Browse Subject Areas

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Pilot Investigation of PTSD, Autonomic Reactivity, and Cardiovascular Health in Physically Healthy Combat Veterans

  • Ashley N. Clausen ,

    Affiliations Department of Psychology, University of Tulsa, Tulsa, OK, United States of America, Laureate Institute for Brain Research, Tulsa, OK, United States of America

  • Robin L. Aupperle,

    Affiliations Department of Psychology, University of Tulsa, Tulsa, OK, United States of America, Laureate Institute for Brain Research, Tulsa, OK, United States of America

  • Jason-Flor V. Sisante,

    Affiliation University of Kansas Medical Center, Department of Physical Therapy and Rehabilitation Science, Kansas City, KS, United States of America

  • David R. Wilson,

    Affiliation University of Kansas Medical Center, Department of Physical Therapy and Rehabilitation Science, Kansas City, KS, United States of America

  • Sandra A. Billinger

    Affiliation University of Kansas Medical Center, Department of Physical Therapy and Rehabilitation Science, Kansas City, KS, United States of America

Pilot Investigation of PTSD, Autonomic Reactivity, and Cardiovascular Health in Physically Healthy Combat Veterans

  • Ashley N. Clausen, 
  • Robin L. Aupperle, 
  • Jason-Flor V. Sisante, 
  • David R. Wilson, 
  • Sandra A. Billinger


Posttraumatic stress disorder (PTSD), and combat-related PTSD in particular, has been associated with increased rates of cardiovascular disease, and cardiovascular-related death. However, less research has examined possible factors that may link PTSD to poorer cardiovascular health in combat veteran populations. The current pilot study investigated whether psychological symptomology and autonomic reactivity to emotional scripts would relate to poorer cardiovascular health in combat veterans without a current diagnosis of cardiovascular disease. Male veterans (N = 24), who served in combat since Operation Iraqi Freedom, completed a semi-structured interview and self-report measures to assess psychological symptomology. Autonomic reactivity, measured using heart rate variability (HRV; low to high frequency ratio), was obtained during script-driven imagery of emotional memories. Cardiovascular health was assessed using flow-mediated dilation (FMD) of the brachial artery. Correlational analyses and discriminant analysis were used to assess the relationship between psychological symptoms (PTSD, depression, anger, as measured via self-report), autonomic reactivity to emotional scripts (HRV), and FMD. Overall, veterans in the current study showed poor cardiovascular health despite their relatively young age and lack of behavioral risk factors, with 15/24 exhibiting impaired FMD (FMD < 5%). Psychological symptomology was not associated with FMD; whereas autonomic reactivity to emotional (compared to neutral) scripts was found to relate to FMD. Autonomic reactivity to negative scripts correctly classified 76.5% of veterans as having impaired versus normative FMD. Results from this pilot study highlight the importance of cardiovascular screening with combat veterans despite psychological diagnosis. Results also support the need for longitudinal research assessing the use of autonomic reactivity to emotionally valenced stimuli as a potential risk factor for poorer cardiovascular health.


It is estimated that approximately 90 percent of adults within the United States will experience a traumatic event [1]. Of those, only an estimated eight percent will go on to develop PTSD [2]. However, when compared to the general adult population, veterans who experience combat are over three times more likely to develop PTSD [3, 4], with prevalence estimates of 20–30 percent [35]. Due to the recent conflicts in Iraq and Afghanistan, the prevalence of PTSD for combat-exposed veterans in the United States has doubled from 1997–2005, and continues to rise [6], highlighting the importance of PTSD research in veteran populations. PTSD is characterized by symptoms of re-experiencing, avoidance, as well as hyperarousal and hypervigilance. The latter symptoms involve increased and prolonged emotional and autonomic reactivity (including cardiovascular response) to trauma-related cues [79]. There is evidence that prolonged autonomic reactivity may be associated with increased prevalence of physical health problems such as musculoskeletal disorders, and hypertension [8, 9].

Previous research indicates that combat exposure [10, 11] and PTSD symptoms [1220], as well as comorbid disorders such as depression [21, 22] are associated with a higher risk for developing cardiovascular (CV) disease. Retrospective and cross-sectional research has identified a relationship between combat-related PTSD and CV risk factors including hypertension, and dyslipidemia [23, 24], as well as a diagnosis of CV disease and CV-related death [12, 1416]. Notably, these relationships remain significant when controlling for potential lifestyle factors including smoking status and substance use [13, 17, 25, 26], and other psychological symptoms, such as depression [13, 25]. Thus, similar to findings concerning anxious symptoms and CV health in non-PTSD populations [26], this literature suggests that mechanisms other than conventional risk factors may be responsible for the relationship between PTSD and CV disease. The lifetime prevalence rate for CV disease in the United States is approximately 33 percent [27]. Given the high prevalence rate, it is important to gain a more clear understanding of the factors associated with the development of CV disease.

Most studies investigating the relationship between combat-related PTSD, and CV health have been epidemiological, investigating rates of diagnosed CV disease for those with and without combat exposure and PTSD. The studies that include assessment of CV health have most often relied on resting blood pressure, heart rate (HR), or lipid levels. Flow mediated dilation (FMD) provides unique and potentially predictive information concerning CV health. Specifically, FMD uses Doppler ultrasound to measure the vasodilatory response of an artery after an increase in luminal blood flow (flow within the artery), and is an assessment of endothelial function [28]. FMD is calculated as the peak arterial diameter from the baseline value (percent dilation) when exposed to increased blood flow [29]. Endothelial dysfunction, as measured by FMD, is one indicator of the development of atherosclerotic vascular disease [30]. FMD has been validated with angiography diagnosis of CV disease [31], and has been shown to be predictive of CV events, even after controlling for conventional risk factors [32]. Prior research utilizing FMD suggests that FMD dilation less than five percent is classified as impaired FMD, and is associated with an increased risk for the development of CV disease, whereas FMD dilation of individuals without CV disease is approximately seven percent [33]. In addition, FMD has been used to assess CV health in atherosclerotic vascular disease [34], anxiety disorders [3538], and PTSD within police personnel [39]. While the summation of the current literature suggests a significant relationship between PTSD and CV health, research has yet to explore CV health via FMD in combat veteran populations. Furthermore, potential mechanisms for the development of CV disease in individuals with PTSD remains unclear [40].

Prior research suggests several possible links between PTSD and poorer CV health including dysreguation of the hypothalamic-pituitary-adrenal axis, which impacts corticosteroid release (which in turn influences the immune system, and lipid and glucose metabolism) and autonomic nervous system regulation (which in turn influences CV responses via regulation of heart rate, blood pressure, respiration, etc. [41]). Dysregulation of the vagus nerves, closely associated with autonomic function, has been shown to precede the development of CV disease [27, 4245], making autonomic regulation a prime target for study. Prior research has established that increased sympathetic reactivity to emotional provocation (hyperarousal) is associated with combat-related PTSD and is considered a hallmark symptom of PTSD [16, 4652]. Laboratory studies have objectively quantified this hyperarousal during script-driven imagery, a form of emotional provocation, using measures of sympathetic arousal [46, 4852]. However, measurement of only sympathetic activity limits generalization of findings regarding autonomic reactivity. Heart rate variability (HRV) provides a measure of parasympathetic activity or the sympathetic/parasympathetic balance. Previous studies have reported combat-related PTSD to relate to depressed baseline heart rate variability (HRV) compared to those without PTSD [5356]. However, it has yet to be determined whether autonomic reactivity relates to specific indicators of CV health, such as FMD, in veterans with PTSD.

The current pilot study aimed to explore how psychological symptoms (PTSD, depression), autonomic reactivity (HRV) to emotional events, and combat-exposure may relate to FMD in a veteran sample. A focus on relatively young, and physically healthy combat veterans was to allow for examination of FMD prior to the development of CV disease or other chronic health problems. It was hypothesized that greater PTSD symptoms would relate to more impaired FMD. Further, we hypothesized that increased autonomic reactivity during emotional provocation (specifically, script driven imagery of combat events) would significantly predict impaired FMD (FMD < 5% [33]), above and beyond that of psychological symptoms and combat exposure.

Materials and Methods


Participants included male combat veterans (N = 24; mean age = 32.75, SD = 7.69) who served since the onset of Operation Iraqi Freedom (OIF), with varying levels of PTSD symptomatology (7 diagnosed with full PTSD, 11 with partial PTSD; 6 not meeting PTSD diagnosis; definition of partial PTSD provided below). Exclusion criteria included active suicidal plan or intent, substance abuse within the past six months, schizophrenia or bipolar I disorder (confirmed via the Mini International Neuropsychiatric Inventory [57]), history of moderate to severe head injury (loss of consciousness >30 minutes or post-traumatic amnesia >1day), neurological disorder, CV disease, any medical condition directly affecting CV health, or use of medications within 30 days known to affect CV health. In addition, no participants included in the current study were taking psychotropic medication. Exclusion criteria for the current study were meant to limit possible confounding variables that may influence emotional processing and/or CV health, but to not exclude some of the more common comorbidities associated with PTSD (e.g., mild traumatic brain injury [mTBI], depression, other anxiety disorders).

Participants were recruited via advertisements in the general community (i.e., radio, newspaper, and Facebook) and on local college campuses (i.e., via emails, flyers, etc.), and by providing informational flyers to clinicians at local VA hospitals. This study was approved by the University of Kansas Medical Center and the University of Missouri—Kansas City Institutional Review Boards. All participants provided written, signed consent.


The current study procedures described below were conducted across two study visits. During the first visit, participants completed a clinical assessment to assess symptoms of PTSD (described below). Participants were asked to return for a second study visit within six months (ranging from one week to six months) to complete the remainder of the clinical assessment, assessment of CV health, and the script-driven imagery task (described below). During the second study visit, participants completed the assessments in the following order: assessment of CV health, script-driven imagery task, and clinical assessment (i.e., self-reported questionnaires). Assessment of CV health was always conducted prior to script-driven imagery to minimize subject burden due to fasting, as well as to minimize potential carry-over effects of emotional responses to script-driven imagery that may have influenced the FMD response.

Psychological and Demographic Assessment.

Data collection began prior to the dissemination of Diagnostic and Statistical Manual– 5 [7]. Therefore, psychological assessments were based on the Diagnostic and Statistical Manual-IV [39]. PTSD symptom severity and diagnosis were assessed with the Clinician Administered PTSD Scale (CAPS—IV [58]). CAPS-IV interviews were conducted by a licensed clinical psychologist (RA), or a doctoral clinical psychology student (AC) under direct supervision. Given the variable time between CAPS and CV assessment (one week to six months), the primary outcome measure for the CAPS was PTSD symptom severity based on lifetime report. Full PTSD criteria was defined as a total severity score greater than or equal to 30 and full criteria for each symptom cluster (reporting frequency of at least “1” and intensity of at least “2” for at least 1 cluster B symptom, 3 cluster C symptoms, and 2 cluster D symptoms) on the CAPS-IV [58]. Similar to previously published methods [59], partial PTSD was defined as CAPS total severity score greater than or equal to 30, but not meeting full criteria for cluster C or D symptoms (missing 1 symptom).

Depressive symptoms were assessed with the Beck Depression Inventory II (BDI-II [60]). The Combat Experiences sub-scale of the Deployment Risk and Resilience Inventory (DRRI [61]), was used to assess level of combat experiences. Alcohol use was assessed with the Alcohol Use Disorders Identification Test (AUDIT [62]). Higher scores on self-reported measures of depression, combat, and alcohol use indicate increased depressive symptoms, increased number of combat experiences, and greater alcohol use, respectively. Height and weight were obtained to calculate body mass index (BMI). Participants were asked about prior history of traumatic brain injury (TBI) by asking them to report any experienced of “a concussion, blow to the head, or other head-related injuries”, the duration of loss of consciousness for the event(s), and any neurologic symptoms experienced with the event (i.e., dizziness, headaches, vision problems, etc.). Fourteen participants reported events consistent with mild TBI (LOC < 30 minutes), while individuals with history of moderate to severe TBI were excluded. Current smoking status was also collected. Participants were identified as non-smokers if they abstained from smoking for the past 12 months.

Physiological Assessment.

Participants completed an anxiety-provoking task using script-driven imagery. This assessment is a slightly modified version of previously described script-driven imagery methods [49, 50]. Participants created four individualized scripts, including one each for negative, positive, neutral, and combat events. Participants were provided written instructions (modified from previous studies [49, 50] for script construction. Participants were instructed to write a description of each event (positive, neutral, negative, and combat), and include in that description bodily sensations they experienced at that time. Participants were also provided an example script, as well as a list of common physiological descriptors to aid in script generation. Scripts were recorded by a male research assistant and played back to the participant for two minutes, with a two-minute rest between scripts. The order in which participants heard negative, positive and neutral scripts was counterbalanced. The combat-related script was always played last to minimize prolonged carry over effects. Heart rate variability was obtained from 20 participants during script-driven imagery using an electrocardiogram (ECG) and corresponding software (CardioCard, Nasiff Associates, Central Square, NY). A frequency domain method (Fast Fourier Transformation) was used to analyze HRV [63]. Therefore, the LF/HF, which is thought to indicate balance between the sympathetic and parasympathetic systems, was used to index autonomic reactivity during script-driven imagery. The LF/HF was averaged for each script, with higher ratios indicating decreased parasympathetic activity. Data were extracted using QRSTool/CMetx software (Allen, Chambers, and Towers, Psychophysiology Lab, The University of Arizona), and processed using Kubios analysis software 2.0 (Biomedical Signal and Medical Imaging Analysis Group, University of Kuopio, Finland [64]). Data from three participants were excluded due to poor EKG data quality.

Endothelial Function.

Flow-mediated dilation (FMD) was used to assess endothelial function, as an index of CV health. Participants were asked to refrain from food or caffeine for 12 hours and any medications prior to the procedure. Participants were asked to rest supine for 20 minutes prior to the start of the procedure in a temperature-controlled room (21–24 degrees C) that was quiet with dim lighting. We used a 9.0 Mhz linear array probe attached to a high-resolution ultrasound machine (Acuson, Sequoia 512, Siemens Medical Solutions USA, Inc., Mountain View, CA) to create an image of the brachial artery and blood flow. Our methods for the FMD procedure have been previously published [6567].

Briefly, once the brachial artery was identified, a stereotactic clamp was used to stabilize the ultrasound transducer and hold it in place during the procedure. A resting baseline for diameter and blood flow velocity was recorded for 60-seconds. An automated blood pressure cuff (D.E. Hokanson, Bellevue, WA) was placed 2–3 cm below the anecubital fossa and was inflated above suprasystolic pressure to 220 mmHg for five minutes. Twenty seconds prior to cuff deflation, recording resumed for 3 minutes. All images were analyzed off-line using specialized software (Brachial Analyzer, Medical Imaging Applications, Coralville, Iowa).

Statistical Analyses

Total severity scores calculated for the CAPS and the combat experiences sub-scale of the DRRI were the primary self-report variables of interest. We examined relationships with symptom severity rather than comparing dichotomous groups (i.e., PTSD versus non-PTSD) due to the fact that all participants had experienced trauma (combat exposure) and PTSD symptoms were normally distributed across the sample. Total severity scores were also calculated for the BDI-II and AUDIT. Autonomic reactivity was calculated by subtracting the LF/HF ratio during the neutral script from the LF/HF ratio for positive (POS-NEU), negative (NEG-NEU) or combat (COMB-NEU) scripts. LF/HF was also measured during baseline (2-minutes prior to script onset), and recovery (5-minute post combat script) periods. All LF/HF variables were log-transformed prior to analyses due to non-normal distribution. Relationships between these variables, as well as FMD, were then explored using two-tailed Pearson’s correlations. Exploratory correlations between FMD and known CV risk factors including age, current smoking status, and BMI were also conducted to determine possible covariates for the primary analyses.

The primary outcome measure for the dependent variable, FMD, was separated into a dichotomous measure of dilation less than or greater than five percent, with less than five percent indicating an impaired FMD response [33]. Variables in which the relationship with FMD was in the moderate to large effect size range were entered into a step-wise discriminant analysis to explore the predictive ability of FMD. Given the exploratory nature of the study, p < 0.05 was considered significant. Effect sizes are reported to aid in the interpretation of findings and inform the design of future studies.


Descriptive analyses of the current sample are presented in Table 1. Participants on average demonstrated impaired FMD (Table 1), with 15/24 participants exhibiting FMD < 5%. Age, mTBI history, alcohol use, BMI, and LF/HF during neutral scripts were unrelated to FMD and therefore not included as covariates (p > 0.10 for each variable). Excluding participants who were smokers did not alter study results.

PTSD symptoms related to combat experiences (R = -0.43, p = 0.037), but not to LF/HF ratio to emotional scripts (all p’s > 0.10). The relationship between PTSD and LF/HF at baseline was trending with a moderate effect size (R = 0.41, p = 0.082). Combat experiences were not significantly related to LF/HF at baseline or LF/HF reactivity to emotional scripts (all p’s > 0.10). Self-reported PTSD symptoms (R = -0.01, p = 0.968), depressive symptoms (R = 0.379, p = 0.068), combat exposure (R = 0.13, p = 0.534) and LF/HF during recovery periods (R = -0.35, p = 0.150) were not related to FMD. Greater LF/HF reactivity to positive scripts related to higher FMD (R = 0.526, p = 0.030) and there were trends for LF/HF reactivity to negative (R = 0.48, p = 0.052) and combat (R = 0.43, p = 0.085) scripts (Fig 1). A moderate to large effect size was found for higher LF/HF at baseline relating to lower FMD (R = -0.44, p = 0.058).

Fig 1. Relationships between autonomic reactivity to script-driven imagery and cardiovascular health.

Relationships between autonomic reactivity (heart rate variability; low to high frequency power ratio) to script-driven imagery and flow-mediated dilation (FMD). Baseline = autonomic activity during baseline; POS-NEU = autonomic reactivity of positive scripts relative to neutral scripts; NEG-NEU = autonomic reactivity of negative scripts relative to neutral scripts; COMB-NEU = autonomic reactivity of combat scripts relative to neutral scripts; Recovery = autonomic reactivity during the recovery period; FMD = flow mediated dilation percent change; dilation less than 5% (green) indicates impaired FMD; dilation greater than 5% (blue) indicates FMD within the normal range.

LF/HF at baseline, as well as LF/HF reactivity to positive, negative and combat scripts were entered into a stepwise discriminate analysis. LF/HF ratio to negative events emerged as the only significant predictor of impaired FMD (FMD < 5%; CC = 0.608, λ = 0.631, X2 = 6.685, p = 0.010), correctly classifying 76.5% of all cases.


Results from this pilot study provided partial support for our hypotheses. While psychological symptoms did not relate to FMD, we observed surprisingly low FMD values in our current sample of relatively young, physically healthy, combat veterans with only mild to moderate levels of PTSD. Secondly, results from discriminant analyses suggest that autonomic reactivity to emotional provocation, as measured by LF/HF, relates to poorer FMD in combat veterans and should be further investigated as a potential predictor or risk factor for poorer CV health. These pilot results have important implications for the screening and assessment of CV health in combat veterans and can be used to inform future research.

CV Health in Combat Veterans

A large percentage (62.5%) of the current sample exhibited impaired FMD, with vessel dilation less than five percent (mean FMD = 4.79). In contrast, the average FMD reported for healthy adults is closer to seven and a half percent [33], which is significantly greater than observed in the current sample of combat veterans (Welsh’s t = 7.011, p < 0.001). This reduced FMD response was observed in our study population, despite their young age (M = 32.38), lack of significant alcohol and tobacco use, and moderate levels of PTSD symptoms. To our knowledge, two other studies have assessed the relationship between PTSD and FMD [39, 68]. Violanti and colleagues found that when compared to police officers with moderate levels of PTSD symptoms, those with high levels of PTSD symptoms showed significantly poorer FMD response [39]. This relationship was not altered by demographic or lifestyle factors. This previous study also reported relatively low FMD response [39], similar to what was observed in the current sample. A more recent study investigating PTSD and FMD in older adult veteran populations (mean age = 68 years) found that veterans with PTSD were more likely to exhibit poorer endothelial function relative to those without PTSD [68]. Importantly, Grenon and colleague’s study enrolled those with known CV disease, thus limiting the ability to determine if poorer endothelial function is a result of PTSD, age, or cardiovascular disease [68]. Taken together, these results suggest that impaired FMD response may be a by-product of high levels of trauma exposure or stress that can be exacerbated by severe levels of chronic PTSD. Exposure to traumatic and/or stressful events elicits an autonomic (fight or flight) response that can be adaptive in stressful situations [69]. It is therefore possible that even adaptive autonomic arousal subsequent to traumatic and/or stressful events may lead to endothelial dysfunction. Individuals who then go on to develop PTSD may therefore experience increased difficulty in regulating autonomic responses, which may then further exacerbate poorer CV health.

FMD provides the unique opportunity to assess endothelial-dependent function, adding to information provided by other measures of CV health (i.e., blood pressure, heart rate, lipid levels). The present results demonstrate the importance for physicians and healthcare providers to regularly assess for CV health with combat veterans (or other populations with high levels of trauma exposure), regardless of age or other demographic variables via measures of autonomic reactivity and/or FMD. Our findings highlight the importance of future research to identify factors that predict poor CV health in combat veterans and to identify targets for early intervention.

Autonomic Reactivity and CV Health

Autonomic reactivity (HRV; LF/HF) to any emotionally valenced script (negative, positive, or combat-related) was found to positively relate to FMD (with a moderate to large effect size). This finding supports future investigations assessing the use of autonomic reactivity to emotional scripts as a predictor of CV health in populations with trauma history. Autonomic reactivity to negatively valenced stimuli emerged as the only significant predictor of impaired FMD. Interestingly, average LF/HF ratio to negative events was relatively lower than for neutral events suggesting decreased autonomic balance during neutral compared to negative events. This could reflect participant attempts to regulate autonomic arousal specifically during negatively valenced emotional provocation. It could be useful for future research to investigate whether one’s ability to purposefully down-regulate autonomic arousal may be an important contributor to chronic CV health, and a potential target for reducing impaired FMD.

The current pilot results also suggest that measures of autonomic reactivity may be more powerful predictors of CV health in combat veterans than self-report measures of psychological symptoms or combat experiences. This may be due to sympathetic and parasympathetic reactivity being a more direct indicator of adrenal reactivity and stress hormone release [70] than PTSD symptoms in general. In addition, measures of autonomic reactivity are less biased by retrospective recall, insight, clinical subjective judgments, or the under- or over-reporting of symptoms, than self-report measures or clinical interviews.

Clinical Implications

The current findings suggest that autonomic reactivity to emotional provocation could potentially serve as a cost-efficient and objective screening measure for CV health. Moreover, this begs the question of whether interventions aimed at modifying autonomic reactivity could be beneficial in reducing impaired FMD. It is estimated that greater than 50% of CV disease reduction is attributed to changing CV risk factors [71]. Therefore, it is reasonable to speculate that if autonomic dysfunction is viewed as a CV risk factor, then interventions targeting autonomic reactivity could prove to be fruitful. Previous research provides strong evidence for biofeedback training, of either HRV or HR, for reducing CV risk [72]. Modulation of autonomic reactivity (specifically HRV) via regular exercise and stress management have reduced CV risk factors in patients with ischemic heart disease, above and beyond that of medication or treatment as usual [73]. More specifically, psychological research suggests that relaxation techniques such as progressive muscle relaxation are able to modulate physiological responses to visual stressors by reducing recovery time [74]. However, it would be important to test if 1) autonomic reactivity is a risk factor for the development of CV disease, and 2) interventions targeting autonomic reactivity decrease the propensity for developing CV disease in larger, longitudinal studies.


The current pilot study was limited by a small sample size (N = 24), lack of a non-trauma-exposed control group, and a cross-sectional design. The current sample included male veterans who have served in combat since the onset of OIF, limiting generalizability of findings to other types of trauma. Additionally, the symptom severity reported by veterans in the current study was in the mild to moderate range, which may have limited our ability to identify relationships between symptom severity, FMD, and autonomic reactivity. Future research should assess the potential impact of PTSD on autonomic reactivity and FMD in treatment-seeking veterans with more severe PTSD symptomology. Lastly, FMD is specific to endothelial-dependent dilation. It would be important for future studies to incorporate several modes of vasodilation (e.g. measures of endothelial and non-endothelial vasodilation) to further understand relationships to trauma, PTSD, and autonomic reactivity.


Our results suggest that young combat veterans exhibit impaired FMD, and that autonomic reactivity to emotionally valenced events is a potential predictor of CV health. Previous research has established relationships between hyperarousal symptoms associated with PTSD and parasympathetic function [4852, 75], as well as relations between depressed parasympathetic activity and CV disease [27, 76]. In contrast to previous research [22], but in line with research investigating the impact of combat exposure [10, 11], our results suggest that combat veterans in general (not just those with PTSD) may be at risk for poorer CV health. If replicated, the current findings emphasize the importance of regularly assessing CV health in all combat veterans, regardless of psychological diagnoses, and suggest that increased autonomic reactivity to emotional provocation is predictive of poorer CV health. These results provide initial support for future research investigating mediating relationships between trauma exposure, autonomic reactivity and CV health, as well as intervention research aimed at improving CV health.


The authors would like to thank Paula Martin, Heather Cameron, Jack Tilton, and John Kaleekal whose data collection was a vital contribution to this study.

Author Contributions

  1. Conceived and designed the experiments: ANC RLA SAB.
  2. Performed the experiments: ANC SAB JFVS DRW.
  3. Analyzed the data: ANC JFVS DRW.
  4. Contributed reagents/materials/analysis tools: RLA SAB.
  5. Wrote the paper: ANC RLA JFVS DRW SAB.


  1. 1. Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress. 2013;26(5):537–47. pmid:24151000
  2. 2. American Psychiatric Association. Diagnostic and Statistical Manual-IV Text Revisions. Washington D.C.: American Psychiatric Association; 2000.
  3. 3. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048–60. pmid:7492257
  4. 4. Ramchand R, Schell TL, Karney BR, Osilla KC, Burns RM, Caldarone LB. Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: possible explanations. Journal of traumatic stress. 2010;23(1):59–68. pmid:20135699
  5. 5. Richardson LK, Frueh BC, Acierno R. Prevalence estimates of combat-related post-traumatic stress disorder: critical review. The Australian and New Zealand journal of psychiatry. 2010;44(1):4–19. pmid:20073563
  6. 6. Rosenheck RA, Fontana AF. Recent trends In VA treatment of post-traumatic stress disorder and other mental disorders. Health affairs. 2007;26(6):1720–7. pmid:17978391
  7. 7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013.
  8. 8. Friedman MJ, Schnurr PP. The relationship between trauma, PTSD, and physical health. In: Friedman MJ, Charney DS, Deutch AY, editors. Neurobiological and clinical consequences of stress: From normal adaptation to PTSD. New York, NY: Lippincott-Raven; 1995. p. 507–24.
  9. 9. O'Toole BI, Catts SV. Trauma, PTSD, and physical health: an epidemiological study of Australian Vietnam veterans. J Psychosom Res. 2008;64(1):33–40. pmid:18157997
  10. 10. Elder GH Jr., Shanahan MJ, Clipp EC. Linking combat and physical health: the legacy of World War II in men's lives. Am J Psychiatry. 1997;154(3):330–6. pmid:9054779
  11. 11. Page WF, Brass LM. Long-term heart disease and stroke mortality among former American prisoners of war of World War II and the Korean Conflict: results of a 50-year follow-up. Mil Med. 2001;166(9):803–8. pmid:11569446
  12. 12. Bedi US, Arora R. Cardiovascular manifestations of posttraumatic stress disorder. Journal of the National Medical Association. 2007;99(6):642–9. pmid:17595933
  13. 13. Boscarino JA, Chang J. Electrocardiogram abnormalities among men with stress-related psychiatric disorders: implications for coronary heart disease and clinical research. Annals of behavioral medicine: a publication of the Society of Behavioral Medicine. 1999;21(3):227–34.
  14. 14. Cohen BE, Marmar C, Ren L, Bertenthal D, 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. pmid:19654382
  15. 15. Solter V, Thaller V, Karlovic D, Crnkovic D. Elevated serum lipids in veterans with combat-rlated chronic Posttraumatic Stress Disorder. Croatian Medican Journal. 2002;43(6):684–9.
  16. 16. Buckley TC, Holohan D, Greif JL, Bedard M, Suvak M. Twenty-four-hour ambulatory assessment of heart rate and blood pressure in chronic PTSD and non-PTSD veterans. J Trauma Stress. 2004;17(2):163–71. pmid:15141790
  17. 17. Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation. 1994;90(5):2225–9. pmid:7955177
  18. 18. Walczewska J, Rutkowski K, Wizner B, Cwynar M, Grodzicki T. Stiffness of large arteries and cardiovascular risk in patients with post-traumatic stress disorder. European heart journal. 2011;32(6):730–6. pmid:20971746
  19. 19. Boscarino JA. Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Annals of epidemiology. 2006;16(4):248–56. pmid:16099672
  20. 20. Vogelzangs N, Seldenrijk A, Beekman AT, van Hout HP, de Jonge P, Penninx BW. Cardiovascular disease in persons with depressive and anxiety disorders. J Affect Disord. 2010;125(1–3):241–8. pmid:20223521
  21. 21. Carney RM, Freedland KE. Depression and heart rate variability in patients with coronary heart disease. Cleve Clin J Med. 2009;76 Suppl 2:S13–7. pmid:19376975
  22. 22. Kemp AH, Quintana DS, Felmingham KL, Matthews S, Jelinek HF. Depression, comorbid anxiety disorders, and heart rate variability in physically healthy, unmedicated patients: implications for cardiovascular risk. PLoS One. 2012;7(2):e30777. pmid:22355326
  23. 23. Schnurr PP, Spiro A 3rd. Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans. J Nerv Ment Dis. 1999;187(6):353–9. pmid:10379722
  24. 24. Holman EA, Silver RC, Poulin M, Andersen J, Gil-Rivas V, McIntosh DN. Terrorism, acute stress, and cardiovascular health: a 3-year national study following the September 11th attacks. Arch Gen Psychiatry. 2008;65(1):73–80. pmid:18180431
  25. 25. Boscarino JA. A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosom Med. 2008;70(6):668–76. pmid:18596248
  26. 26. Kubzansky LD, Koenen KC, Spiro A 3rd, Vokonas PS, Sparrow D. Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the Normative Aging Study. Arch Gen Psychiatry. 2007;64(1):109–16. pmid:17199060
  27. 27. World Health Organization. ICD-10: International statistical classification of diseases and related health problems. 10th Revised ed. New York: World Health Organization; 2010.
  28. 28. Thijssen DH, Black MA, Pyke KE, Padilla J, Atkinson G, Harris RA, et al. Assessment of flow-mediated dilation in humans: a methodological and physiological guideline. Am J Physiol Heart Circ Physiol. 2011;300(1):H2–12. pmid:20952670
  29. 29. Guthikonda S, Sinkey CA, Haynes WG. What is the most appropriate methodology for detection of conduit artery endothelial dysfunction? Atherosclerosis Thrombosis and Vascular Biolology. 2007;27:1172–6.
  30. 30. Widlanksy ME, Gokce N, Keaney JF, Vita JA. The clinical implications of endothelial dysfunction. J Am Coll Cardiol. 2003;42:1149–60. pmid:14522472
  31. 31. Cox DA, Vita JA, Treausre CB, Fish RD, Alexander RW, Ganz P, et al. Atherosclerosis impairs flow-mediated dilation of coronary arteries in humans. Circulation. 1989;80:458–65. pmid:2527643
  32. 32. Yeboah J, Crouse JR, Hsu FC, Burke GL, Herrington DM. Brachial flow-mediated dilation predicts incident cardiovascular events in older adults: The cardiovascular health study. x. Circulation. 2007;115:2390–7 pmid:17452608
  33. 33. Dalli E, Segarra L, Ruvira J, Esteban E, Cabrera A, Lliso R, et al. Brachial artery flow-mediated dilation in healthy men, men with risk factors, and men with acute myocardial infarction. Importance of occlusion-cuff position. Revista espanola de cardiologia. 2002;55(9):928–35. pmid:12236922
  34. 34. Kobayashi K, Akishita M, Yu W, Hashimoto M, Ohni M, Toba K. Interrelationship between non-invasive measurements of atherosclerosis: flow-mediated dilation of brachial artery, carotid intima-media thickness and pulse wave velocity. Atherosclerosis. 2004;173(1):13–8. pmid:15177119
  35. 35. Harris KF, Matthews KA, Sutton-Tyrrell K, Kuller LH. Associations between psychological traits and endothelial function in postmenopausal women. Psychosomatic Medicine. 2003;65:402–9. pmid:12764213
  36. 36. Cooper DC, Milic MS, Tafur JR, Mills PJ, Bardwell WA, Ziegler MG, et al. Adverse impact of mood on Flow-Mediated Dilation. Psychosomatic Medicine. 2010;72:122–7. pmid:20100885
  37. 37. Narita K, Murata T, Hamada T, Takahashi T, Kosaka H, Yoshida H, et al. Association of trait anxiety and endothelial function observed in elderly males but not in young males. International Psychogeriatrics 2007;19:947–54. pmid:17147843
  38. 38. Narita K, Murata T, Hamada T, Takahashi T, Kosaka H, Yoshida H, et al. Associations between trait anxiety, insulin resistance, and atherosclerosis in the elderly: a pilot cross-sectional study. Psychoneuroendocrinology. 2008;33:305–12. pmid:18178323
  39. 39. Violanti JM, Andrew ME, Burchfiel CM, Dorn J, Hartley T, Miller DB. Posttraumatic stress symptoms and subclinical cardiovascular disease in police officers. International Journal of Stress Management 2006;13(4):541–54.
  40. 40. Stillman AN, Moser DJ, Fiedorowicz J, Robinson HM, Haynes WG. Association of Anxiety with Resistance Vessel Dysfunction in Human Atherosclerosis. Psychosomatic Medicine. 2013;75:537–44. pmid:23788697
  41. 41. Wentworth BA, Stein MB, Redwine LS, Xue Y, Taub PR, Clopton P, et al. Post-traumatic stress disorder: a fast track to premature cardiovascular disease? Cardiology in review. 2013;21(1):16–22. pmid:22717656
  42. 42. Klabunde RE. Cardiovascular Physiology Concepts. 2 ed. Baltimare, MD: Lippincott Williams and Wilkins; 2012.
  43. 43. Pagani M, Lucini D. Autonomic dysregulation in essential hypertension: insight from heart rate and arterial pressure variability. Auton Neurosci. 2001;90(1–2):76–82. pmid:11485295
  44. 44. Thayer JF, Yamamoto SS, Brosschot JF. The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. Int J Cardiol. 2010;141(2):122–31. pmid:19910061
  45. 45. Thayer JF, Lane RD. The role of vagal function in the risk for cardiovascular disease and mortality. Biol Psychol. 2007;74(2):224–42. pmid:17182165
  46. 46. Cohen H, Neumann L, Shore M, Amir M, Cassuto Y, Buskila D. Autonomic dysfunction in patients with fibromyalgia: application of power spectral analysis of heart rate variability. Seminars in arthritis and rheumatism. 2000;29(4):217–27. pmid:10707990
  47. 47. Lindauer RT, van Meijel EP, Jalink M, Olff M, Carlier IV, Gersons BP. Heart rate responsivity to script-driven imagery in posttraumatic stress disorder: specificity of response and effects of psychotherapy. Psychosomatic medicine. 2006;68(1):33–40. pmid:16449409
  48. 48. Orr SP, Meyerhoff JL, Edwards JV, Pitman RK. Heart rate and blood pressure resting levels and responses to generic stressors in Vietnam veterans with posttraumatic stress disorder. J Trauma Stress. 1998;11(1):155–64. pmid:9479684
  49. 49. Pitman RK, Orr SP, Forgue DF, Altman B, de Jong JB, Herz LR. Psychophysiologic responses to combat imagery of Vietnam veterans with posttraumatic stress disorder versus other anxiety disorders. Journal of abnormal psychology. 1990;99(1):49–54. pmid:2307766
  50. 50. Pitman RK, Orr SP, Forgue DF, de Jong JB, Claiborn JM. Psychophysiologic assessment of posttraumatic stress disorder imagery in Vietnam combat veterans. Arch Gen Psychiatry. 1987;44(11):970–5. pmid:3675137
  51. 51. Orr SP, Claiborn JM, Altman B, Forgue DF, de Jong JB, Pitman RK, et al. Psychometric profile of posttraumatic stress disorder, anxious, and healthy Vietnam veterans: correlations with psychophysiologic responses. J Consult Clin Psychol. 1990;58(3):329–35. pmid:2365896
  52. 52. Orr SP, Lasko NB, Shalev AY, Pitman RK. Physiologic responses to loud tones in Vietnam veterans with posttraumatic stress disorder. J Abnorm Psychol. 1995;104(1):75–82. pmid:7897056
  53. 53. Tan G, Dao TK, Farmer L, Sutherland RJ, Gevirtz R. Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): a pilot study. Appl Psychophysiol Biofeedback. 2011;36(1):27–35. pmid:20680439
  54. 54. Cohen H, Kotler M, Matar MA, Kaplan Z, Loewenthal U, Miodownik H, et al. Analysis of heart rate variability in posttraumatic stress disorder patients in response to a trauma-related reminder. Biol Psychiatry. 1998;44(10):1054–9. pmid:9821570
  55. 55. Cohen H, Kotler M, Matar MA, Kaplan Z, Miodownik H, Cassuto Y. Power spectral analysis of heart rate variability in posttraumatic stress disorder patients. Biol Psychiatry. 1997;41(5):627–9. pmid:9046997
  56. 56. Cohen H, Loewenthal U, Matar M, Kotler M. Association of autonomic dysfunction and clozapine. Heart rate variability and risk for sudden death in patients with schizophrenia on long-term psychotropic medication. Br J Psychiatry. 2001;179:167–71. pmid:11483480
  57. 57. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of clinical psychiatry. 1998;59 Suppl 20:22–33;quiz 4–57. pmid:9881538
  58. 58. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, et al. The development of a Clinician-Administered PTSD Scale. Journal of Traumatic Stress. 1995;8(1):75–90. pmid:7712061
  59. 59. Aupperle RL, Allard CB, Grimes EM, Simmons A, Flagan T, Behrooznia M, et al. Dorsolateral prefrontal cortex activation during emotional anticipation and neuropsychological performance in PTSD. Archives of General Psychiatry. 2012;69(4):360–71. pmid:22474105
  60. 60. Beck AT, Steer RA, Brown G. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation; 1996.
  61. 61. King LA, King DW, Vogt DS, Knight J, Samper RE. Deployment Risk and Resilience Inventory: A Collection of Measures for Studying Deployment-Related Experiences of Military Personnel and Veterans. Military Psychology. 2006;18(2):89–120.
  62. 62. Babor TF, De la Fuente JR, Saunders J, Grant M. Audit. The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Health Care. Geneva, Switzerland: World Health Organization; 1992.
  63. 63. Xhyheri B, Manfrini O, Mazzolini M, Pizzi C, Bugiardini R. Heart rate variability today. Progress in cardiovascular diseases. 2012;55(3):321–31. pmid:23217437
  64. 64. Tarvainen MP, Georgiadis S, Lipponen JA, Hakkarainen M, Karjalainen PA. Time-varying spectrum estimation of heart rate variability signals with Kalman smoother algorithm. Conference proceedings: Annual International Conference of the IEEE Engineering in Medicine and Biology Society IEEE Engineering in Medicine and Biology Society Annual Conference. 2009;2009:1–4.
  65. 65. Billinger SA, Mattlage AE, Ashenden AL, Lentz AA, Harter G, Rippee MA. Aerobic exercise in subacute stroke improves cardiovascular health and physical performance. Journal of neurologic physical therapy: JNPT. 2012;36(4):159–65. pmid:23111686
  66. 66. Kluding PM, Pasnoor M, Singh R, D'Silva LJ, Yoo M, Billinger SA, et al. Safety of aerobic exercise in people with diabetic peripheral neuropathy: single-group clinical trial. Phys Ther. 2015;95(2):223–34. pmid:25278335
  67. 67. Billinger SA, Sisante JV, Alqahtani AS, Pasnoor M, Kluding PM. Aerobic Exercise Improves Measures of Vascular Health in Diabetic Peripheral Neuropathy. Int J Neurosci. 2016:1–16.
  68. 68. Grenon SM, Owens CD, Alley H, Perez S, Whooley MA, Neylan TC, et al. Posttraumatic Stress Disorder Is Associated With Worse Endothelial Function Among Veterans. J Am Heart Assoc. 2016;5(3).
  69. 69. Christopher M. A broader view of trauma: a biopsychosocial-evolutionary view of the role of the traumatic stress response in the emergence of pathology and/or growth. Clin Psychol Rev. 2004;24(1):75–98. pmid:14992807
  70. 70. Olshansky B, Sabbah HN, Hauptman PJ, Colucci WS. Parasympathetic nervous system and heart failure: pathophysiology and potential implications for therapy. Circulation. 2008;118(8):863–71. pmid:18711023
  71. 71. Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). European heart journal. 2012;33(13):1635–701. pmid:22555213
  72. 72. Moravec CS. Biofeedback therapy in cardiovascular disease: rationale and research overview. Cleve Clin J Med. 2008;75 Suppl 2:S35–8. pmid:18540144
  73. 73. Blumenthal JA, Sherwood A, Babyak MA, Watkins LL, Waugh R, Georgiades A, et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial. Jama. 2005;293(13):1626–34. pmid:15811982
  74. 74. Rausch SM, Gramling SE, Auerbach SM. Effects of a single session of large-group meditation and progressive muscle relaxation training on stress reduction, reactivity, and recovery. International Journal of Stress Management. 2006;13(3):273–90.
  75. 75. Orr SP, Metzger LJ, Lasko NB, Macklin ML, Hu FB, Shalev AY, et al. Physiologic responses to sudden, loud tones in monozygotic twins discordant for combat exposure: association with posttraumatic stress disorder. Arch Gen Psychiatry. 2003;60(3):283–8. pmid:12622661
  76. 76. Leung WH, Lau CP, Wong CK. Beneficial effect of cholesterol-lowering therapy on coronary endothelium-dependent relaxation in hypercholesterolaemic patients. Lancet. 1993;341(8859):1496–500. pmid:8099379