PSYCHOLOGICAL TRAUMA AND HEART HEALTH IN PTSD AND CVD

PSYCHOLOGICAL TRAUMA AND HEART HEALTH IN PTSD AND CVD

Rohit Gouttam *, A. Sushmitha, B. Sendilkumar, Vinitha Sri. U, G. Rajkumar and M. Gesavardhini

School of Allied Health Sciences, Vinayaka Mission’s Research Foundation-Deemed to be University, Salem, Tamil Nadu, India.

ABSTRACT: Post-traumatic stress disorder (PTSD) affects a significant portion of the global population and can lead to chronic psychiatric complications and other secondary health issues. Among these, cardiovascular disease (CVD) stands out prominently. The relationship between PTSD and CVD is complex and bidirectional, with PTSD increasing the risk of developing CVD and worsening its prognosis. This review explores the physiological, psychological, and behavioral pathways through which PTSD influences cardiovascular health, including dysregulation of the autonomic nervous system, chronic inflammation, and endothelial dysfunction. These mechanisms highlight the profound impact of PTSD on cardiovascular risk factors such as hypertension, dyslipidemia, and metabolic syndrome. Effective management strategies necessitate integrated approaches that address both PTSD symptoms and cardiovascular risk factors, emphasizing early intervention, lifestyle modifications, and psychological therapies. Understanding and managing the PTSD-CVD link is crucial for optimizing care and improving outcomes in affected individuals.

Keywords: Coronary artery disease, Post-traumatic stress disorder, Myocardial infarction, Cardiovascular disease, Psychological trauma

INTRODUCTION: Post traumatic stress disorder (PTSD) prevails in about 3.9% of the world population as reported by the World Health Organisation ¹. Patients usually develop post-traumatic stress disorder depending upon the events they have encountered. About 35-40% of the subjects overcome the effects of the event in less than a year. Although there are treatment options available, a smaller number of people report the condition, its symptoms or seek help or treatment. PTSD under certain conditions, develop to evolve as a chronic illness in some patients and can cause comorbid psychiatric complications and is also inclined towards development of other secondary complications ².

PTSD can affect an individual’s social, personal and professional life. It can diversely affect social interactions and professional performance of the individuals. PTSD disrupts multiple functions biologically including neuro chemistry, immunity, metabolic functions, brain circuits, endocrine and cellular functions. Recent studies convey that each patient experiences and exhibits the symptoms of PTSD differently ³ PTSD is clinically manifested by alterations in mod, cognition, overall behaviour and somatic or auditory experiences that can lead to chronic psychiatric disturbances that may sometimes trigger suicide ².

The symptoms of PTSD manifested by patients are categorised as avoidance symptoms, intrusive symptoms, cognition and mood symptoms and altered physical and emotions reactions ^{4, 5}. PTSD often leads to complications like development of chronic psychiatric conditions, suicidal thoughts and also is a risk factor for other diseases. PTSD involves with the pathophysiology of certain diseases and also affects the quality of treatment given for the conditions. This worsens the mental and physical health of the individual. Among many diseases that are influenced by PTSD, cardiac diseases tend to be one of the majorly affected conditions ⁶. Cardiovascular disease is a collective term that encompasses atherosclerosis, atrial fibrillation, congenital heart disease, coronary heart diseases, thromboembolism, deep vein thrombosis, heart failure and cardiac arrest. PTSD has known to enhance the risk of CVD occurrence and mortality and also increases the incidence of hypertension. We observe that the PTSD serves as an independent risk factor for most cardiac complications ⁷.

PTSD can significantly impact the treatment and management of cardiovascular disease through its effects on adherence, stress levels, lifestyle behaviors, medication interactions, healthcare utilization, and overall recovery processes. Recognizing these challenges is essential for providing effective care to individuals with both PTSD and CVD. The link can be perceived as the interaction between mechanism involved in behaviour and physiology in relation to PTSD ⁸.

Although the relationship between PTSD and CVD is interchangeable, the link eventually affects and worsens both CVD and PTSD, in terms of prognosis, treatment and aftercare. In a study, JAMA psychiatry reported that PTSD has a strong relationship with CVD and PTSD leads to 1.5 – 2-fold increase in risk of developing coronary heart disease ⁹.

It is also revealed that, persistent PTSD in patients diagnosed with CVD, it also worsens the cardiovascular manifestations, treatment outcomes and also increases the risk of mortality. While exact prevalence rates can vary, the consensus from multiple studies supports the notion that PTSD significantly increases the risk of developing cardiovascular disease. The exact magnitude of this risk may depend on factors such as the severity and duration of PTSD symptoms, co-existing health conditions, and access to healthcare. Early detection, intervention, and integrated care models that address both mental health and cardiovascular risk factors are crucial in managing and reducing this risk.

PTSD and CVD- The Link: The association between PTSD and CVD can be understood by categorising the factors as biological, physiological and behavioural pathways. The link between PTSD and CVD is schematically depicted in Fig. 1. The major physiological symptoms include, hypothalamic- pituitary-adrenal axis dysregulation, chronic system inflammation and autonomic nervous system dysregulation while the behavioural factors include, smoking, improper diet and sedentary lifestyle ¹⁰.

FIG. 1: SCHEMATIC REPRESENTATION OF THE PTSD-CVD LINK

The brain-heart axis refers to a complex network that connects various regions of the brain, particularly the frontal and limbic areas involved in emotional processing, to the brainstem and peripheral organs via the autonomic nervous system (ANS). This pathway plays a crucial role in regulating physiological functions such as heart rate, blood pressure, and other cardiovascular responses. In the context of PTSD (Post-Traumatic Stress Disorder), several studies have highlighted alterations in the functioning of the autonomic nervous system and increased levels of systemic inflammation as potential contributors to cardiovascular disease (CVD) risk. These physiological changes are often seen alongside neural alterations in PTSD, which affect regions of the brain involved in emotional regulation, memory processing, and stress responses. Despite these observations, there has been relatively little integration of neural deficits in discussions about the PTSD-CVD link. Neural deficits in PTSD can include structural and functional changes in brain regions crucial for regulating autonomic function and stress responses. These alterations can dysregulate the brain-heart axis, potentially contributing to increased cardiovascular risk in individuals with PTSD. Therefore, understanding the brain-heart axis as a model for exploring the PTSD-CVD relationship offers a promising avenue for research. It underscores the importance of considering both neural and physiological mechanisms in understanding how PTSD impacts cardiovascular health, potentially leading to new insights into prevention and treatment strategies for individuals affected by PTSD ^{11, 12}.

 Mechanism of PTSD and CVD Association: Individuals with PTSD are frequently observed to engage in behaviors that elevate their risk of cardiovascular disease (CVD). The pathways contributing to the development of CVD as a complication of PTSD is illustrated in Fig. 2.

FIG. 2: PATHWAYS INVOLVED IN PTSD-CVD ASSOCIATION

Exposure to traumatic or violent environments often correlates with problematic alcohol use, and individuals may also have higher rates of smoking initiation and relapse after quitting ^{13, 14}. These behaviors are often attempts to self-medicate, providing temporary relief from the arousal and anxiety symptoms associated with PTSD. However, they can complicate efforts to maintain sobriety or quit smoking due to the anxiety and withdrawal symptoms that accompany cessation efforts ¹⁵. In addition to these substance use patterns, individuals with PTSD also tend to experience higher rates of overweight and obesity compared to the general population, despite their relatively younger age. They are more likely to have conditions such as dyslipidemia and diabetes, which are significant contributors to cardiovascular risk ^{10, 16}.

Furthermore, among those who already have CVD, individuals with PTSD often demonstrate lower levels of engagement in physical activity and are more prone to medication nonadherence. This lack of adherence can exacerbate cardiovascular health issues and increase the risk of adverse cardiac events. Sleep disturbances are another hallmark of PTSD, with affected individuals frequently experiencing difficulties falling and staying asleep, as well as nightmares and sleep disordered breathing. These disturbances not only impair overall well-being but also contribute to cardiovascular risk ¹⁷. Psychologically, PTSD is often accompanied by symptoms such as depression, hostility, and easily triggered anger. These emotional states are known to contribute to CVD risk and can potentially trigger cardiac events ¹⁸. Socially, PTSD symptoms like avoidance behaviors can lead to social isolation and reduced levels of social support, which are crucial for maintaining cardiovascular health. Lower levels of social support have been linked to increased CVD risk in various studies ¹⁹. Individuals with PTSD often experience profound physiological changes in response to stress, which can significantly impact their cardiovascular health. Key alterations include heightened heart rate and blood pressure responses, dysregulation of the autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis, and increased sensitivity to stress hormones like glucocorticoids. This dysregulation is characterized by exaggerated sympathetic nervous system (SNS) activity, reduced cardiac vagal control, and impaired baroreflex function ^{18, 20}. The dysregulated SNS activity leads to elevated levels of circulating catecholamines (such as norepinephrine), which play a role in cardiovascular function and regulation. Additionally, individuals with PTSD often exhibit higher levels of inflammatory markers like tumor necrosis factor α and interleukin 1β, and increased platelet reactivity, all of which are associated with cardiovascular risk ^{21, 23}. A critical aspect of the link between PTSD and cardiovascular disease (CVD) lies in endothelial dysfunction. The endothelium, a single layer of cells lining blood vessels, plays a crucial role in maintaining vascular tone and function ²⁴. Endothelial dysfunction occurs when the endothelium fails to properly regulate vasodilation and vasoconstriction in response to various physiological stimuli. This dysfunction is considered an early indicator of CVD risk, preceding clinical manifestations ^{25, 26}.

FIG. 3: FACTORS CONTRIBUTING TO THE PTSD- CVD RELATIONSHIP

Emotional stress, which is pervasive in individuals with PTSD, has been shown to directly impact endothelial function ²⁷. Norepinephrine, a neurotransmitter involved in the stress response, contributes to vasoconstriction. Endothelin-1 (ET-1), another potent vasoconstrictor, is also implicated in stress-triggered cardiovascular events. Both substances are released in response to stress and contribute to endothelial dysfunction, potentially increasing the risk of cardiovascular events ^{28, 29}. Research has demonstrated that acute activation of negative emotions under controlled conditions can lead to endothelial dysfunction in both large coronary vessels and smaller peripheral vessels. This dysfunction can persist for extended periods, further elevating the risk of cardiovascular complications. The combination of chronic stress, dysregulated physiological responses, and endothelial dysfunction in individuals with PTSD creates a milieu that significantly increases the risk of developing cardiovascular disease. Understanding these mechanisms is crucial for developing targeted interventions aimed at mitigating cardiovascular risk in this vulnerable population ^{30, 31}. The factors associated with this intervened complication are depicted in Fig. 3.

Significance of Assessing the Link between PTSD and CVD: PTSD, despite not traditionally being recognized as a major risk factor for cardiovascular disease (CVD), has become more prevalent in recent times due to worsening mental and physical health conditions. PTSD arises from a prolonged maladaptive response following severe psychological trauma, such as personal assaults, disasters, or combat exposure. While PTSD itself isn't classified as an independent CVD risk factor, it shares associations with key CVD risk factors like hypertension, dyslipidemia, and diabetes, as well as adverse outcomes such as heart attacks and heart failure. However, it remains uncertain whether these links are causal or influenced by other factors like depression. At a physiological level, PTSD involves disruptions in neural circuits related to emotional memory and stress response regulation. Brain imaging studies show changes in areas controlling emotions and cognition, correlating with altered behaviors like heightened sensitivity to threat and exaggerated responses to stressful cues. Dysfunctions in the autonomic nervous system and inflammatory responses are proposed as potential mechanisms linking PTSD to increased CVD risks.

Further research utilizing animal models and human tissue biobanks is crucial to understanding how PTSD-related brain changes and inflammation might causally contribute to CVD. Future genome-wide studies may provide insights through Mendelian randomization, helping to clarify the nature and direction of associations between PTSD and CVD outcomes. To advance understanding, comprehensive prospective studies are needed, encompassing diverse populations and rigorously assessing PTSD alongside biological and behavioral CVD risk factors ³⁴.

Approaches for Prevention:

Early Intervention and Treatment for PTSD: Effective early intervention strategies for PTSD can significantly mitigate its long-term impact, particularly in reducing the likelihood of chronic symptoms. Cognitive Behavioral Therapy (CBT), when administered promptly after a traumatic event, has been consistently shown to lower the risk and severity of PTSD. Alongside CBT, providing immediate psychological support following trauma helps individuals process emotions and cope with distress, which can prevent the development of severe PTSD symptoms and associated physiological consequences ³⁵.

Education and Awareness: Education and awareness initiatives play a crucial role in mitigating PTSD-related health risks by facilitating early identification and intervention. Training programs for first responders, healthcare professionals, and the public are essential. They educate on recognizing PTSD symptoms early and implementing appropriate interventions. Public health campaigns are also vital in raising awareness about the potential long-term health effects of PTSD, including cardiovascular disease. Increased awareness encourages individuals to seek support and treatment earlier, improving overall outcomes ³⁶.

Stress Management and Resilience-Building: Stress management and resilience-building strategies are integral to reducing the risk of PTSD and its related health consequences. Practices such as mindfulness and meditation promote relaxation and emotional regulation, potentially lowering the risk of developing PTSD after exposure to trauma. Additionally, resilience training programs teach coping skills and adaptive strategies, enhancing individuals' ability to recover effectively from traumatic experiences and reducing the likelihood of chronic PTSD symptoms ³⁶.

Physical Health Monitoring and Management: Monitoring and managing physical health are critical components of PTSD prevention, particularly in relation to cardiovascular health. Regular cardiovascular risk assessments during health check-ups enable early detection of potential issues exacerbated by PTSD. Promoting healthy lifestyles, including regular exercise, balanced nutrition, adequate sleep, and smoking cessation, is essential in managing cardiovascular risk factors and supporting overall well-being in PTSD survivors ³⁷. Advancements in research and policy are essential for developing effective strategies to prevent PTSD and mitigate its health impacts. Longitudinal studies continue to provide insights into the long-term health outcomes of PTSD survivors, informing preventive measures and treatment approaches. Policy development supporting mental health services and PTSD prevention efforts is crucial in enhancing early intervention capabilities and improving overall health outcomes for at-risk populations.

Approaches for Management:

Psychological Therapies:

Cognitive Behavioral Therapy (CBT): Cognitive Behavioral Therapy (CBT) is a structured, evidence-based psychotherapy aimed at modifying dysfunctional thoughts and behaviors associated with PTSD. In the context of PTSD-induced cardiovascular disease, CBT focuses on addressing maladaptive stress responses, which can contribute to cardiovascular complications. By helping patients identify and challenge negative thought patterns and develop healthier coping mechanisms, CBT not only reduces PTSD symptoms but also potentially improves cardiovascular outcomes. Studies have shown that CBT can lead to reductions in PTSD severity, improvements in overall psychological well-being, and enhanced quality of life for individuals with PTSD and comorbid cardiovascular conditions.

Eye Movement Desensitization and Reprocessing (EMDR): EMDR is a therapeutic approach that involves recalling distressing memories while simultaneously focusing on external stimuli (such as hand movements or sounds). This technique aims to facilitate the reprocessing of traumatic memories, thereby reducing their emotional impact and associated symptoms. In the context of PTSD-induced cardiovascular disease, EMDR has shown effectiveness in reducing PTSD symptoms, including intrusive thoughts and hyperarousal, which can exacerbate cardiovascular stress responses. By addressing underlying trauma, EMDR may contribute to impro ³⁸.

Therapeutic Management:

Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are a class of antidepressant medications commonly prescribed to alleviate symptoms of PTSD, such as anxiety and depression. By enhancing serotonin levels in the brain, SSRIs stabilize mood and reduce psychological distress associated with PTSD. While the primary goal of SSRIs is to manage psychiatric symptoms, their use may indirectly benefit cardiovascular health by promoting emotional stability and reducing physiological stress responses. However, the direct impact of SSRIs on cardiovascular outcomes in individuals with PTSD requires further investigation ³⁹.

Lifestyle Interventions:

Physical Activity: Regular physical activity plays a crucial role in managing both PTSD symptoms and cardiovascular health. Exercise has been shown to reduce symptoms of anxiety and depression, common in PTSD, while also lowering blood pressure, improving lipid profiles, and enhancing cardiovascular fitness. Aerobic exercise, in particular, promotes cardiovascular endurance and resilience, which can mitigate the impact of stress on the cardiovascular system. Incorporating structured exercise routines tailored to individual capabilities and preferences is recommended to maximize therapeutic benefits for both mental and cardiovascular health.

Healthy Diet: A balanced and nutritious diet rich in fruits, vegetables, lean proteins, and omega-3 fatty acids supports overall cardiovascular health and psychological well-being. Dietary interventions can complement other treatment modalities for PTSD-induced cardiovascular disease by addressing metabolic risk factors and promoting systemic health.

For instance, omega-3 fatty acids found in fish and nuts have anti-inflammatory properties that may benefit cardiovascular function and mood regulation. Educating patients on the importance of dietary choices and encouraging healthy eating habits are essential components of comprehensive PTSD management ⁴⁰.

Integrated Care Models:

Collaborative Care: Integrating mental health services with primary care facilitates comprehensive management of PTSD-induced cardiovascular disease. Collaborative care models involve close coordination between psychologists, psychiatrists, cardiologists, and primary care physicians to develop personalized treatment plans addressing both psychiatric symptoms and cardiovascular risk factors. This holistic approach ensures that patients receive timely interventions, monitoring, and support across multiple domains of health. By addressing the complex interplay between mental and physical health, collaborative care models aim to optimize therapeutic outcomes and enhance overall well-being.

Team-Based Approach: A team-based approach to PTSD-induced cardiovascular disease management leverages the expertise of multidisciplinary healthcare professionals. This includes specialists in psychology, psychiatry, cardiology, nursing, and social work, who collaborate to deliver comprehensive, patient-centered care. Each team member contributes unique perspectives and interventions tailored to the specific needs and preferences of the individual. By fostering interdisciplinary communication and shared decision-making, team-based care promotes continuity of care and enhances treatment adherence. This approach recognizes the interconnected nature of PTSD and cardiovascular disease, addressing both acute symptoms and long-term health outcomes.

Behavioral Interventions:

Stress Management Techniques: Effective stress management is essential for mitigating cardiovascular risk factors exacerbated by PTSD. Techniques such as mindfulness-based stress reduction (MBSR), relaxation training, and biofeedback help individuals cultivate awareness and resilience in response to stressors.

By promoting relaxation and reducing physiological arousal, these interventions support cardiovascular health and psychological well-being. Integrating stress management techniques into daily routines empowers patients to proactively manage symptoms and enhance adaptive coping strategies, thereby reducing the impact of chronic stress on cardiovascular function.

Sleep Hygiene: Addressing sleep disturbances associated with PTSD is critical for optimizing cardiovascular health. Behavioral interventions for sleep hygiene focus on promoting regular sleep patterns, creating a conducive sleep environment, and adopting relaxation techniques before bedtime. Cognitive behavioral interventions for insomnia (CBT-I) may be particularly beneficial, offering structured approaches to improve sleep quality and duration. Adequate sleep facilitates physiological restoration, regulates stress hormones, and enhances cardiovascular resilience. By addressing sleep disturbances, clinicians can mitigate the adverse effects of sleep deprivation on cardiovascular function and overall health outcomes ⁴¹.

CONCLUSION: Conclusively, this article underscores a significant correlation between PTSD and CVD, elucidating the intricate mechanisms at play. This linkage manifests through chronic stress-induced dysregulation of neuroendocrine and immune systems, fostering inflammation, endothelial dysfunction, and metabolic abnormalities all precursors to CVD.

The clinical implications are profound, necessitating heightened vigilance in screening PTSD patients for cardiovascular risk factors and early signs of disease. Integrative management strategies should encompass both psychological interventions to mitigate trauma-related stress and comprehensive cardiovascular risk reduction measures. By addressing PTSD not only as a mental health concern but also as a potential driver of cardiovascular morbidity, healthcare providers can strive for holistic care that improves both mental well-being and cardiovascular outcomes.

ACKNOWLEDGEMENTS: Nil

CONFLICTS OF INTEREST: Nil

REFERENCES:

1. Kessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet EJ and Cardoso G: Trauma and PTSD in the WHO World Mental Health Surveys. Eur J Psychotraumatol 2017; 8(5): 1353383.
2. Mann SK, Marwaha R and Torrico TJ: Posttraumatic Stress Disorder.  StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2024, StatPearls Publishing LLC.; 2024.
3. Yehuda R, Hoge CW, McFarlane AC, Vermetten E, Lanius RA and Nievergelt CM: Post-traumatic stress disorder. Nat Rev Dis Primers 2015; 1: 15057.
4. Du J, Diao H, Zhou X, Zhang C, Chen Y and Gao Y: Post-traumatic stress disorder: a psychiatric disorder requiring urgent attention. Med Rev (2021). 2022; 2(3): 219-43.
5. Bryant RA: Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry 2019; 18(3): 259-69.
6. Coughlin SS: Post-traumatic Stress Disorder and Cardiovascular Disease. Open Cardiovasc Med J 2011; 5: 164-70.
7. Burg MM and Soufer R: Post-traumatic Stress Disorder and Cardiovascular Disease. Current Cardiology Reports 2016; 18(10): 94.
8. Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA and Neria Y: Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS One 2012; 7(6): 38915.
9. Shah AJ, Veledar E, Hong Y, Bremner JD and Vaccarino V: Depression and history of attempted suicide as risk factors for heart disease mortality in young individuals. Arch Gen Psychiatry 2011; 68(11): 1135-42.
10. Cohen BE, Marmar C, Ren L, Bertenthal D and Seal KH: Association of cardiovascular risk factors with mental health diagnoses in iraq and afghanistan war veterans using va health care. JAMA 2009; 302(5): 489-92.
11. Seligowski AV, Webber TK, Marvar PJ, Ressler KJ and Philip NS: Involvement of the brain-heart axis in the link between PTSD and cardiovascular disease. Depress Anxiety 2022; 39(10-11): 663-74.
12. Noble NC, Merker JB, Webber TK, Ressler KJ and Seligowski AV: PTSD and depression severity are associated with cardiovascular disease symptoms in trauma-exposed women. European Journal of Psychotraumatology 2023; 14(2): 2234810.
13. Calhoun PS, Elter JR, Jones ER, Kudler H and Straits-Tröster K: Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan. JCP 2008; 69(11): 1686-93.
14. Smith B, Ryan M, Wingard D, Patterson T, Slymen D and Macera C: Cigarette smoking and military deployment: a prospective evaluation. American Journal of Preventive Medicine 2008; 35: 539-46.
15. Dedert EA, Calhoun PS, Harper LA, Dutton CE, McClernon FJ and Beckham JC: Smoking withdrawal in smokers with and without posttraumatic stress disorder. Nicotine & Tobacco Research 2011; 14(3): 372-6.
16. Barber J, Bayer L, Pietrzak RH and Sanders KA: Assessment of rates of overweight and obesity and symptoms of posttraumatic stress disorder and depression in a sample of operation enduring freedom/operation iraqi freedom veterans. Military Medicine 2011; 176(2): 151-5.
17. Maker MJ, Rego SA and Asnis GM: Sleep Disturbances in Patients with Post-Traumatic Stress Disorder. CNS Drugs 2006; 20(7): 567-90.
18. Rozanski A, Blumenthal JA, Davidson KW, Saab PG and Kubzansky L: The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: The emerging field of behavioral cardiology. J of the American College of Cardiology 2005; 45(5): 637-51.
19. Beckham JC, Vrana SR, Barefoot JC, Feldman ME, Fairbank J and Moore SD: Magnitude and duration of cardiovascular responses to anger in Vietnam veterans with and without posttraumatic stress disorder. J Consult Clin Psychol 2002; 70(1): 228-34.
20. Yehuda R: Advances in Understanding Neuroendocrine Alterations in PTSD and Their Therapeutic Implications. Annals of the New York Academy of Sciences 2006; 1071(1): 137-66.
21. Krystal JH and Neumeister A: Noradrenergic and serotonergic mechanisms in the neurobiology of posttraumatic stress disorder and resilience. Brain Research 2009; 1293: 13-23.
22. von Känel R, Begré S, Abbas CC, Saner H, Gander ML and Schmid JP: Inflammatory Biomarkers in Patients with Posttraumatic Stress Disorder Caused by Myocardial Infarction and the Role of Depressive Symptoms. Neuroimmunomodulation 2009; 17(1): 39-46.
23. von Känel R, Hepp U, Kraemer B, Traber R, Keel M and Mica L: Evidence for low-grade systemic proinflammatory activity in patients with posttraumatic stress disorder. Journal of Psychiatric Research 2007; 41(9): 744-52.
24. Furchgott RF and Zawadzki JV: The obligatory role of endothelial cells in the relaxation of arterial smooth muscle by acetylcholine. Nature 1980; 288(5789): 373-6.
25. Vidović A, Grubišić-Ilić M, Kozarić-Kovačić D, Gotovac K, Rakoš I and Markotić A: Exaggerated platelet reactivity to physiological agonists in war veterans with posttraumatic stress disorder. Psychoneuroendocrinology 2011; 36(2): 161-72.
26. Verma S, Buchanan MR and Anderson TJ: Endothelial Function Testing as a Biomarker of Vascular Disease. Circulation 2003; 108(17): 2054-9.
27. Harris CW, Edwards JL, Baruch A, Riley WA, Pusser BE and Rejeski WJ: Effects of mental stress on brachial artery flow-mediated vasodilation in healthy normal individuals. American Heart Journal 2000; 139(3): 405-11.
28. Gottdiener JS, Kop WJ, Hausner E, McCeney MK, Herrington D and Krantz DS: Effects of mental stress on flow-mediated brachial arterial dilation and influence of behavioral factors and hypercholesterolemia in subjects without cardiovascular disease. Am J Cardiol 2003; 92(6): 687-91.
29. Wilbert-Lampen U, Nickel T, Leistner D, Güthlin D, Matis T and Völker C: Modified serum profiles of inflammatory and vasoconstrictive factors in patients with emotional stress-induced acute coronary syndrome during world cup soccer 2006. Journal of the American College of Cardiology 2010; 55(7): 637-42.
30. Finucane AM, Dima A, Ferreira N and Halvorsen M: Basic emotion profiles in healthy, chronic pain, depressed and PTSD individuals. Clinical Psychology & Psychotherapy 2012; 19(1): 14-24.
31. Fernandez AB, Soufer R, Collins D, Soufer A, Ranjbaran H and Burg MM: Tendency to angry rumination predicts stress-provoked endothelin-1 increase in patients with coronary artery disease. Psychosomatic Medicine 2010; 72(4).
32. Savioli G, Ceresa IF, Caneva L, Gerosa S and Ricevuti G: Trauma-induced coagulopathy: overview of an emerging medical problem from pathophysiology to outcomes. Medicines [Internet]. 2021; 8(4).
33. Medina de Chazal H, Del Buono MG, Keyser-Marcus L, Ma L, Moeller FG and Berrocal D: Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review. Journal of the American College of Cardiology 2018; 72(16): 1955-71.
34. O'Donnell CJ, Schwartz Longacre L, Cohen BE, Fayad ZA, Gillespie CF and Liberzon I: Posttraumatic Stress Disorder and Cardiovascular Disease: State of the Science, Knowledge Gaps, and Research Opportunities. JAMA Cardiol 2021; 6(10): 1207-16.
35. Dar T, Radfar A, Abohashem S, Pitman RK, Tawakol A and Osborne MT: Psychosocial stress and cardiovascular disease. Current Treatment Options in Cardiovascular Medicine 2019; 21(5): 23.
36. Franklin BA, Rusia A, Haskin-Popp C and Tawney A: Chronic Stress, Exercise and Cardiovascular Disease: Placing the Benefits and Risks of Physical Activity into Perspective. International Journal of Environmental Research and Public Health 2021; 18(18).
37. Chinnaiyan KM: Role of stress management for cardiovascular disease prevention. Current Opinion in Cardiology 2019; 34(5).
38. Hudays A, Gallagher R, Hazazi A, Arishi A and Bahari G: Eye movement desensitization and reprocessing versus cognitive behavior therapy for treating post-traumatic stress disorder: a systematic review and meta-analysis. Inter J of Environ Res and Public Health 2022; 19(24).
39. Williams T, Phillips NJ, Stein DJ and Ipser JC: Pharmacotherapy for post traumatic stress disorder (PTSD). (1469-493X (Electronic).
40. Ozemek C, Tiwari S, Sabbahi A, Carbone S and Lavie CJ: Impact of therapeutic lifestyle changes in resistant hypertension. Progress in Cardiovascular Diseases 2020; 63(1): 4-9.
41. Ravichandran R, Gupta L, Singh M, Nag A, Thomas J and Panjiyar BK: The Interplay Between Sleep Disorders and Cardiovascular Diseases: A Systematic Review. Cureus 2023; 15(9): 45898.
    

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    How to cite this article:

    Gouttam R, Sushmitha A, Sendilkumar B, Sri VU, Rajkumar G and Gesavardhini M: Psychological trauma and heart health in PTSD and CVD. Int J Pharm Sci & Res 2025; 16(7): 1746-54. doi: 10.13040/IJPSR.0975-8232.16(7).1746-54.

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