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The Relationship between Military Combat and Cardiovascular Risk: A Systematic Review and Meta-Analysis
Christopher J Boos1,2,3,4, Norman De Villiers1,2,3, Daniel Dyball1,2
1Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Near Loughborough, Stanford Hall Estate, Nottinghamshire LE12 5QW, UK.
Insights
Combat-related traumatic injury (TI) significantly increases cardiovascular disease (CVD) risk and coronary heart disease (CHD) death in veterans. However, evidence linking combat without TI to adverse cardiovascular outcomes remains insufficient.
Area of Science:
- Military medicine
- Cardiovascular epidemiology
- Traumatic injury research
Background:
- Cardiovascular disease (CVD) is a major cause of mortality in military veterans.
- Previous studies suggest a correlation between combat exposure, traumatic injury (TI), and elevated CVD risk.
- Understanding this link is crucial for veteran health outcomes.
Purpose of the Study:
- To systematically review and meta-analyze the association between military combat exposure with or without TI and CVD risk.
- To investigate the relationship between combat/TI and cardiovascular risk factors.
- To synthesize current evidence on combat-related CVD risks in veterans.
Main Methods:
- Systematic review and meta-analysis of observational studies from PubMed, Embase, ProQuest, Cinahl, and Cochrane Reviews.
- Inclusion of studies reporting CVD risk following military combat exposure +/- TI versus a control group.
- Data extraction, quality appraisal (AXIS tool), risk of bias assessment (ROBANS tool), and strength of evidence (SOE) evaluation.
Main Results:
- 26 studies met inclusion criteria, predominantly male participants with long follow-up periods.
- Combat-related TI showed a significant increase in CVD risk (RR 1.80) and coronary heart disease (CHD)-related death (RR 1.57), though with low SOE.
- Military combat without TI was linked to a significantly lower pooled risk of cardiovascular death (RR 0.90), also with low SOE.
Conclusions:
- Low strength of evidence supports a link between combat-related TI and increased cardiovascular and CHD mortality.
- Insufficient evidence exists for associations between combat exposure and other adverse cardiovascular outcomes or risk factors.
- High-quality prospective cohort studies are needed to further elucidate these relationships.
Background And Objectives:
Cardiovascular disease (CVD) is a leading cause of death among military veterans with several reports suggesting a link between combat and related traumatic injury (TI) to an increased CVD risk. The aim of this paper is to conduct a widespread systematic review and meta-analysis of the relationship between military combat ± TI to CVD and its associated risk factors.
Methods:
PubMed, EmbaseProQuest, Cinahl databases and Cochrane Reviews were examined for all published observational studies (any language) reporting on CVD risk and outcomes, following military combat exposure ± TI versus a comparative nonexposed control population. Two investigators independently extracted data. Data quality was rated and rated using the 20-item AXIS Critical Appraisal Tool. The risk of bias (ROB using the ROBANS 6 item tool) and strength of evidence (SOE) were also critically appraised.
Results:
From 4499 citations, 26 studies (14 cross sectional and 12 cohort; 78-100% male) met the inclusion criteria. The follow up period ranged from 1 to 43.6 years with a sample size ranging from 19 to 621901 participants in the combat group. Combat-related TI was associated with a significantly increased risk for CVD (RR 1.80: 95% CI 1.24-2.62; I 2 = 59%, p = 0.002) and coronary heart disease (CHD)-related death (risk ratio 1.57: 95% CI 1.35-1.83; I 2 = 0%, p = 0.77: p < 0.0001), although the SOE was low. Military combat (without TI) was linked to a marginal, yet significantly lower pooled risk (low SOE) of cardiovascular death in the active combat versus control population (RR 0.90: CI 0.83-0.98; I 2 = 47%, p = 0.02). There was insufficient evidence linking combat ± TI to any other cardiovascular outcomes or risk factors.
Conclusion:
There is low SOE to support a link between combat-related TI and both cardiovascular and CHD-related mortality. There is insufficient evidence to support a positive association between military combat ± any other adverse cardiovascular outcomes or risk factors. Data from well conducted prospective cohort studies following combat are needed.
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