AHA.18: The cardiovascular consequences of a violent America

Violence, an ever-growing presence in our global communities, isn’t just a social issue, according to research presented at the American Heart Association’s annual scientific sessions in Chicago Nov. 12. It’s a public health one, too, and it can have serious consequences for our heart health.

Violent crime is a topic Michelle A. Albert, MD, MPH, thinks about a lot. Her work in San Francisco centers around preventive cardiology in understudied populations, like those most affected by the U.S. gun epidemic or global rise in terrorism. Violent crime is a real biological issue with real biological consequences, she said.

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

Indeed, the mental and physical effects of community violence can take hold early in childhood, Albert said. One in two kids experiences at least one adverse childhood experience (ACE) in their youth, which can include anything from physical abuse to divorce to sexual assault. One in four reports having experienced at least two ACEs.

For adolescents, each standard deviation increase in an ACE is associated with around a 6 percent increase in CVD risk, Albert said. Adults with seven or more ACEs in their past see three-to-one odds of developing CVD.

Albert frames cardiovascular well-being as an equation: CVD outcomes are equal to the balance between adversity and resilience divided by wealth, which can be considered monetary or emotional. A person’s adaptability, or allostatic load, is compromised when they’re overloaded with stressors like violence.

“When we are faced with a stressor, we’re able to adapt to that stressor and our biological processes are in equilibrium,” Albert said. “However, I like to think of allostatic load as a short-circuiting of our electrical system, where there’s excessive loading into our systems such that there’s maladaptation, resulting in disease processes.”

She said a neuroimaging study of kids in Los Angeles found that, five years after children reported experiencing violence, they showed decreased hippocampal and amygdalar volumes on brain scans. Researchers also found increased resting connectivity between the patients’ front and temporal lobes in the hippocampus—an indicator of hypervigilance.

In adults, exposure to physical or psychological violence is actually associated with an increase in amygdalar volume, which is tied to high stress levels and worse cardiovascular outcomes. And while that exposure to violence will likely affect those men and women for years, Albert said an epigenetic link means it might also affect their kids, potentially leading to a handful of adverse cognitive and somatic outcomes in adulthood.

Biologically, CVD has also been associated with blunted salivary cortisol responses, elevated IL-6 responses and increases in both C-reactive proteins and TNF alpha levels. But Albert said it’s important to also think of violence as a community problem, not just an individual one.

One component of the Jackson Heart Study focused on neighborhood adversity and segregation in relation to CVD and found that one standard deviation increase in adversity led to a 25 percent increased risk of cardiovascular disease. A recent trial published in the Lancet found the unarmed killing of black men resulted in 55 million increased mental health days in the black community, while another study concluded statewide violence in California increased fatal MIs in the state.

“There are many community risk factors for violence,” Albert said. “We also have to think about community-level resilience factors. Because we are seeing increasing violence in our communities, violence does not only affect the individual to whom it’s perpetrated against but it also affects our population as a whole.”

Community risk factors like neighborhood deterioration, lack of academic opportunities, weapon prevalence and a belief in the inevitability of violence could be mitigated by resilience factors like strong social networks, positive interracial interactions and quality schooling, she said. But to make progress, policy needs to change, coalitions need to be formed, providers need to be educated and individuals must be committed to learning about these issues.

“Community violence and adversity is a public health issue,” Albert said. “And prevention is key.”