Posttraumatic Stress Disorder Is Associated With Worse Endothelial Function Among Veterans
S. Marlene GrenonChristopher OwensHugh AlleySandra PérezMary A. WhooleyThomas C. NeylanKirstin AschbacherWarren J. GasperJoan F. HiltonBeth E. Cohen
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Background Current research in behavioral cardiology reveals a significant association between posttraumatic stress disorder ( PTSD ) and increased risk for cardiovascular disease and mortality; however, the underlying mechanisms remain poorly understood. We hypothesized that patients with PTSD would exhibit endothelial dysfunction, a potential mechanism involved in the development and progression of cardiovascular disease. Methods and Results A total of 214 outpatients treated at the San Francisco Veterans Affairs Medical Center underwent tests of endothelial function and evaluation for PTSD . Flow‐mediated vasodilation of the brachial artery was performed to assess endothelial function, and current PTSD status was defined by the PTSD Checklist, based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), with a score ≥40. Multivariable linear regression models were used to estimate the association between PTSD status and endothelial function. Patients with PTSD (n=67) were more likely to be male (99% versus 91%, P =0.04) and to have depression (58% versus 8%, P <0.0001) and were less likely to be on an angiotensin‐converting enzyme inhibitor (17% versus 36%, P =0.007) or β‐blocker treatment (25% versus 41%, P =0.03). Univariate analysis demonstrated that patients with PTSD had significantly lower flow‐mediated vasodilation (5.8±3.4% versus 7.5±3.7%; P =0.003); furthermore, lower flow‐mediated vasodilation was associated with increasing age ( P =0.008), decreasing estimated glomerular filtration rate ( P =0.003), hypertension ( P =0.002), aspirin ( P =0.03), and β‐blocker treatments ( P =0.01). In multivariable analysis, PTSD remained independently associated with lower flow‐mediated vasodilation ( P =0.0005). Conclusions After adjusting for demographic, comorbidity, and treatment characteristics, PTSD remained associated with worse endothelial function in an outpatient population. Whether poor endothelial function contributes to the higher risk of cardiovascular disease in patients with PTSD deserves further study.Keywords:
Endothelial Dysfunction
Veterans Affairs
Univariate analysis
Stroke
Ideas and Opinions1 November 2016Chlorthalidone Versus Hydrochlorothiazide: A New Kind of Veterans Affairs Cooperative StudyFrank A. Lederle, MD, William C. Cushman, MD, Ryan E. Ferguson, ScD, MPH, Mary T. Brophy, MD, MPH, and Louis D. Fiore, MD, MPHFrank A. Lederle, MDFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., William C. Cushman, MDFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., Ryan E. Ferguson, ScD, MPHFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., Mary T. Brophy, MD, MPHFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., and Louis D. Fiore, MD, MPHFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M16-1208 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Thiazide-type diuretics, including hydrochlorothiazide and chlorthalidone, have been used to treat hypertension for more than 50 years. The Seventh Report of the Joint Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (1) and the current Veterans Affairs (VA) and Department of Defense guidelines consider them first-line treatment for hypertension. Hydrochlorothiazide is the most commonly used agent, accounting for 95% of thiazide prescriptions in VA patients compared with 2.5% for chlorthalidone (2). However, indirect evidence summarized in a recent network meta-analysis (3) suggests that chlorthalidone may be more effective than hydrochlorothiazide in preventing cardiovascular events. Possible mechanisms for ...References1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-72. [PMID: 12748199] CrossrefMedlineGoogle Scholar2. Ernst ME, Lund BC. Renewed interest in chlorthalidone: evidence from the Veterans Health Administration. J Clin Hypertens (Greenwich). 2010;12:927-34. [PMID: 21122058] doi:10.1111/j.1751-7176.2010.00373.x CrossrefMedlineGoogle Scholar3. Roush GC, Holford TR, Guddati AK. Chlorthalidone compared with hydrochlorothiazide in reducing cardiovascular events: systematic review and network meta-analyses. Hypertension. 2012;59:1110-7. [PMID: 22526259] doi:10.1161/HYPERTENSIONAHA.112.191106 CrossrefMedlineGoogle Scholar4. Ernst ME, Carter BL, Goerdt CJ, Steffensmeier JJ, Phillips BB, Zimmerman MB, et al. Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure. Hypertension. 2006;47:352-8. [PMID: 16432050] CrossrefMedlineGoogle Scholar5. Woodman R, Brown C, Lockette W. Chlorthalidone decreases platelet aggregation and vascular permeability and promotes angiogenesis. Hypertension. 2010;56:463-70. [PMID: 20625077] doi:10.1161/HYPERTENSIONAHA.110.154476 CrossrefMedlineGoogle Scholar6. D'Avolio L, Ferguson R, Goryachev S, Woods P, Sabin T, O'Neil J, et al. Implementation of the Department of Veterans Affairs' first point-of-care clinical trial. J Am Med Inform Assoc. 2012;19:e170-6. [PMID: 22366293] CrossrefMedlineGoogle Scholar7. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-16. [PMID: 26551272] doi:10.1056/NEJMoa1511939 CrossrefMedlineGoogle Scholar8. Hernandez AF, Fleurence RL, Rothman RL. The ADAPTABLE Trial and PCORnet: shining light on a new research paradigm. Ann Intern Med. 2015;163:635-6. [PMID: 26301537]. doi:10.7326/M15-1460 LinkGoogle Scholar9. Pletcher MJ, Lo B, Grady D. Informed consent in randomized quality improvement trials: a critical barrier for learning health systems [Editorial]. JAMA Intern Med. 2014;174:668-70. [PMID: 24615554] doi:10.1001/jamainternmed.2013.13297 CrossrefMedlineGoogle Scholar10. Institute of Medicine. Learning What Works: Infrastructure Required for Comparative Effectiveness Research: Workshop Summary. Washington, DC: National Academies Pr; 2011. Google Scholar Author, Article, and Disclosure InformationAffiliations: From the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts.Grant Support: By the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development (Washington, DC).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1208.Corresponding Author: Frank A. Lederle, MD, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417; e-mail, frank.[email protected]gov.Current Author Addresses: Dr. Lederle: Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417.Dr. Cushman: Memphis Veterans Affairs Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104.Drs. Ferguson, Brophy, and Fiore: Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130.Author Contributions: Conception and design: F.A. Lederle, W.C. Cushman, R.E. Ferguson, M.T. Brophy, L.D. Fiore.Analysis and interpretation of the data: F.A. Lederle.Drafting of the article: F.A. Lederle, R.E. Ferguson.Critical revision of the article for important intellectual content: F.A. Lederle, W.C. Cushman, R.E. Ferguson, M.T. Brophy.Final approval of the article: F.A. Lederle, W.C. Cushman, R.E. Ferguson, M.T. Brophy, L.D. Fiore.Statistical expertise: R.E. Ferguson.Obtaining of funding: F.A. Lederle, R.E. Ferguson, M.T. Brophy, L.D. Fiore.Administrative, technical, or logistic support: R.E. Ferguson, L.D. Fiore.Collection and assembly of data: F.A. Lederle.This article was published at www.annals.org on 16 August 2016. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byComparison of Clinical Outcomes and Safety Associated With Chlorthalidone vs Hydrochlorothiazide in Older Adults With Varying Levels of Kidney FunctionArterial hypertensionRace-Specific Comparisons of Antihypertensive and Metabolic Effects of Hydrochlorothiazide and ChlorthalidoneChlorthalidone versus hydrochlorothiazide: major cardiovascular events, blood pressure, left ventricular mass, and adverse effectsGuideline-Driven Management of HypertensionThe Ecology of Antihypertensives in the United States, 1997–2017KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney DiseasePorous and highly responsive cross-linked β-cyclodextrin based nanomatrices for improvement in drug dissolution and absorptionRandomization and masking – randomization at what unit? Masking of who and what?Chlorthalidone or Hydrochlorothiazide for Treatment of HypertensionHypertension in the Time of the COVID-19 Pandemic: New Issues and Enduring ControversiesComparison of Cardiovascular and Safety Outcomes of Chlorthalidone vs Hydrochlorothiazide to Treat HypertensionReport of the National Heart, Lung, and Blood Institute Working Group on HypertensionThe Present and the Future of Occupational TherapyElectronic Health Record DatabasesWhich thiazide to choose—A "dynamic" question with a mundane answer?Study Designs for Post-Authorization Safety StudiesEvidence for Health Decision Making — Beyond Randomized, Controlled Trials 1 November 2016Volume 165, Issue 9Page: 663-664KeywordsDisclosureDiureticsDrug adherenceDrugsHealth careHealth information technologyHypertensionPatientsRandomized trialsVeteran care ePublished: 16 August 2016 Issue Published: 1 November 2016 PDF downloadLoading ...
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A survey was conducted to evaluate the relationship between Veterans Affairs Healthcare Systems and academic departments of pathology in their respective affiliated schools of medicine. Most (73%) of the responding academic departments were within 5 miles of their Veterans Affairs Healthcare Systems; 60% of Veterans Affairs Healthcare Systems supported 1 to 5 full-time pathologist positions at the Veterans Affairs Healthcare Systems while 70% provided 1 to 5 full-time resident positions; only 34% of academic departments had "without compensation" appointments at the Veterans Affairs Healthcare Systems while 20% had fee-based consulting appointments; 62% of academic departments granted academic appointments to full-time Veterans Affairs Healthcare Systems pathologists while few (26%) had split appointments between the academic department and the Veterans Affairs Healthcare Systems; only half of academic departments granted the same academic privileges to Veterans Affairs Healthcare Systems pathologists as they did to full-time university faculty; 60% of the Veterans Affairs Healthcare Systems pathologists were not involved in recruitment of medical school faculty while 58% of medical school faculty were not involved in recruitment of Veterans Affairs Healthcare Systems pathologists; most academic departments reported no research space at the Veterans Affairs Healthcare Systems (68%) and no Veterans Affairs Healthcare Systems research support (72%); only 23% of academic departments reported a sharing agreement that allows the Veterans Affairs Healthcare Systems to perform clinical work for the academic department while 36% reported an agreement that permits the academic department to perform clinical work for the Veterans Affairs Healthcare Systems; only 32% of academic departments indicated that the Veterans Affairs Healthcare Systems Chief of Pathology and Laboratory Medicine Service is a member of the academic department leadership team. All academic departments reported that the Veterans Affairs Healthcare Systems plays a significant role in education of medical students, residents, and fellows. Strengths and weaknesses of the Veterans Affairs Healthcare Systems/academic department relationships are identified.
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This study uses the most recent national data available from Medicare and the Department of Veterans Affairs to quantify the savings Medicare Part D would achieve if it paid the same prices for prescription drugs currently paid by the Department of Veterans Affairs.
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The authors describe the role the Veterans Affairs (VA) medical system plays as a provider of clinic and hospital services by examining utilization levels and users' characteristics.The Veterans Affairs hospital discharge database, the Veterans Affairs outpatient clinic files, and the veteran population files were used to estimate the number of persons using the Veterans Affairs medical care system in 1994 and the intensity of their clinic and hospital use. Demographic and clinical characteristics of users were tabulated.In 1994, 2.7 million veterans, 10.3% of all US veterans, and approximately 23% of veterans who would have met the statutory eligibility requirements for Veterans Affairs care, used the hospital and/or clinic components of the Veterans Affairs medical system. Sixty-three percent of the system's users were younger than age 65, and 10.5% were women. These 2.7 million veterans had 901,665 Veterans Affairs hospital stays, 15.5 million bed-days, and 31.2 million outpatient visits in fiscal year 1994. The average number of hospitalizations per hospital user was 1.71; the average number of visits per clinic user was 11.7. Medical, surgical, and psychiatric diagnosis-related groups (DRGs) accounted for 56%, 21%, and 23%, respectively, of hospitalizations, but psychiatric diagnosis-related groups accounted for 43% of all inpatient days. Principal medicine clinic visits and psychiatry clinic visits accounted for 21% and 16% of Veterans Affairs ambulatory care.Because the patient population served by the Veterans Affairs system is skewed in a number of ways, its contribution as a provider of health services in the United States varies by gender, age, socioeconomic status, and diagnosis.
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This cohort study examines changes in the use of Veterans Affairs (VA) and non-VA hospitals by VA enrollees and mortality associated with these policies.
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To measure and compare mortality outcomes between dually eligible veterans transported by ambulance to a Veterans Affairs hospital and those transported to a non-Veterans Affairs hospital.
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Chronically ill patients who are not satisfied with their care may change healthcare providers or systems, which could disrupt continuity of care and impede management of their conditions. We examined whether patient satisfaction affected subsequent use of non-Veterans Affairs (VA) services among chronically ill veterans discharged from VA hospitals.The data used in this study came from a multicenter trial of increased access to primary care. We enrolled patients with diabetes, heart failure, and/or chronic obstructive pulmonary disease who were discharged from 1 of 9 VA medical centers. At baseline, we assessed satisfaction using the Patient Satisfaction Questionnaire. VA and non-VA utilization over the subsequent 6 months were assessed using VA and Medicare administrative data, non-VA billing data, and patient interviews. Using multivariable logistic regression analyses, we examined whether baseline patient satisfaction was associated with non-VA inpatient or outpatient utilization during the next 6 months. We conducted the same analysis for Medicare-eligible veterans, a group with better access to non-VA care.Of 1375 study patients, 174 (13%) used non-VA healthcare. Patients with non-VA utilization were older and lived farther from a VA. The odds of non-VA use decreased by 11% as satisfaction increased (odds ratio 0.89; 95% confidence interval 0.83-0.97; P = 0.005). This relationship was strongest among Medicare-eligible veterans (odds ratio 0.85; 95% confidence interval 0.77-0.93; P = 0.001).Dissatisfied veterans discharged from the hospital were more likely to go outside VA for care. Thus, improvements in patient satisfaction may lead to improvements in continuity of care.
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Recently, the Centers for Medicare and Medicaid (CMS) announced the inclusion of
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