Abstract
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; I2 = 59%, p = 0.002) and coronary heart disease (CHD)-related death (risk ratio 1.57: 95% CI 1.35–1.83; I2 = 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; I2 = 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.
Highlights
In 1979 US Veterans Administration published the results of their review examining the potential causal relationship between traumatic limb amputation and future risk of cardiovascular disease (CVD) [1]
Studies with a total score of >15 were deemed to be high quality, those of 10–15 of moderate quality, whilst those scoring
Following the preliminary title and abstract review, 73 full-text articles were screened for eligibility
Summary
In 1979 US Veterans Administration published the results of their review examining the potential causal relationship between traumatic limb amputation and future risk of cardiovascular disease (CVD) [1]. Owing to the inconsistency of existing published data, coupled with their concern regarding the health implications of a potential link between increased CVD risk, combat- related amputations and potentially other forms of severe traumatic injury (TI), the Veteran’s Administration concluded. Is retrospective cohort study was the first to provide evidence to support a significant link between combat- related traumatic amputation and a higher risk of future adverse cardiovascular outcomes [8, 9]. This data represented military populations who were injured more than seventy years ago, and the relevance for those injured in current conflicts is open to question. E objective of this review was to systematically search and review the literature to determine whether military combat exposure, both with and separately without TI is linked to an increased CVD risk and adverse outcomes
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