Stroke hospitalizations, posttraumatic stress disorder, and 9/11‐related dust exposure: Results from the World Trade Center Health Registry

Abstract

Background Few studies have examined the association between disaster‐related factors and stroke by subtype or number. We investigated the association between 9/11‐related posttraumatic stress disorder (PTSD), dust exposure, and stroke subtype as well as recurrent strokes. Methods The study included 29,012 individuals enrolled in the World Trade Center Health Registry. Stroke cases were obtained by matching Registry enrollees to the New York State Department of Health's discharge records for inpatient visits between 2000 and 2016. Cox proportional hazards regression models were performed to examine the association between 9/11‐related risk factors and stroke by subtype. Multinomial logistic regression models were conducted to assess the associations between the same risk factors and the number of stroke hospitalizations. Results Having PTSD significantly increased the risk of developing ischemic and hemorrhagic stroke, with adjusted hazards ratios (AHRs) of 1.64 (95% confidence interval [CI]: 1.28–2.10) and 1.73 (95% CI: 1.10–2.71), respectively. The point estimate for dust cloud exposure, although not significant statistically, suggested an increased risk of ischemic stroke (AHR = 1.20, 95% CI: 0.96–1.50). PTSD was significantly associated with recurrent strokes with an adjusted odds ratio of 1.79 (95% CI: 1.09–2.95). Conclusions PTSD is a risk factor for both ischemic and hemorrhagic stroke and is associated with recurrent strokes. Dust exposure on 9/11 is a possible risk factor for ischemic stroke but not for hemorrhagic stroke, and was not associated with recurrent strokes. Our findings warrant additional research on stroke‐morbidity and mortality associated with 9/11‐related PTSD and dust exposure.

Associations between posttraumatic stress and stroke: A systematic review and meta‐analysis

“…For these reasons, we opted to exclude this study. In total, the search efforts yielded 11 studies, eight of which were cohort studies (Beristianos et al., 2016; Chen et al., 2015; Gaffey et al., 2021; Jordan et al., 2013; Remch et al., 2018; Rosman et al., 2019; Song et al., 2019; S. Yu et al., 2021) and three of which were cross‐sectional studies (Brass & Page, 1996; Spitzer et al., 2009; Tsai & Shen, 2017).…”

“…All but Remch et al. (Remch et al., 2018) used ICD‐9 or ICD‐10 codes for stroke case ascertainment (Beristianos et al., 2016; Chen et al., 2015; Gaffey et al., 2021; Jordan et al., 2013; Rosman et al., 2019; Song et al., 2019; S. Yu et al., 2021). Five studies specified stroke subtype categories, two of which measured both ischemic and hemorrhagic stroke outcomes.…”

“…reported that 51.5% of the total strokes reported in their sample (N = 227) were ischemic strokes (Chen et al., 2015), whereas S. Yu et al. (2021) reported that 77% of 475 total events were ischemic strokes. Two studies only measured ischemic stroke risk (Rosman et al., 2019; Song et al., 2019), whereas one study only measured hemorrhagic stroke risk (Gaffey et al., 2021).…”

“…For example, lifetime PTSD prevalence and incident stroke are higher among women versus men and among Black versus White individuals (Olff, 2017;Tsao et al, 2022). All but one study in the present review (S. Yu et al, 2021) accounted for sex or gender in their models. Rosman et al (2019) reported a significant interaction whereby the association between PTSD and stroke was stronger among men compared with women.…”

The World Trade Center Health Program: Twenty years of health effects research

“…In this issue, Yu et al (2021) examine the relationship between PTSD, dust exposure, and stroke in nearly 30,000 persons enrolled in the WTC Health Registry. 55 In dose–response models they found that 9/11 dust exposures were a possible risk factor for ischemic stroke, but not for hemorrhagic stroke. They also found association between PTSD and ischemic, hemorrhagic, and recurrent strokes.…”