Table 1.

Studies of PTSD and Cardiovascular Disease among Veterans and Civilian Populations Exposed to Traumatic Experiences

Study	Sample	Study Design	Results	Limitations	Other Information
Falger et al. (1992)	Male WW II Dutch Resistance veterans (n=147), aged 60-65 years, and age and sex-matched controls with recent hospitalization for MI (n=65) or surgery (n=79).	Clinical interviews of surviving veterans conducted more than 4 decades after the war had ended. PTSD was assessed using structured interviews based on DSM-III.	The Resistance veterans, especially those with PTSD, scored higher than the matched controls on angina pectoris, type A behavior, life stressors, and vital exhaustion. About 10% of the veterans reported having had an MI in the past 15 years. About 56% percent of the veterans were currently suffering from PTSD.	The use of controls with recent MI may have partly obscured associations with cardiovascular risk factors. History of MI was based on self-reported information.	Half of these Resistance veterans had been arrested and incarcerated in Nazi prisons and forced labor and death camps. All were exposed to extraordinary war-time trauma.
Boscarino (1997)	National sample of male Vietnam veterans (n=1,399) who served in the U.S. Army.	In-person interviews conducted about 20 years post combat exposure. Circulatory diseases were assessed retrospectively.	After controlling for age, race, region of birth, enlistment status, volunteer status, Army marital status, Army medical profile, smoking history, substance abuse, education, income, and other factors, lifetime PTSD status was associated with reported circulatory diseases (OR = 1.62, p = .007) and other illnesses after military service. About 63% (n=332 ) had a lifetime history of PTSD.	Self-reported information about disease history was used in the analysis. The response rate was 65%.
Boscarino and Chang (1999)	National sample of male U.S. Army veterans who served in theatre during the Vietnam war (n=2,490) or during the same era (n=1,972).	Medical examinations (conducted about 17 years after combat exposures for Vietnam theatre veterans). Psychiatric evaluations included the Diagnostic Interview Schedule based on DSM-III.	After controlling for age, place of service, illicit drug use, medication use, race, body mass index, alcohol use, cigarette smoking, and education, PTSD was associated with ECG findings including atrioventricular conduction defects (OR =2.81, 95% CI 1.03-7.66, p < 0.05) and infarctions (OR=4.44, 95% CI 1.20-16.43, p < 0.05).	The overall participation rate was 60%. Soldiers who served in theatre may have had greater exposure to toxic chemicals.	The average age of first onset of PTSD was 21 years.
Boscarino (2006)	National sample of male U.S. Army veterans (n=15,288) who served during the Vietnam War era.	Cohort mortality study with16 years of follow-up following completion of a telephone survey (or about 30 years after their military service).	After controlling for race, Army volunteer status, entry age, and discharge status, Army illicit drug abuse, age, and other factors, PTSD among Vietnam theatre veterans was associated with cardiovascular mortality (hazards ratio = 1.7, p = 0.034), all-cause mortality, cancer, and external causes of death.	Adjustment was made for pack-years of cigarette smoking only when looking at cancer mortality.
Boscarino (2008)	National sample of male Vietnam veterans (n=4,328) who served in the U.S. Army. The men were < 65 years of age at follow-up.	Cohort mortality study	PTSD was assessed using two measures include one based on DSM-III. Having more PTSD symptoms was positively associated with early-age heart disease mortality.
Dobie et al. (2004)	Female veterans (n=1,259) who received care at the VA Puget Sound Health Care System between October 1996 and January 1998	Cross-sectional postal survey	Of the eligible women who completed the survey, 21% screened positive for current PTSD (PTSD Checklist-Civilian Version score ≥ 50). A statistically nonsignificant association was observed with myocardial infarction or coronary artery disease (OR = 1.8, 95% CI 0.9-3.6).	Study limitations include the cross-sectional design and the reliance on self-reported information about medical conditions.
Kang et al. (2006)	Former WW II prisoners of war (n=19,442) and non POW controls (n=9,728)	Review of healthcare utilization data for 10 years (1991-2000) from VA and non-VA healthcare providers.	After adjustment for age and race, former POWs with PTSD had statistically significant increased risks of CVD, including ischemic heart disease and hypertension, as compared with both non-POWS and POWs without PTSD. The magnitude of the increased risk of ischemic heart disease was modest.	POWs might be more likely than the study controls to be in VA medical treatment files.
Schnurr et al. (2000)	Male combat veterans of WW II and the Koren conflict (n=605). The average age at study entry was 43.9 years. The majority of the men (98%) were white.	Follow-up study. Medical examinations were performed periodically beginning in 1960. PTSD symptoms were assessed in 1990.	PTSD was assessed using the Mississippi Scale for Combat-Related PTSD. PTSD symptoms were positively associated with the onset of arterial disorders (hazard ratio =1.3, 95% CI 1.2-1.5) after controlling for age, smoking, alcohol consumption, and body mass index. The hazard ratios for hypertensive and ischemic cardiovascular disease were not significantly different than one.	PTSD was not measured at the beginning of the study but rather in 1990 after many of the outcomes had already occurred.
Kubzansky et al. (2007)	Community dwelling men (n=1,002) from the greater Boston, Massachusetts area who were aged 21 to 80 years in 1961. Over 90% of the men are veterans and most were white. Men with preexisting coronary heart disease or diabetes were excluded.	Prospective cohort study.	PTSD was assessed using the Mississippi Scale for Combat-Related PTSD. For each standard deviation increase in PTSD symptom level, the age-adjusted relative risk for nonfatal and fatal myocardial infarction combined was 1.3 (95% CI 1.05-1.5).		The data were from the VA Normative Aging Study.
Kubzansky et al. (2009)	Community dwelling women who participated in the Baltimore cohort of the Epidemiologic Catchment Area Study (n=1,059)	Prospective cohort study that assessed incident coronary heart disease over a 14-year period	Past year trauma and associated PTSD symptoms were assessed using the NIMH Diagnostic Interview Schedule. Women with 5 or more symptoms of PTSD were over three times more likely to develop coronary heart disease than those with no symptoms (age-adjusted OR = 3.2, 95% CI 1.3-8.0). The association persisted after further adjustment was made for coronary risk factors and depression or trait anxiety.
Dirkzwager et al. (2007)	Sample of adult survivors (n=896) of a fire disaster in Enschede, Netherlands that killed 23 persons and destroyed or damaged almost 1,500 houses.	Longitudinal design. Electronic medical records from family practitioners (1 year and 4 years post disaster) were used. Survey data were also collected at 3 weeks and 18 months post disaster to assess PTSD and physical health.	The Self-Rating Scale for PTSD was used to assess the condition. After controlling for demographic factors, smoking, and predisaster physical health, PTSD was positively associated with risk of new vascular problems (OR = 1.9, 95% CI 1.04-3.6).
Spitzer et al. (2009)	Community dwelling adults in Germany (n=3,171)	Cross-sectional survey	PTSD was assessed using the Structured Clinical Interview for DSM-IV. After controlling for demographic factors, smoking, body mass index, blood pressure, depression, and alcohol use disorders, PTSD was positively associated with angina (OR = 2.4, 95% CI 1.3-4.5), heart failure (OR = 3.4, 95% CI 1.9-6.0), and peripheral arterial disease.	Study limitations include the cross-sectional design and the reliance on self-reported information about medical conditions.
Johnson et al. (2010)	Male residents of four U.S. communities (n=5,347)	Population-based study of the prevalence of subclinical atherosclerosis (carotid intima thickness and carotid plaque) measured noninvasively at two study visits (1987-1989 and 1990-1992).	Compared to non-combat veterans, non-veterans and combat veterans had higher age-adjusted mean carotid intima thickness. Differences remained for combat veterans after adjustment for race, father’s education, and age at service entry but not years of service. No differences in carotid plaque were noted.	PTSD was not assessed in this study.	The data were from the Atherosclerosis Risk in Communities (ARIC) Study.