Post-traumatic stress disorder and cardiometabolic disease: improving causal inference to inform practice

Abstract

Posttraumatic stress disorder (PTSD) has been declared “a life sentence” based on evidence that the disorder leads to a host of physical health problems. Some of the strongest empirical research—in terms of methodology and findings—has shown that PTSD predicts higher risk of cardiometabolic diseases, specifically cardiovascular disease (CVD) and type 2 diabetes (T2D). Despite mounting evidence, PTSD is not currently acknowledged as a risk factor by cardiovascular or endocrinological medicine. This view is unlikely to change absent compelling evidence that PTSD causally contributes to cardiometabolic disease. This review suggests that with developments in methods for epidemiologic research and the rapidly expanding knowledge of the behavioral and biological effects of PTSD the field is poised to provide more definitive answers to questions of causality. First, we discuss methods to improve causal inference using the observational data most often used in studies of PTSD and health, with particular reference to issues of temporality and confounding. Second, we consider recent work linking PTSD with specific behaviors and biological processes, and evaluate whether these may plausibly serve as mechanisms by which PTSD leads to cardiometabolic disease. Third, we evaluate how looking more comprehensively into the PTSD phenotype provides insight into whether specific aspects of PTSD phenomenology are particularly relevant to cardiometabolic disease. Finally, we discuss new areas of research that are feasible and could enhance understanding of the PTSD-cardiometabolic relation, such as testing whether treatment of PTSD can halt or even reverse the cardiometabolic risk factors causally related to CVD and T2D.

Cross-Sectional and Longitudinal Associations of Chronic Posttraumatic Stress Disorder With Inflammatory and Endothelial Function Markers in Women

“…Sixth, for the sake of parsimony, we did not include information on medical conditions like hypertension that might be on the pathway from PTSD to CVD risk biomarkers or occur simultaneously with these elevated biomarker values. However, these conditions are unlikely to be confounders because they are unlikely to cause PTSD(2). Seventh, we note that, overall, biomarker change over the 10–16-year period was modest.…”

Childhood and Adolescent Adversity and Cardiometabolic Outcomes: A Scientific Statement From the American Heart Association

“…Although investigators have examined posttraumatic stress disorder in relation to a range of health outcomes (including rheumatoid arthritis, stroke, heart disease, and cancer), some of the strongest empirical research, in terms of methodology and findings, has been with cardiometabolic diseases. 70,71 Numerous methodologically rigorous prospective population-based observational studies have found that posttraumatic stress disorder is associated with increased risk of incident CVD [72][73][74][75][76][77][78][79][80][81][82][83][84] and T2DM. [85][86][87] However, whether and how much of the relation between childhood adversity and cardiometabolic disease may be explained by posttraumatic stress disorder is unclear, especially because these studies have included traumatic events over the life course, with a substantial proportion of studies focused on veterans and military service-related trauma, not just adversity during childhood.…”

Traumatic Stress and Accelerated Cellular Aging: From Epigenetics to Cardiometabolic Disease

“…This includes heart disease and heart failure [20–23], hypertension [24], stroke and/or myocardial infarction [25, 26], and chronic obstructive pulmonary disease [27]. Based on these associations, we [4] and others [28] have suggested that it may be appropriate to consider PTSD as a risk factor when deciding which patients require early screening for cardiometabolic pathology.…”