A study of veterans with post-traumatic stress disorder (PTSD) — published in the November 2019 issue of the journal Stroke — found that young and middle-aged veterans with the condition had a 61 percent greater risk of transient ischemic attack (sometimes called a “ministroke”) and a 36 percent greater risk of a regular ischemic stroke than those without PTSD. “Given the evidence from studies of older adults and their elevated exposure to stressful life events, we anticipated that PTSD may be a potentially important risk factor for stroke in young people,” says lead study author, Lindsey Rosman, PhD, assistant professor of medicine in the division of cardiology at the University of North Carolina (UNC) School of Medicine in Chapel Hill. “But we were surprised by the strength of the association compared with other well-known risk factors for stroke.” Dr. Rosman and her team observed that PTSD was a stronger predictor of transient ischemic attack (TIA) than diabetes, sleep apnea, and COPD. PTSD was also more strongly linked to early-onset ischemic stroke compared with lifestyle factors such as smoking, obesity, and drug use. PTSD, however, was a weaker predictor of ischemic stroke than atrial fibrillation, vascular disease, and several other clinical comorbidities. Study authors based results on medical data from 1.1 million veterans who served in Iraq and Afghanistan. Subjects were about 88 percent male, primarily white, with an average age of 30 at the start of the investigation. None had experienced either an ischemic stroke or a ministroke. Over a 13-year period, however, 766 suffered a ministroke and 1,877 had an ischemic stroke.
Differences Between Men and Women
While Rosman and her colleagues did find not any sex differences in PTSD-related risk for TIA, they did discover men with PTSD have a higher risk of having an ischemic stroke event than women. They speculate that the risk difference could be driven by age-related differences in stroke risk. “Since men are more likely to develop stroke at younger ages and the mean age of our sample was relatively young, we may have just captured more strokes in men than in women,” says Rosman. “It’s also possible that the effect of sex on PTSD and other risk markers for stroke changes over time as the population ages.” RELATED: Women and PTSD, the Public Health Problem Nobody Talks About
Why Stress Raises Stroke Risk
Previous research has shown that stress is linked to stroke risk in older adults. It can lead to higher blood pressure and cholesterol levels, as well as increased smoking, overeating, and physical inactivity, according to the American Heart Association. “Psychological stress may lead to the secretion of pro-inflammatory chemicals — cytokines — in the blood stream,” says Rohan Arora, MD, director of the stroke program at Long Island Jewish Forest Hills–Northwell Health in Queens, New York. “These chemicals may cause injury to the walls of the arteries, leading to clogged arteries.” Indirectly, stress is associated with a greater likelihood of smoking, physical inactivity, poor diet, and substance abuse, which may all increase risk for early stroke.
All Young Adults Face Consequences of Severe Stress
Rosman emphasizes that PTSD is not just a veteran issue but a serious public health problem. The patients followed in this study may not only have developed the condition from combat, but from exposure to other stressful or traumatic life events, such as a sexual assault, gun violence in their communities, or deadly and destructive natural disasters. “The daily lifestyle of young people is also filled up with stress,” says Dr. Arora. “This affects young adults beyond the military — daily psychological stress is something that all young people should identify and treat.” Increased awareness is the first step to improving matters among this population, according to study authors. “From a public health perspective, there exists a great opportunity to improve stroke prevention in young adults through the development of targeted screening programs, tailored patient counseling on individual risks, and age-appropriate interventions,” says Rosman. Evidence-based treatments include talk therapy, such as cognitive-processing therapy and prolonged exposure therapy, and medication like selective serotonin reuptake inhibitors (SSRIs). “Patients who are having difficulty adjusting and coping with a traumatic event should seek care for their symptoms,” says Rosman. Arora adds that young adults need to address unhealthy behaviors that can be aggravated by stress. “Cigarette smoking, physical inactivity, and increase in substance and alcohol abuse will all indirectly cause people to be more prone to stroke,” he says. Because the study was limited by focusing strictly on a mostly male veteran population, scientists would like to validate findings in a more diverse, nonveteran population and explore underlying mechanisms between stress and PTSD. “Future studies will need to determine whether early identification of PTSD symptoms and treatment mitigates the risk of early stroke,” says Rosman. “If so, addressing mental health issues, including PTSD, may be an important part of a broader public health initiative to reduce the growing burden of stroke in young people.”
