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Original Investigation
March 17, 2021

Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans

Author Affiliations
  • 1Department of Medicine, Cardiology Section, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
  • 2Department of Medicine, UCLA (University of California, Los Angeles)
  • 3Department of Medicine, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
  • 4Department of Internal Medicine, University of Utah, Salt Lake City
  • 5Department of Psychiatry, Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 6Department of Psychology, Duke School of Medicine, Durham, North Carolina
  • 7Department of Surgery, Northport Veterans Affairs Medical Center, Northport, New York
  • 8Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
  • 9Department of Psychology, UCLA
JAMA Cardiol. 2021;6(6):642-651. doi:10.1001/jamacardio.2021.0227
Key Points

Question  Is a prior diagnosis of posttraumatic stress disorder (PTSD) associated with incident ischemic heart disease (IHD) in women veterans?

Findings  In this longitudinal cohort study of 398 769 women veterans, including 132 923 with PTSD matched 1:2 to 265 846 without PTSD, those with PTSD had a 44% higher rate of developing incident IHD. Propensity score matching was used to account for various risk factors, including traditional and female-specific cardiovascular risk factors and mental and physical health disorders.

Meaning  These findings suggest that PTSD is associated with an increased risk of developing incident IHD among women veterans.


Importance  Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking.

Objective  To determine whether PTSD is associated with incident IHD in women veterans.

Design, Setting, and Participants  In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020.

Exposures  PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters.

Main Outcomes and Measures  Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes.

Results  A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38).

Conclusions and Relevance  This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.

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