Associations of Initial Injury Severity and Posttraumatic Stress Disorder Diagnoses With Long-Term Hypertension Risk After Combat Injury

Abstract

The associations between injury severity, posttraumatic stress disorder (PTSD), and development of chronic diseases, such as hypertension, among military service members are not understood. We sought to (1) estimate the prevalence and incidence of PTSD within a severely injured military cohort, (2) assess the association between the presence and chronicity of PTSD and hypertension, and (3) determine whether or not initial injury severity score and PTSD are independent risk factors for hypertension. Administrative and clinical databases were used to conduct a retrospective cohort study of 3846 US military casualties injured in the Iraq and Afghanistan conflicts between February 1, 2002, and February 1, 2011. Development of PTSD and hypertension after combat injury were determined using the codes. Multivariable competing risk regression models were used to assess associations between injury severity score, PTSD, and hypertension, while controlling for covariates. Overall prevalence of PTSD was 42.4%, and prevalence of hypertension was 14.3%. Unadjusted risk of hypertension increased significantly with chronicity of PTSD (1-15 diagnoses: hazard ratio, 1.77; 95% confidence interval, 1.46-2.14;<0.001; >15 diagnoses: hazard ratio, 2.29; 95% confidence interval, 1.85-2.84; <0.001) compared with patients never diagnosed with PTSD. The association between injury severity score (hazard ratio, 1.06 per 5-U increment; 95% confidence interval, 1.03-1.10; <0.001) and hypertension was significant, with little change in effect in the multivariable model (hazard ratio, 1.05 per 5-U increment; 95% confidence interval, 1.01-1.09; =0.03). In a cohort of service members injured in combat, we found that chronicity of PTSD diagnoses and injury severity were independent risk factors for hypertension.

The Enduring Health Consequences of Combat Trauma: a Legacy of Chronic Disease

“…Our prior work on this topic has suggested that PTSD and injury severity are independent risk factors for the subsequent development of HTN. 15 However, the present study suggests that may only be true for more severely injured patients.…”

“…[9][10][11][12] However, these associations are complicated by the high prevalence of psychiatric morbidity in critically ill patients, 13,14 which has in turn been correlated with poor longterm outcomes such as cardiovascular disease. 15 The primary limitation of the literature so far is selection bias: patients who become acutely ill are fundamentally different from those that do not. From this lens, combat casualties are a particularly interesting group to study.…”

US Military Service and Racial/Ethnic Differences in Cardiovascular Disease: An Analysis of the 2011-2016 Behavioral Risk Factor Surveillance System

“…For example, military service puts individuals at increased risk of traumatic injury, which has been shown to be associated with higher risk of subsequent CVD 11 and hypertension. 11,20 Increased mental health diagnoses, including depression, anxiety 21 and posttraumatic stress disorder 20,22 within military veterans has also been linked to subsequent CVD risk. Higher prevalence of obesity 23 and smoking behavior 24 have also been linked to higher risk of CVD in military veterans.…”

Not all posttraumatic stress disorder symptoms are equal: fear, dysphoria, and risk of developing hypertension in trauma-exposed women

“…Hypertension is a major modifiable CVD risk factor and a promising intermediary mechanism by which trauma and PTSD may influence CVD risk (Benjamin et al ., 2018). Both trauma and PTSD have been linked to increased hypertension risk across cross-sectional (Cohen et al ., 2009; Granado et al ., 2009; Riley et al ., 2010; Glaesmer et al ., 2011; Pietrzak et al ., 2011; Stein et al ., 2014) and longitudinal studies (Sumner et al ., 2016; Howard et al ., 2018). Additional studies have indicated that individuals with trauma and sub-clinical PTSD symptoms also have elevated hypertension risk compared to individuals without trauma (Pietrzak et al ., 2011; Sumner et al ., 2016).…”