AHA Puts Focus on the Impact of Violence on Cardiovascular Health

CHICAGO, IL—Exposure to violence can lead both directly and indirectly to detrimental effects on cardiovascular health, researchers highlighted during a series of talks held earlier this week at the American Heart Association (AHA) 2018 Scientific Sessions.

The session came about in part as a way to take advantage of the meeting’s location in Chicago, where people have been exploring untraditional approaches to get to the root causes of the high levels of violent crime there and to develop novel solutions, Clyde Yancy, MD (Northwestern University Feinberg School of Medicine, Chicago), one of the moderators of the session, told TCTMD.

Through discussions with Selwyn Rogers Jr, MD, founding director of the University of Chicago Medicine Trauma Center, it became apparent that the search for answers to the city’s violence intersected with the interests of the AHA, said Yancy, who moderated the session along with Shakira Suglia, ScD (Emory University Rollins School of Public Health, Atlanta, GA).

“As we become an organization more focused on the totality of the population at risk and as we’ve begun to have these conversations about the social determinants of health, you cannot ignore that exposure to violence is one of those social determinants of health,” Yancy said.

Damage to Heart and Brain Health

Michelle Albert, MD (Center for the Study of Adversity and Cardiovascular Disease at the University of California, San Francisco), started off the discussion with a presentation on the biology of violence, noting that exposure to adverse childhood experiences—which include violence and other types of adversity—has been associated with increased CVD risk in both adolescents and adults.

The body usually adapts to psychosocial stress caused by violence through changes to inflammatory processes, the hypothalamic-pituitary-adrenal axis, and the autonomic nervous system, but chronic exposure to that stress increases allostatic load and starts to cause problems.

“I like to think of allostatic load as a short-circuiting of our electrical system, where there’s . . . excessive loading of our systems such that there’s maladaptation resulting in disease processes such as metabolic perturbations, diabetes, coronary artery disease, [and] accelerated aging,” Albert explained.

Albert reviewed studies supporting links between exposure to violence and negative changes in the brain, increased inflammatory markers, higher blood pressure, subclinical atherosclerosis, and changes to DNA expression that potentially influence neurobehavioral outcomes, cognition, and somatic diseases like CVD.

“Violence is a prevalent form of adversity that is preventable,” she concluded. “Violence is understudied as a cardiovascular health issue, which is why it is on the stage today. And violence exposure is a form of toxic stress that is biologically embedded.”

Rogers argued in his presentation that the presence of violence, which is triggered by social, environmental, and community factors, “makes health or wellness impossible.”

Regarding cardiovascular risk, he cited studies showing relationships between community violence and hypertension, obesity, and poorer access to resources that would allow people to lead healthier lives, like grocery stores, pharmacies, and gyms or fitness centers.

“I think these are all factors an organization like the American Heart Association should invest in to look at—potentially—violence as a risk factor for adverse cardiovascular health,” Rogers said.

Making an Impact at the Policy Level

During a panel discussion after the series of talks, which also included perspectives from a representative of the faith-based community and a pediatrician specializing in child abuse, Yancy spoke to the importance of the topic of violence as it relates to cardiovascular health, particularly when children are involved.

“This is a scientific discussion about the consequences of exposure to violence,” he said. “I would argue that many persons in the room who are hearing this conversation for the first time would not have had these adverse childhood experiences . . . in a list of recognized cardiovascular disease factors, and I think what I heard you [Albert] saying is that it’s time for us to understand that in certain communities this may unpack a lot of the substrate for the development of cardiovascular disease longitudinally.”

Albert followed up by stressing that these issues affect all communities, regardless of culture, race, or ethnicity, but that the distribution and intensity of the exposures may vary by geography or socioeconomic status.

In terms of next steps, Albert said the cardiovascular community needs to start thinking about systematic ways to study violence and interventions to reduce its adverse effects, much like it tackled conditions like STEMI. “I would like to challenge our community to think of violence as a social determinant, a form of adversity that we need more research on across the translational spectrum from the basic sciences to the population level,” she said.

That would require a major shift within cardiology, where discussions of the impact of violence have been lacking, Yancy indicated.

“This is probably the most salient discussion I’ve heard in my career to bring together violence and exposure to trauma and a link to cardiovascular disease with some plausible biology to make it so that it’s not just an unexplained phenomenon, but [possibly] real lines of association between the exposure, the changes biologically, and then the end-organ manifestation, which would be hypertension, heart failure, etc,” he said. “Pretty fascinating stuff.”

Yancy argued that the greatest impact on mitigating the effects of violence would be made at the policy level, and not in the clinic.

“To the extent that we can do something about these exposures to violence, we can actually do more to change cardiovascular health from a public health perspective than the stuff we do in the office,” he told TCTMD. “I think a lot of what needs to happen based on what you heard today is policy-based, not individual-based. . . . But potentially effective policies could, in fact, change the contribution of violence in cardiovascular disease.”