Post-9/11 PTSD Among First Responders Linked With Increased Risk of Heart Disease, Stroke
Brian P. Dunleavy
Helaina Hovitz Regal was in middle school in lower Manhattan when 2 planes crashed into the Twin Towers of the World Trade Center on September 11, 2001. In the ensuing chaos, she and her classmates evacuated under orders to cover their mouths to avoid inhaling the soot and smoke that hung in the air, and to avert their eyes from the area that would come to be known as "Ground Zero," so as not to witness the death and destruction.
The family apartment was located just blocks from the site of the attack. It left her rattled, and she was eventually diagnosed with post-traumatic stress disorder (PTSD). The diagnosis was not surprising, but the shocking part of her story is that it took several years for her health care team to agree on it. By then, her PTSD had already begun to take a toll mentally and physically, causing migraine headaches and gastrointestinal (GI) issues.
"In my research, I found that 1 in 2 children in America will have a traumatic experience at some point in their lives," said Hovitz Regal, a freelance journalist who has since written about her experiences in several articles and in a memoir titled After 9/11: One Girl's Journey through Darkness to a New Beginning. "Not all of them will experience something like 9/11, of course, but it's still trauma. And from my own experience, I can tell you that trauma has an effect on your brain and your body."
In the 17 years since the attacks, medicine has only recently come to understand their health implications. A recent study in the journal Circulation: Cardiovascular Quality and Outcomes, a publication of the American Heart Association, highlights that those diagnosed with PTSD, as a result, may be at increased risk for future cardiovascular disease, including myocardial infarction (MI) and stroke.
"There [is] evidence from studies on veterans that PTSD could cause cardiovascular disease," said Alfredo Morabia, MD, PhD, professor, clinical epidemiology, Mailman School of Public Health, Columbia University, in an interview with MD Magazine®. "Since PTSD was so prevalent [in our study], we decided to test the hypothesis in this population. What makes this study unique is that we have a 15-year follow-up of people who were all exposed to the same highly traumatic event at the same time."
The so-called "World Trade Center-Heart" study focuses on a cohort of more than 6400 first responders (nonfirefighter workers and untrained volunteers, 82.8% of whom are men; average age: 51 years) enrolled in the World Trade Center Health Program (WTCHP) in New York City, which is operated under the auspices of the US Centers for Disease Control and Prevention.
Starting in 2012, epidemiologists and physicians working within the WTCHP and affiliated with the City University of New York (CUNY) and the Mailman School of Public Health at Columbia University began baseline assessments for the cohort, recording blood pressure, weight and height, and blood lipids for each of the participants. Study subjects self-reported any diagnosis of PTSD or depression and a history of smoking and dust exposure during the 2001 cleanup. Investigators followed the cohort for a 4-year period.
In all, among this subset of first responders, the prevalence of PTSD was 19.9% in men and 25.9% in women. To compare, among Americans as a whole, according to statistics available from the US Department of Veterans' Affairs, 3.6% of men and 9.7% of women will be diagnosed with the condition during their respective lifetimes. Over the course of the 4-year study period, for those diagnosed with PTSD, Morabia and his colleagues calculated adjusted hazard ratios at 2.22 for MI and 2.51 for stroke; for pooled MI and stroke, adjusted hazard ratios were 2.35 in all and 1.88 in men free of depression. Using hospitalization registry data, the authors calculated adjusted hazard ratios of 2.17 for MI and 3.01 for stroke.
Simply put, this means those first responders on September 11th subsequently diagnosed with PTSD are more than twice as likely to suffer from MI or stroke, both of which are significant health concerns. Interestingly, the authors were not able to identify any correlation between World Trade Center dust exposure and future cardiovascular considerations within this population of first responders.
"Hopefully, [as a result of our findings], medical personnel will be looking for PTSD and when it is present, be ultra-careful that their patients refrain from cardiovascular disease risk factors such as smoking, or obesity, or treat aggressively biologic risk factors such as high blood pressure and high cholesterol," Morabia said. In future work, he and his colleagues hope to obtain a greater understanding of the long-term effects of PTSD on cardiovascular disease risk among the population of first responders. If they have 2.5 times the risk for cardiovascular disease in the short-term, he added, "long-term, when people get into the age categories when cardiovascular disease becomes more common, what will it be?"
Despite the large sample size of the World Trade Center-Heart study, however, Morabia cautions that the findings may not be generalizable to the nearly 90,000 first responders who helped in lower Manhattan following the September 11th attack. And to truly understand the effects of PTSD on cardiovascular health, there must first be an accurate diagnosis of the mental health disorder.
"John," a pseudonym for a 70-year-old now-retired technician for a telecommunications company who performed repair work in lower Manhattan in the weeks after the World Trade Center attack, has not been diagnosed with PTSD, but has suffered myriad health problems since, including pneumonia and chronic obstructive pulmonary disease (COPD), as well as high blood pressure. Enrolled in the WTCHP, he has been told by his health care team that he is at increased risk for cardiovascular disease, likely as a result of his time in lower Manhattan.
Hovitz Regal, meanwhile, is not a first responder. But her PTSD diagnosis, which stems from her experiences on 9/11 and the days and weeks that followed, has forced her to pay greater attention to her overall health in the years since. She is not a clinician but recommends that those who experience trauma seek out specialists with expertise in diagnosing and managing PTSD as a first step to ensuring they receive quality care.
"With PTSD, you have high levels of anxiety, and stress hormone levels spiking," she said. "It affects your sleep and blood pressure, and so many other things. Unfortunately, I'm not surprised at the connection found in [World Trade Center-Heart] study at all. I'm not a doctor, but people I know who had many of the same experiences I had on 9/11 are having similar health problems to what I have had. I think we'll all have to be vigilant, even as time goes on."
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