Ian J Stewart1,2, Megan E Amuan3,4, Chen-Pin Wang5, Eamonn Kennedy3,4, Kimbra Kenney6,7, J Kent Werner7, Kathleen F Carlson8, David F Tate3,9, Terri K Pogoda10, Clara E Dismuke-Greer11, W Shea Wright3,9, Elisabeth A Wilde3,9, Mary Jo Pugh3,4. 1. Department of Medicine, Uniformed Services University, Bethesda, Maryland. 2. Military Cardiovascular Outcomes Research Program, Bethesda, Maryland. 3. Informatics, Decision-Enhancement, and Analytic Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah. 4. Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City. 5. University of Texas Health San Antonio, Department of Population Health Sciences, San Antonio. 6. National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland. 7. Department of Neurology, Uniformed Services University, Bethesda, Maryland. 8. VA Portland Health Care System and Oregon Health and Science University, School of Public Health, Portland. 9. Department of Neurology, University of Utah School of Medicine, Salt Lake City. 10. VA Boston Healthcare System, Boston University School of Public Health, Boston, Massachusetts. 11. VA Palo Alto Healthcare System, Health Economics Resource Center, Palo Alto, California.
Abstract
Importance: Traumatic brain injury (TBI) was common among US service members deployed to Iraq and Afghanistan. Although there is some evidence to suggest that TBI increases the risk of cardiovascular disease (CVD), prior reports were predominantly limited to cerebrovascular outcomes. The potential association of TBI with CVD has not been comprehensively examined in post-9/11-era veterans. Objective: To determine the association between TBI and subsequent CVD in post-9/11-era veterans. Design, Setting, and Participants: This was a retrospective cohort study conducted from October 1, 1999, to September 30, 2016. Participants were followed up until December 31, 2018. Included in the study were administrative data from the US Department of Veterans Affairs and the Department of Defense from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium. Participants were excluded if dates did not overlap with the study period. Data analysis was conducted between November 22, 2021, and June 28, 2022. Exposures: History of TBI as measured by diagnosis in health care records. Main Outcomes and Measures: Composite end point of CVD: coronary artery disease, stroke, peripheral artery disease, and cardiovascular death. Results: Of the 2 530 875 veterans from the consortium, after exclusions, a total of 1 559 928 veterans were included in the analysis. A total of 301 169 veterans (19.3%; median [IQR] age, 27 [23-34] years; 265 217 male participants [88.1]) with a TBI history and 1 258 759 veterans (80.7%; median [IQR] age, 29 [24-39] years; 1 012 159 male participants [80.4%]) without a TBI history were included for analysis. Participants were predominately young (1 058 054 [67.8%] <35 years at index date) and male (1 277 376 [81.9%]). Compared with participants without a history of TBI, diagnoses of mild TBI (hazard ratio [HR], 1.62; 95% CI, 1.58-1.66; P < .001), moderate to severe TBI (HR, 2.63; 95% CI, 2.51-2.76; P < .001), and penetrating TBI (HR, 4.60; 95% CI, 4.26-4.96; P < .001) were associated with CVD in adjusted models. In analyses of secondary outcomes, all severities of TBI were associated with the individual components of the composite outcome except penetrating TBI and CVD death. Conclusions and Relevance: Results of this cohort study suggest that US veterans with a TBI history were more likely to develop CVD compared with veterans without a TBI history. Given the relatively young age of the cohort, these results suggest that there may be an increased burden of CVD as these veterans age and develop other CVD risk factors. Future studies are needed to determine if the increased risk associated with TBI is modifiable.
Importance: Traumatic brain injury (TBI) was common among US service members deployed to Iraq and Afghanistan. Although there is some evidence to suggest that TBI increases the risk of cardiovascular disease (CVD), prior reports were predominantly limited to cerebrovascular outcomes. The potential association of TBI with CVD has not been comprehensively examined in post-9/11-era veterans. Objective: To determine the association between TBI and subsequent CVD in post-9/11-era veterans. Design, Setting, and Participants: This was a retrospective cohort study conducted from October 1, 1999, to September 30, 2016. Participants were followed up until December 31, 2018. Included in the study were administrative data from the US Department of Veterans Affairs and the Department of Defense from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium. Participants were excluded if dates did not overlap with the study period. Data analysis was conducted between November 22, 2021, and June 28, 2022. Exposures: History of TBI as measured by diagnosis in health care records. Main Outcomes and Measures: Composite end point of CVD: coronary artery disease, stroke, peripheral artery disease, and cardiovascular death. Results: Of the 2 530 875 veterans from the consortium, after exclusions, a total of 1 559 928 veterans were included in the analysis. A total of 301 169 veterans (19.3%; median [IQR] age, 27 [23-34] years; 265 217 male participants [88.1]) with a TBI history and 1 258 759 veterans (80.7%; median [IQR] age, 29 [24-39] years; 1 012 159 male participants [80.4%]) without a TBI history were included for analysis. Participants were predominately young (1 058 054 [67.8%] <35 years at index date) and male (1 277 376 [81.9%]). Compared with participants without a history of TBI, diagnoses of mild TBI (hazard ratio [HR], 1.62; 95% CI, 1.58-1.66; P < .001), moderate to severe TBI (HR, 2.63; 95% CI, 2.51-2.76; P < .001), and penetrating TBI (HR, 4.60; 95% CI, 4.26-4.96; P < .001) were associated with CVD in adjusted models. In analyses of secondary outcomes, all severities of TBI were associated with the individual components of the composite outcome except penetrating TBI and CVD death. Conclusions and Relevance: Results of this cohort study suggest that US veterans with a TBI history were more likely to develop CVD compared with veterans without a TBI history. Given the relatively young age of the cohort, these results suggest that there may be an increased burden of CVD as these veterans age and develop other CVD risk factors. Future studies are needed to determine if the increased risk associated with TBI is modifiable.
Authors: James F Burke; Jessica L Stulc; Lesli E Skolarus; Erika D Sears; Darin B Zahuranec; Lewis B Morgenstern Journal: Neurology Date: 2013-06-26 Impact factor: 9.910
Authors: Elena Birman-Deych; Amy D Waterman; Yan Yan; David S Nilasena; Martha J Radford; Brian F Gage Journal: Med Care Date: 2005-05 Impact factor: 2.983
Authors: Arleen F Brown; Li-Jung Liang; Stefanie D Vassar; Jose J Escarce; Sharon Stein Merkin; Eric Cheng; Adam Richards; Teresa Seeman; W T Longstreth Journal: Ann Intern Med Date: 2018-03-20 Impact factor: 25.391
Authors: Mary Jo V Pugh; Jean A Orman; Carlos A Jaramillo; Martin C Salinsky; Blessen C Eapen; Alan R Towne; Megan E Amuan; Gustavo Roman; Shane D McNamee; Thomas A Kent; Katharine K McMillan; Hamada Hamid; Jordan H Grafman Journal: J Head Trauma Rehabil Date: 2015 Jan-Feb Impact factor: 2.710
Authors: Lauren E Walker; Jessica Watrous; Eduard Poltavskiy; Jeffrey T Howard; Jud C Janak; Warren B P Pettey; Lee Ann Zarzabal; Alan Sim; Adi Gundlapalli; Ian J Stewart Journal: Brain Behav Date: 2021-03-04 Impact factor: 2.708
Authors: Shih-Wei Liu; Liang-Chung Huang; Wu-Fu Chung; Hsuan-Kan Chang; Jau-Ching Wu; Li-Fu Chen; Yu-Chun Chen; Wen-Cheng Huang; Henrich Cheng; Su-Shun Lo Journal: Int J Environ Res Public Health Date: 2017-02-25 Impact factor: 3.390