Editorial
Veterans of Combat
Still at Risk When the Battle Is Over
Rachel Lampert, MD
A
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in a subset of approximately one third, who remained on
active duty (in whom records were thus accessible). Among
the entire cohort, in a model adjusting only for demographic
variables, combat exposure increased the odds of self-reported
cardiovascular disease by 1.8. In the final longitudinal model
adjusting for clinical and psychological variables, the odds
ratio was 1.63. PTSD was associated with CHD in unadjusted
analysis but lost significance after adjustment for depression and anxiety, with which it was moderately associated.
Among the continuing active duty participants, results were
similar, with combat doubling the likelihood of development
of CHD. The addition of PTSD along with other health- and
­behavior-related variables attenuated the magnitude of the
effect of combat, although combat remained highly significantly associated with CHD even after this adjustment. These
data have some limitations, which do not detract from the validity. Less than one third of those invited to participate agreed,
but demographic and military variables were only minimally
different, suggesting that the results are generalizable. Also,
concordance between self-report and r­ecord-diagnosed CHD
was only moderate; however, the 2 types of analyses showed
very similar results. The large size and prospective nature of
the study, as well as longitudinal analyses with control for
appropriate covariates, strongly support the definitive nature
of the results.
The findings raise interesting questions about the pathophysiologic links among combat, PTSD, and cardiovascular disease. This study shows combat experience to be more
important than PTSD. In other studies, however, PTSD prospectively predicted the development of clinical CHD, as well
as perfusion abnormalities, in a rigorous twin-design study of
Vietnam veterans9 and was more predictive of development of
coronary disease than combat alone.10 The truth is likely not
either-or/combat-versus-PTSD, but, rather, is more complex.
The stress of combat has been described from World War I to
the present day, with variations in the technology of combat
but not the psychological impact.11,12 Acutely, psychological
stress increases sympathetic13 and decreases vagal14 activity,
and ongoing stressors have longer-term effects on the body15
through the wear and tear of recurrent sympathetic activation.16 These autonomic changes have, in turn, been linked
with inflammation,17 well known to be associated with the
development of CHD. PTSD perpetuates the physiologic stress
response through reminiscences of the trauma triggered by
external stimuli and has also been associated with ­long-term
autonomic changes.18 For some individuals, the physiologic
damage wrought by the initial stressor may be enough; for
others, the amplification and repetition of this response attributed to PTSD may mediate some of the effects of the initial
combat-related stress, as suggested by the data here showing
pproximately 2.6 million troops have served or are
serving overseas as part of Operation Iraqi Freedom/
Operation New Dawn in Iraq and Operation Enduring Freedom
in Afghanistan, as of September 2013.1 There have been 6664
casualties and 51 904 wounded as of February 2014.2 Although
definitions of combat experience vary, 30% of veterans with
service in Afghanistan and 71% to 86% of those serving in
Iraq have participated in a firefight.3 The rising mental health
problems of returning veterans are well documented,4 with
≤20% of returning veterans meeting diagnostic criteria for
posttraumatic stress disorder (PTSD)5 and up to 17% meeting
criteria for any psychological disorder (depression, anxiety,
or PTSD).3 These mental health problems stem directly from
combat, with a dose-response relationship–the more firefights
the soldiers had experienced, the higher the rate of PTSD and
depression.3
Article see p 1813
However, evidence is emerging for a role of combat in
exerting not just a psychological but also a physiologic toll.
Previous studies of the long-term physical consequences of
combat have shown mixed results. In one prospective longitudinal study enrolling veterans shortly after World War II, those
who had experienced combat were more likely to die or report
physical decline over a 15-year period.6 In the Atherosclerotic
Risk in Communities study, however, no increase in coronary
heart disease (CHD) was seen in combat-exposed veterans
compared with those who had not seen combat or who had not
served in the military.7 Both studies included limited numbers
of combat veterans, however, and in the Atherosclerotic Risk
in Communities study, combat experience had occurred more
than 30 years earlier, in World War II or Korea.
In this issue of Circulation, Crum-Cianflone et al8 use the
Millennium Cohort Study, which enrolled >60 000 military
personnel, including active duty, Reserve, and National Guard
from all branches of the military, starting in 2001, to provide a
definitive answer to the question. All were free of CHD at the
onset of the study. Overall, approximately one quarter of the
troops reported exposure to combat before (N=900) or during
(n≈13 000) the study period. Self-reported CHD was evaluated in all, and record-confirmed diagnoses were evaluated
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Yale University School of Medicine, New Haven, CT.
Correspondence to Rachel Lampert, MD, Yale University School
of Medicine, Cardiology, 789 Howard Ave, Dana 319, New Haven,
CT 06520. E-mail [email protected]
(Circulation. 2014;129:1797-1798.)
© 2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.114.009286
1797
1798 Circulation May 6, 2014
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some attenuation of the combat effect when PTSD is added to
the model.
Differences in the relative importance of combat and
PTSD between this and previous studies10 may also in part
be explained by the fact that those studies examined veterans many years after their active service, when the prolonged
stress of PTSD may be more important than combat years
earlier. Recall bias may also play a role in studies conducted
long after the sentinel time period. Other differences between
returning veterans of the current wars compared with previous wars have also been noted, such as the all-volunteer force
deployed to Iraq and Afghanistan compared with previous
drafts and the type of warfare conducted in the regions.3
The role of health-related behaviors is uncertain. Although
adverse health behaviors such as smoking were more common
with combat exposure in the present study8 and with PTSD in
the Vietnam veterans twins study above,9 in both cases, controlling for these factors did not impact the significance of combat
or PTSD. Although there may be some mediating role, health
behaviors do not appear to be a large part of the explanation.
These data suggest that combat experience should be considered a risk factor for CHD. Although past combat experience
is not modifiable, like family history, presence of this risk factor should draw attention to surveillance and treatment of other,
modifiable, risk factors, such as hypertension, cholesterol, and
smoking. This is particularly important, because both hypertension and hyperlipidemia have been associated with PTSD.19,20
Although PTSD did not explain the entire impact of combat on
cardiovascular risk, it does appear to have at least some mediating role. Several modalities for PTSD treatment have been
shown to reduce symptoms. The most effective of these is prolonged exposure, in which patients relive and confront traumarelated stimuli to extinguish conditioned fear responses.21
Veterans Administration hospitals are required to offer either
this therapy or cognitive processing therapy.21 Whether PTSD
screening and treatment will reduce cardiovascular risk is
unknown, but treatment of other stressors has shown cardiovascular benefits.22 The findings of Crum-Cianflone et al8 emphasize the importance of cardiovascular health as a priority for
returning veterans who are at increased risk.
Disclosures
None.
References
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JAMA. 2005;293:1626–1634. Key Words: Editorials ◼ coronary artery disease ◼ stress, psychological
Veterans of Combat: Still at Risk When the Battle Is Over
Rachel Lampert
Circulation. 2014;129:1797-1798; originally published online March 11, 2014;
doi: 10.1161/CIRCULATIONAHA.114.009286
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