Stroke in Young Adults: The Lasting Effects of Trauma

Table. Traditional and nontraditional risk factors for stroke among young adults [6,17,20,21]

Significance for Practicing Psychiatrists

In today’s era of mind-body medicine we continue to gain a more sophisticated understanding of the effects of trauma on cardiovascular and cerebrovascular functioning. Such information complements our comparatively vast knowledge concerning the psychological and psychosocial effects of trauma. Acute psychological stress and chronic stress disorders, including PTSD have been linked to increased risk of vascular events in older adults (eg, hypertension, metabolic syndrome, myocardial infarction, stroke).¹

Based on emerging data, this generation of young people may have a unique risk of exposure to stress and researchers and clinicians are increasingly concerned about the long-term health consequences of such chronic exposure for young adults.² In addition to a potential history of early life adversity (eg, sexual or physical abuse) and chronic stress, young people in the general population are increasingly exposed to extremely stressful or traumatic life events and the associated aftermath of events like gun violence and natural disaster.

Moreover, PTSD may develop after indirect or vicarious exposure to trauma (eg, repeatedly watching acts of violence or terrorism online). Those indirect experiences may be more accessible than ever and may contribute to worse long-term health outcomes, particularly for victims of multiple traumas.^3,4

PTSD and vascular risk

Of the cardiovascular and cerebrovascular conditions associated with PTSD, stroke is often thought of as a disease of later life, a perception that may result in the underdiagnosis of stroke among young adults. An estimated 10% to 14% of strokes occur in adults aged 45 and younger and the incidence of ischemic stroke and transient ischemic attack (TIA) among young adults has steadily increased over the past decade.^5,6 Nearly 50% of stroke cases among young adults are attributed to traditional cardiovascular risk factors such as hypertension, smoking, and diabetes. Strikingly, many more (40% to 50%) of cases are due to undetermined etiologies.^7,8

These statistics are especially worrisome given the significant psychological, physical, and financial effects of stroke on young adults in the prime of their life, on their loved ones, and on the health care system. Yet, young adults remain largely underrepresented in epidemiological research and randomized clinical trials. That omission makes it difficult to investigate potential age-specific contributory mechanisms and to develop novel therapeutic strategies to curb the growing burden of stroke in the young.

The causes, characteristics, and consequences of stroke for young patients likely differ from those observed in the average stroke patient who is generally older and is more likely to have concomitant disease. Over the years, many traditional and non-traditional risk factors for stroke in young adults have been identified (Table). Cross-sectional evidence suggests that trauma exposure and PTSD are risk factors for stroke among older adults and highlights psychological stress as a greater predictor of stroke among young adults relative to older individuals.⁹

A prospective study

Our group recently conducted one of the first known prospective studies on trauma-induced stress disorders and stroke.¹⁰ The study comprised 1 million young and middle-aged US military veterans who were discharged since September 11, 2001 and who had minimal traditional risk factors for stroke. Over a 13-year period, nearly 30% of veterans had a diagnosis of PTSD. Those with PTSD had a 36% greater risk of ischemic stroke and a 61% greater risk of TIA than those without PTSD. Importantly, PTSD remained strongly linked to stroke and TIA even after adjusting for demographic, clinical, and lifestyle risk factors, other common psychiatric disorders (eg, depression, generalized anxiety disorder), and health care utilization.

Potential sex differences

Men and women report different perceptions of and demonstrate varying emotional and physiological responses to acute and chronic stress.^11,12 Sex is an influential moderator of risk for stroke, and women with PTSD may be more vulnerable to cardiovascular disease than men. There may also be sex differences in the risk of stroke among younger individuals with PTSD.¹³

Findings from our study indicate that men with PTSD had a higher risk of having an ischemic stroke event than women, whereas men and women did not differ in PTSD-related risk for TIA.¹⁰ The former finding align with other observations that men have a greater risk of stroke at younger ages. It is possible that the effect of sex on PTSD and other risk factors for stroke changes over the lifespan. On the other hand, we recognize that young veterans are a unique subsample of the population with a higher rate of trauma exposure than the typical same-aged adult, meaning that these findings are not directly generalizable to the average young adult with PTSD.

Additional research is required to interpret these findings and to develop effective primary prevention strategies in this high-risk population. For example, it may be important to promote young veterans’ awareness of their elevated risk for cerebrovascular events.

From PTSD to stroke

The PTSD-associated risk for developing stroke at an early age relative to risk later in life is likely attributable to different physiological mechanisms. In general, long-term exposure to intense psychological stress may lead to:

Chronic inflammation (eg, elevated levels of C-reactive protein [CRP], interleukin-6 [IL-6], interleukin-1 [IL-1β], and tumor necrosis factor α [TNF-α])

• Platelet activation and aggregation

• Neuroendocrine dysregulation of the sympathetic adrenal medullary system

• Increased or decreased sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis

• Altered autonomic nervous system activity

Endothelial dysfunction

These perturbations could elevate coronary artery calcium, increase carotid intima-media thickness, and the ankle-brachial index, leading to an increased risk of myocardial infarction and stroke. Perhaps PTSD accelerates these processes in the young to evoke more deleterious cardiovascular and cerebrovascular effects compared with those observed in older adults. Finally, stress is associated with unhealthy lifestyle behaviors such as smoking, physical inactivity, poor diet, and substance abuse, behaviors that may exacerbate one’s risk for early stroke or TIA.

PTSD is also likely to interact with other non-traditional cardiovascular risk factors such as sleep. Cross-sectional and epidemiologic evidence indicates that deficient sleep (ie, short or long sleep duration, insomnia) increases one’s risk of cardiovascular disease and stroke, associations which may be more robust among younger adults.^14-17

Our group conducted another recent investigation of PTSD, insomnia, and hypertension (a traditional risk factor for stroke) among young and middle-aged veterans.¹⁸ Several symptoms of insomnia linked PTSD with hypertension. Insomnia also appeared to be an independent cardiovascular risk factor. Exploring the exchange between PTSD, sleep, and subsequent effects on vascular functioning requires further longitudinal studies.

Treatment and risk of stroke

Emerging evidence regarding PTSD-related vascular risk gives clinicians yet another reason to be vigilant in screening for trauma and related psychological conditions among younger adults. Mental health treatment of trauma and PTSD may play a particularly influential role in the primary prevention of stroke, effects that could have a greater impact among young people with additional vascular risk factors.

Clearly more research is needed to determine the best methods for patient management in those with PTSD and elevated vascular risk. In lieu of that work, clinicians should adopt a more personalized, tailored approach to patient counseling on individual risk for cardiovascular and cerebrovascular events in clinical practice.

Extant research can also be incorporated into treatment, namely through patient education regarding both the published and hypothesized physical health risks of PTSD. These efforts may particularly benefit young patients who do not consider themselves to be at risk for such conditions. Younger patients with multiple traditional and non-traditional risk factors for stroke (eg, a trauma history, poor sleep, substance use) but who do not receive routine primary care also may benefit from a referral to their health care provider concerning their elevated vascular risk. Finally, as observed with older adults following a stroke, clinical efforts to educate young patients regarding cardiovascular and cerebrovascular risk factors may be central to secondary prevention.¹⁹

Given the increasing burden, longer life-expectancy, and potential socioeconomic consequences of early-onset stroke, research needs to focus on improved risk stratification, prevention, and treatment among younger adult patients. This work will encourage mechanistic and therapeutic advances and set the stage for developing future age-appropriate surveillance strategies, interventions, guidelines, and public education campaigns to aggressively target the growing burden of stroke in young adults.

Finally, it is imperative that trauma and PTSD are regarded not only as a veteran health problem, but as central issues within our national public health agenda. Awareness and attention to these issues during routine and specialty care is paramount for providing comprehensive patient-centered care to young adult survivors of trauma, especially when considering the negative, long-term consequences of vascular conditions and events.

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Disclosures:

Dr Gaffey is a Postdoctoral Research Fellow, Department of Internal Medicine, Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; and an Advances Research Fellow in Women’s Health, VA Connecticut Healthcare System, West Haven, CT. Dr Sico is Associate Professor, Department of Internal Medicine, Section of General Medicine; Associate Professor, Department of Neurology and Center for Neuroepidemiological and Clinical Neurological Research, Yale School of Medicine; and Director Stroke Care, VA Connecticut Healthcare System. Dr Rosman is Assistant Professor, Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC. The authors report no conflicts of interest concerning the subject matter of this article.

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