The Veterans Health Study, conducted by the VA at four ambulatory-care medical clinics in the Boston area in 1993-1995, found that veterans with PTSD (n = 351) screened with the PTSD Checklist-Civilian Version were significantly more likely (p < 0.05) than veterans without PTSD (n = 1455) to complain of angina (OR 2.09, 95% CI 1.64-2.66) and congestive heart failure (OR 1.64, 95% CI 1.03-2.61) but not high blood pressure (OR 1.24, 95% CI 0.98-1.57) or transient ischemic attacks (OR 1.55, 95% CI 0.88-2.70); ORs were adjusted for age and depression. Health status was assessed with the SF-36 self-administered questionnaire (Spiro et al. 2006).

Falger et al. (1992) found that angina was more common in Dutch World War II resistance fighters than in a control group of men of similar age who had not been in the resistance. About half the resistance fighters had PTSD in 1986, and those with it were more likely to complain of angina (31% vs 14%). An analysis of 605 male veterans of World War II and the Korean War with a followup of about 25 years found no increase in hypertension or CHD in relation to PTSD (Schnurr et al. 2000).

Cardiovascular Disease

Two primary studies assessed the effect of having PTSD on cardiovascular disease, one in Vietnam veterans (Boscarino 2005) and one in World War II and Korean War veterans (Kubzansky et al. 2007).

Boscarino (2005) examined the causes of death among male Vietnam Army veterans about 30 years after their military service and 16 years after they had completed a telephone survey to ascertain their health status. The men were included in a national random sample of veterans from the VES. Cardiovascular mortality was increased in the 836 theater veterans with PTSD but not in the 214 era veterans with PTSD (hazard ratio 1.7, 95% CI 1.0-2.7, p = 0.034).

Kubzansky et al. (2007) analyzed data on two cohorts of 1946 male veterans (average age, 60 and 63 years) who were evaluated for PTSD in 1986 and 1990 and followed for 11-15 years for the Normative Aging Study. Two measures were used to screen for PTSD: the Mississippi Scale for Combat-Related PTSD was administered to 1002 men in 1990 and the Keane PTSD scale was administered to 944 men in 1986. The end points included angina, MI, and death from CHD. Although there was a linear relationship between the severity of PTSD and the incidence of cardiovascular events in both cohorts, it lost significance if there was adjustment for potential confounders (including blood pressure and cholesterol) in both cohorts. Thus, for total CHD events, the RR was 1.19 (95% CI 0.98-1.43) in the Mississippi Scale for Combat-Related PTSD cohort and 1.21 (95% CI 0.99-1.48) in the Keane scale cohort. Adjusting for depression as an additional confounder was attempted in both cohorts. In the Mississippi Scale for Combat-Related PTSD cohort, this was done by using the Center for Epidemiological Studies Depression Scale score, but the relationship between PTSD and total CHD events was still not significant (RR 1.21, 95% CI 0.93-1.57), although it did achieve significance in the Keane scale cohort (RR 1.35, 95% CI 1.03-1.78). However, in the latter case, depression was controlled for by using the Symptom Checklist-90 scale, which is not generally regarded as a robust measure of depression. There was no evidence of any effect of PTSD on mortality.

In a secondary study, Boscarino and Chang (1999) examined the electrocardiograms (ECGs) of 4462 randomly selected male Army veterans: 2490 who were deployed to Vietnam and 1972 who were not. The average interval between deployment and the analysis was 17 years. ECGs, medical examinations, and psychiatric evaluations with the DIS (based on DSM-III) were conducted in 1985-1986 at one medical facility. PTSD was present in 54 veterans, anxiety in



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