Long-term follow-up of blood pressure in family members of soldiers killed during the war in Bosnia and Herzegovina

Aim

To asses prevalence of essential arterial hypertension in family members of soldiers killed in 1992-1995 war in Bosnia and Herzegovina.

Methods

The study enrolled 1144 subjects who lost a family member in the war and 582 of their close neighbors who experienced no such loss. Data on their medical history and habits were collected, and their blood pressure was recorded in 1996 and 2003. Arterial hypertension was defined as systolic blood pressure ≥140 mm Hg (≥130 mm Hg in patients with diabetes mellitus), or diastolic blood pressure ≥90 mm Hg (≥80 mm Hg in patients with diabetes mellitus), or taking antihypertensive therapy. Additional laboratory and clinical tests were performed in subjects with hypertension.

Results

The prevalence of hypertension at both time points was higher in the group with a killed family member than in the group without the loss (55.1% vs 42.1%, P<0.001 in 1996, and 50.7% vs 39.0%, P<0.001 in 2003, respectively). However, there was also a significant decrease in the prevalence of hypertension in the group with the loss in 2003 (P<0.001), but not in group without the loss. Posttraumatic stress disorder (PTSD), smoking, and alcohol consumption were more prevalent in the group with a killed family member, but not cholesterol and triglyceride blood concentrations. In both groups, hypertension was more prevalent in subjects with PTSD and smoking or drinking habit. Proportion of subjects with hypertension who smoked and used alcohol was similar in both groups. Proportion of subjects with hypertension who did not smoke or drink was higher in the group with the loss (51.1% vs 36.7%, P<0.001; 46.2% vs 35.0%, P = 0.006; respectively).

Conclusion

This study showed higher prevalence of hypertension in family members of killed soldiers, regardless of the presence of other cardiovascular risk factors. Only the stress of mourning was associated with higher prevalence of hypertension. Over time, proportion of hypertensive subjects with the loss decreased in the group with a killed family member, further suggesting that at least a part of their hypertension might have been of psychological origin.Many studies investigated the effect of stress on various aspects of health status, but few found the association between stress and a particular disease (1-3). At the same time, the belief that stress causes and aggravates arterial hypertension is a widespread opinion among lay public, despite the lack of strong evidence. Arterial hypertension is currently defined as systolic blood pressure ≥140 mm Hg, or diastolic blood pressure ≥90 mm Hg, or taking antihypertensive therapy (4). In patients with diabetes mellitus, it is defined as systolic blood pressure ≥130 mm Hg, or diastolic blood pressure ≥80 mm Hg, or taking antihypertensive therapy (4). The exact etiology of essential arterial hypertension remains an enigma, primarily due to the high number of systems involved in the regulation of arterial pressure (5). Several factors are suggested as contributing to the hypertension – genetic factors, salt sensitivity, changes in ion homeostasis (sodium, potassium, and calcium), changes in renin-angiotensin-aldosteron system, insulin resistance, stimulation of sympathetic nervous system, and deficiency of vasodilator substances (5,6). Also, a number of environmental factors may have a role in the development of high blood pressure, such as salt intake, obesity, occupation, and alcohol intake (5). However, stress itself is not among them (5). This could be the consequence of the fact that it is very hard to design an objective study on the effect of stress on the arterial hypertension, due to substantial difficulties in defining, perception, and measurement of stress (7,8). A large study among employees of Australian government tax office showed no direct effect of job stress on blood pressure, but suggested a significant relationship of increased blood pressure and unhealthy habits, such as smoking, alcohol consumption, physical inactivity, and obesity, especially in men (9).One of the most convincing, although unwanted, models of chronic stress is war. There are many studies on psychiatric health status of the soldiers and war veterans, dealing mainly with the evaluation of posttraumatic stress disorder (PTSD) (10-14), and a considerable number of studies investigating physical health of the soldiers (15-19). At the same time, somatic status of civilians affected by war was evaluated less frequently. A study on Afghan, Iranian, and Somali asylum seekers, and refugees living in the Netherlands showed that they suffered mainly from PTSD, depression, and anxiety (20), whereas the Israeli civilians had significantly higher levels of anxiety, despite the normal levels of cortisol and growth hormone (21). Several studies investigated the effect of the 1991-1995 war in Croatia. A study of prevalence of risk factors for cerebrovascular disease after the war in Croatia found significantly higher rate of arterial hypertension, hyperlipidemia, and obesity in people suffering from PTSD (22). A retrospective study on the prevalence of acute coronary syndrome before and during the 1992-1995 war in Bosnia and Herzegovina revealed increased number of acute myocardial infarctions and unstable angina pectoris cases during the war (23).All of these studies evaluated the effects of general war stress on health, but none of them investigated the effect of the family member loss during the war, which is a frequent situation during military operations, and at the same time, an experience considered to cause great immediate stress reaction, as well as long-lasting psychological consequences (24) even in peace time. In this study, our aim was to investigate the prevalence of essential arterial hypertension in the family members of soldiers killed during the 1992-1995 war in Bosnia and Herzegovina, with the hypothesis that mourning may represent a stress that could affect arterial blood pressure.