A Soldier’s Heart: PTSD and Cardiac Disease

As you will read in Dr. Jain’s article, below, there is a correlation between heart disease, eating disorders, food addiction and PTSD. Please join Dr. Jain at The Commonwealth Club on September 24th to learn more. https://www.commonwealthclub.org/events/2019-09-24/unspeakable-mind-stories-trauma-and-healing-frontlines-ptsd-science


He was too old. Not old in years…but in other ways he was old, old from too much life, old from seeing too much, old from knowing too much. He was tired and broken, walking with a cane and passing blood, and he knew it wouldn’t be long for him.

—Gary Paulsen, Soldier’s Heart

One crisp fall evening, my patient Richard asked his wife to drive him to the ER of his local VA hospital because he was having palpitations and felt pressure in his chest. Richard was in his 60s, a smoker with high blood pressure, so, as one might expect, the ER staff went straight to work ordering EKGs, chest X-rays, stat blood tests, and an urgent cardiology consult. Richard’s EKG showed atrial fibrillation: instead of a smooth, steady beat, his cardiac rhythm was erratic and his heart muscle was pumping inefficiently. Richard was at risk for having a stroke or his heart failing altogether. The ER staff started him on medication to slow his heart, and Richard was soon feeling better. Buried in the documentation of his pulse rate, blood pressure, oxygen levels, and various tests was a note by the ER attending physician that Richard appeared highly anxious.

I had met Richard for the first time a few weeks before. Tall, with a slim build, save for some extra pounds he carried around his midriff, he was dressed in beige khakis and a blue T shirt. His face was round and pale, and his eyes, framed by designer eyeglasses, were rheumy. After settling into his chair, he drummed his fingers on the wooden arm. Richard was able to admit that he felt entirely out of his comfort zone.

“I’m not really sure I need to be here,” he said with a nervous laugh.

When I asked him to elaborate, he told me how the previous year was, “the worst of my life.” He was experiencing bankruptcy after his small business failed. His wife recently lost her job, which not only worsened their financial predicament but was also causing conflict in their thirty-year marriage.

Unemployed for the first time in his life, Richard found himself lost in memories of Vietnam. More than three decades earlier, after his discharge from the military, he threw himself into a career as an entrepreneur, creating profitable businesses from inspirational ideas. He had spent his life since Vietnam so busy that he managed to avoid thinking about the war. He admitted to spending his life in the office, micromanaging every tiny detail and garnering a reputation in the local community for his angry tirades and tough negotiation tactics. He also admitted, with sheepish bravado, there were years when he drank way too much scotch, chain-smoked cigarettes, and avoided sleep by guzzling strong black coffee.

His life grounded to a halt with the death of his business. If the flood of Vietnam War memories was not enough, Richard was waking up every night in a cold sweat, his sleep ravaged by nightmares. His sex drive plummeted, and he was finding it hard to concentrate. He felt like his body was sucked of energy; he was irritable and “felt jumpy” for no reason. He ended up in the ER on more than one occasion thinking he was having a heart attack, only to be told “it was just anxiety” and discharged home. His worsening finances forced him to transfer his healthcare from his private doctor to a VA internist. When she heard about the ER visits, she immediately referred Richard to a psychologist.

The psychologist diagnosed Richard with PTSD and recommended group therapy, but Richard found himself overwhelmed with anxiety when others shared their stories. “I’m used to being the leader, telling people what to do, not having to listen so much or be told what to do.” His therapist referred Richard to my clinic for a medication evaluation, and I agreed that his symptoms were severe enough that medication was warranted.

Thankfully, Richard needed only a short hospital stay to settle his heart back into a regular rhythm. His hospital team did more tests to try and figure out why his heart suddenly went into atrial fibrillation but could find no obvious culprit other than Richard’s severe anxiety. Many months later, after Richard’s PTSD was stabilized with the use of the medication paroxetine and the sleeping pill trazodone, he revealed to me how on that fall day he had experienced, for the first time in his life, a full-blown flashback of his combat experiences in Vietnam. For hours afterward, he felt petrified, and that was when the palpitations started. The truly chilling thing is that Richard’s untreated PTSD may have flipped his heart into chaos.[i]

***

There is a nuanced relationship between having PTSD and the risk of developing heart disease.[ii] Several landmark studies hint to what goes awry in patients like Richard. His uncontrolled PTSD meant his body’s fight or flight response was constantly being triggered. Surges of noradrenaline gushed through his blood vessels, causing his pulse to race and his blood pressure to go through the roof. Abnormally high levels of noradrenaline alter a person’s blood platelets, the disk-shaped cells that are key players in the formation of blood clots. These abnormal changes, in turn, makes one prone to arterial blood clots that can cause a heart attack or stroke.

Other PTSD-induced changes to Richard’s stress hormones left him prone to gaining weight or developing diabetes—both of which elevate the risk for heart disease even further. Finally, Richard’s PTSD could lead to changes in his body’s immune function and increase levels of inflammatory chemicals in his blood. These increases fuel plaque buildup in the crucial blood vessels of the heart, causing heart disease. While research on immune system function in PTSD remains in early stages, many trauma scientists believe it to be the next critical frontier for PTSD research.

A research team led by Dr. Beth Cohen,[iii] a physician at the University of California at San Francisco, mined big data on over 300,000 veterans from the wars in Afghanistan and Iraq, searching for a correlation between risk factors for heart disease (tobacco use, high blood pressure, high cholesterol levels, being obese, and having diabetes) and PTSD. While the medical establishment was aware of studies with older veterans that told of an unhealthy correlation between PTSD and heart health, Cohen’s study was one of the first to examine the correlation in a younger veteran population. The results, which were published in the Journal of the American Medical Association, were startling. For the men in this study, the odds of them being a smoker, being obese, having high blood pressure, or having high cholesterol increased if they also had PTSD. The average age of participants in the study was just thirty-one.

A similar pattern can be found in civilian populations. A 2014 joint study from Harvard and Columbia[iv] analyzed data from over 50,000 women who were followed over sixteen years and found that the women with PTSD were more prone to becoming overweight or obese. Follow-up studies[v] found that the women with more severe PTSD symptoms had a nearly twofold increased risk of developing diabetes and were more likely to have a heart attack[vi] or stroke compared with the women who did not have PTSD.

Such studies are useful in that they illuminate correlations between PTSD and heart disease, but they do not prove that PTSD causes heart disease. A captivating 2013 prospective twin study published in the Journal of the American College of Cardiology[vii]overcame this limitation. The researchers followed male twins for 13 years (studying twins allows for better control over genetics and environmental factors) and investigated whether the presence of PTSD increased their risk for coronary heart disease. Two hundred eighty-one pairs of twins were selected where one of each pair had a history of PTSD. The researchers looked for whether or not participants had ever had a heart attack, been hospitalized for heart disease problems, or needed to undergo cardiac catheterization. They found that the incidence of heart disease was more than double in the twin with PTSD. The results were further adjusted to account for heart-unhealthy habits, such as being a smoker or not exercising enough, as well as other mental health conditions associated with heart disease, such as depression. By stripping away the other elements that might have explained this finding, they unearthed something stunning: PTSD appears to be an independent risk factor for heart disease.[viii]

As a new generation of scientists pushes for PTSD to be reconceptualized beyond the boundaries of mental illness and instead as a condition that impacts every cell, organ, and system in the human body,[ix] it is becoming harder to dismiss the urgent need to understand how this condition contributes to physical disease and suffering.


[i] Untreated PTSD may have flipped his heart into chaos: Patel, Dimpi, Nathaniel D. Mc Conkey, Ryann Sohaney, Ashley Mc Neil, Andy Jedrzejczyk, and Luciana Armaganijan. 2013. “A Systematic Review of Depression and Anxiety in Patients with Atrial Fibrillation: The Mind-Heart Link.” Cardiovascular Psychiatry and Neurology 2013 (April):159850. https://doi.org/10.1155/2013/159850.

[ii] Relationship between having PTSD and the risk of developing heart disease: Coughlin, Steven S. 2011. “Post-Traumatic Stress Disorder and Cardiovascular Disease.” The Open Cardiovascular Medicine Journal 5 (July):164–70. https://doi.org/10.2174/1874192401105010164.

[iii] A research team led by Dr. Beth Cohen: Cohen, Beth E., Charles Marmar, Li Ren, Daniel Bertenthal, and Karen H. Seal. 2009. “Association of Cardiovascular Risk Factors with Mental Health Diagnoses in Iraq and Afghanistan War Veterans Using VA Health Care.” JAMA 302 (5):489–92. https://doi.org/10.1001/jama.2009.1084.

[iv] 2014 joint study from Harvard and Columbia: Kubzansky, Laura D., Paula Bordelois, Hee Jin Jun, Andrea L. Roberts, Magdalena Cerda, Noah Bluestone, and Karestan C. Koenen. 2014. “The Weight of Traumatic Stress: A Prospective Study of Posttraumatic Stress Disorder Symptoms and Weight Status in Women.” JAMA Psychiatry 71 (1):44–51. https://doi.org/10.1001/jamapsychiatry.2013.2798.

[v] Follow-up studies: Roberts, Andrea L., Jessica C. Agnew-Blais, Donna Spiegelman, Laura D. Kubzansky, Susan M. Mason, Sandro Galea, Frank B. Hu, Janet W. Rich-Edwards, and Karestan C. Koenen. 2015. “Posttraumatic Stress Disorder and Incidence of Type 2 Diabetes Mellitus in a Sample of Women: A 22-Year Longitudinal Study.” JAMA Psychiatry 72 (3):203–10. https://doi.org/10.1001/jamapsychiatry.2014.2632.

[vi] More likely to have a heart attack: Sumner, Jennifer A., Laura D. Kubzansky, Mitchell S. V. Elkind, Andrea L. Roberts, Jessica Agnew-Blais, Qixuan Chen, Magdalena Cerdá, et al. 2015. “Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women.” Circulation 132 (4):251–59. https://doi.org/10.1161/CIRCULATIONAHA.114.014492.

[vii] Prospective twin study: Vaccarino, Viola, Jack Goldberg, Cherie Rooks, Amit J. Shah, Emir Veledar, Tracy L. Faber, John R. Votaw, Christopher W. Forsberg, and J. Douglas Bremner. 2013. “Post-Traumatic Stress Disorder and Incidence of Coronary Heart Disease: A Twin Study.” Journal of the American College of Cardiology 62 (11):970–78. https://doi.org/https://doi.org/10.1016/j.jacc.2013.04.085.

[viii] PTSD appears to be an independent risk factor for heart disease: Edmondson, Donald, and Roland von Känel. 2017. “Post-Traumatic Stress Disorder and Cardiovascular Disease.” The Lancet Psychiatry 4 (4):320–29. https://doi.org/10.1016/S2215-0366(16)30377-7.

More recent research concludes that posttraumatic stress disorder is a risk factor for incident cardiovascular disease as well as a common psychiatric consequence of cardiovascular disease events that might worsen the prognosis of the cardiovascular disease.

[ix] A condition that impacts every cell, organ, and system in the human body: Lohr, James B., Barton W. Palmer, Carolyn A. Eidt, Smitha Aailaboyina, Brent T. Mausbach, Owen M. Wolkowitz, Steven R. Thorp, and Dilip V. Jeste. 2015. “Is Post-Traumatic Stress Disorder Associated with Premature Senescence? A Review of the Literature.” The American Journal of Geriatric Psychiatry : Official Journal of the American Association for Geriatric Psychiatry 23 (7):709–25. https://doi.org/10.1016/j.jagp.2015.04.001.

Russian Roulette: The Perilous Bond between Traumatic Stress and Addiction

 


Author: Shaili Jain, M.D.

Psychiatrist; PTSD Specialist; Medical Director for Integrated Care, VA Palo Alto Healthcare System; Author, The Unspeakable Mind: Stories of Trauma and Healing from the Frontlines of PTSD Science

Learn more about Dr. Jain’s work at https://www.shailijainmd.com

Recent Articles

Just want to learn a little more? Or do you want to take a deep dive?

Mushrooms are in Fashion

Lately, seems like mushrooms have been “a thing” – they have even turned them into crispy snack. Whether you are …

Frittata You Gotta

Egg white frittata with shrimp and scallions Serves 4-8 Ingredients 3 tablespoons olive oil ½ medium onion-sliced thin 2 cloves …

Sports Nutrition

Do these statements sound like “no-brainers”? “Proper nutrition is crucial for athletes to optimize performance for training and competition.” “Athletes …