Posttraumatic Stress Disorder Is Associated With Worse Endothelial Function Among Veterans

J Am Heart Assoc. 2016 Mar 23;5(3):e003010. doi: 10.1161/JAHA.115.003010.


Background: Current research in behavioral cardiology reveals a significant association between posttraumatic stress disorder (PTSD) and increased risk for cardiovascular disease and mortality; however, the underlying mechanisms remain poorly understood. We hypothesized that patients with PTSD would exhibit endothelial dysfunction, a potential mechanism involved in the development and progression of cardiovascular disease.

Methods and results: A total of 214 outpatients treated at the San Francisco Veterans Affairs Medical Center underwent tests of endothelial function and evaluation for PTSD. Flow-mediated vasodilation of the brachial artery was performed to assess endothelial function, and current PTSD status was defined by the PTSD Checklist, based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), with a score ≥40. Multivariable linear regression models were used to estimate the association between PTSD status and endothelial function. Patients with PTSD (n=67) were more likely to be male (99% versus 91%, P=0.04) and to have depression (58% versus 8%, P<0.0001) and were less likely to be on an angiotensin-converting enzyme inhibitor (17% versus 36%, P=0.007) or β-blocker treatment (25% versus 41%, P=0.03). Univariate analysis demonstrated that patients with PTSD had significantly lower flow-mediated vasodilation (5.8±3.4% versus 7.5±3.7%; P=0.003); furthermore, lower flow-mediated vasodilation was associated with increasing age (P=0.008), decreasing estimated glomerular filtration rate (P=0.003), hypertension (P=0.002), aspirin (P=0.03), and β-blocker treatments (P=0.01). In multivariable analysis, PTSD remained independently associated with lower flow-mediated vasodilation (P=0.0005).

Conclusions: After adjusting for demographic, comorbidity, and treatment characteristics, PTSD remained associated with worse endothelial function in an outpatient population. Whether poor endothelial function contributes to the higher risk of cardiovascular disease in patients with PTSD deserves further study.

Keywords: endothelial dysfunction; endothelial function; mental disorder; posttraumatic stress disorder.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use
  • Age Factors
  • Aged
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Brachial Artery / diagnostic imaging
  • Brachial Artery / physiopathology*
  • Case-Control Studies
  • Checklist
  • Chi-Square Distribution
  • Comorbidity
  • Cross-Sectional Studies
  • Depression / complications
  • Depression / psychology
  • Endothelium, Vascular / diagnostic imaging
  • Endothelium, Vascular / physiopathology*
  • Female
  • Humans
  • Hyperemia / physiopathology
  • Hypertension / complications
  • Hypertension / drug therapy
  • Likelihood Functions
  • Linear Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Outpatients
  • Peripheral Arterial Disease / diagnosis
  • Peripheral Arterial Disease / etiology*
  • Peripheral Arterial Disease / physiopathology
  • Predictive Value of Tests
  • Psychiatric Status Rating Scales
  • Regional Blood Flow
  • Risk Assessment
  • Risk Factors
  • San Francisco
  • Sex Factors
  • Stress Disorders, Post-Traumatic / complications*
  • Stress Disorders, Post-Traumatic / diagnosis
  • Stress Disorders, Post-Traumatic / psychology
  • Ultrasonography, Doppler
  • Vasodilation*
  • Veterans Health*


  • Adrenergic beta-Antagonists
  • Angiotensin-Converting Enzyme Inhibitors