. PMID: 26884626 No abstract available.
Response to Letter Regarding Article, "Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women".
Sumner JA, Kubzansky LD, Elkind MS, Roberts AL, Agnew-Blais J, Chen Q, Cerdá M, Rexrode KM, Rich-Edwards JW, Spiegelman D, Suglia SF, Rimm EB, Koenen KC. Sumner JA, et al. Circulation. 2016 Feb 16;133(7):e401-2. doi: 10.1161/CIRCULATIONAHA.115.020198. Circulation. 2016. PMID: 26884627 Free PMC article. No abstract available.

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References

1. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors lifestyle risk factors for cardiovascular disease. Circulation. 2008;117:3031–3038. - PubMed
1. Towfighi A, Zheng L, Ovbiagele B. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med. 2009;169:1762–1766. - PubMed
1. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. 2005;45:637–651. - PubMed
1. Rich-Edwards JW, Mason S, Rexrode K, Spiegelman D, Hibert E, Kawachi I, Jun HJ, Wright RJ. Physical and sexual abuse in childhood as predictors of early-onset cardiovascular events in women. Circulation. 2012;126:920–927. - PMC - PubMed
1. Boscarino JA. A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosom Med. 2008;70:668–676. - PMC - PubMed

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[1] Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors lifestyle risk factors for cardiovascular disease. Circulation. 2008;117:3031–3038. - PubMed

[2] Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors lifestyle risk factors for cardiovascular disease. Circulation. 2008;117:3031–3038. - PubMed

[3] Towfighi A, Zheng L, Ovbiagele B. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med. 2009;169:1762–1766. - PubMed

[4] Towfighi A, Zheng L, Ovbiagele B. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med. 2009;169:1762–1766. - PubMed

[5] Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. 2005;45:637–651. - PubMed

[6] Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. 2005;45:637–651. - PubMed

[7] Rich-Edwards JW, Mason S, Rexrode K, Spiegelman D, Hibert E, Kawachi I, Jun HJ, Wright RJ. Physical and sexual abuse in childhood as predictors of early-onset cardiovascular events in women. Circulation. 2012;126:920–927. - PMC - PubMed

[8] Rich-Edwards JW, Mason S, Rexrode K, Spiegelman D, Hibert E, Kawachi I, Jun HJ, Wright RJ. Physical and sexual abuse in childhood as predictors of early-onset cardiovascular events in women. Circulation. 2012;126:920–927. - PMC - PubMed

[9] Boscarino JA. A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosom Med. 2008;70:668–676. - PMC - PubMed

[10] Boscarino JA. A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosom Med. 2008;70:668–676. - PMC - PubMed

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Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women

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Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women

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