Secondary Logo

Journal Logo

Literature Reviews

Cardiovascular Risk and Outcomes in Women Who Have Experienced Intimate Partner Violence

An Integrative Review

Liu, Xiaoyue BSN, RN; Logan, Jeongok PhD, RN; Alhusen, Jeanne PhD, CRNP, RN, FAAN

Author Information
The Journal of Cardiovascular Nursing: 7/8 2020 - Volume 35 - Issue 4 - p 400-414
doi: 10.1097/JCN.0000000000000654
  • Free

Abstract

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the United States, accounting for approximately 1 female death every 80 seconds.1 This chronic disease has been widely recognized as the “female silent killer,” as the acute onset of cardiovascular events often results in fatal consequences without any previous clinical signs or symptoms.2 Although many factors can contribute to the development of CVD, authors of recent studies have suggested that exposure to violence is a potential risk factor for CVD.3,4 Increasingly, researchers have begun exploring the role of intimate partner violence (IPV) on cardiovascular risk. Intimate partner violence includes physical violence, sexual violence, stalking, and/or psychological aggression in an effort to gain power and control over another intimate partner.5,6 An estimated 1 in 3 women has experienced some type of violence during their lifetime.7 Compared with men, women are disproportionately affected by this public health issue regardless of age, socioeconomic status, or cultural backgrounds.8 Given the prevalence of IPV and CVD among women, it is important to examine their relationship in an effort to better understand how the combination of these 2 factors may impact the overall health among female survivors of IPV.

Previous evidence has suggested 2 potential pathways linking IPV to adverse cardiovascular outcomes.9–12 One plausible pathway is alterations at the physiological, biochemical, and endocrine levels caused by the sustained stress from IPV.10,13 The perception of stress immediately stimulates the autonomic nervous system and the hypothalamic-pituitary-adrenal axis, targeting end organs such as the heart and producing glucocorticoid hormones. Examples of related systematic changes include increased heart rate, elevated blood pressure (BP), reduced insulin sensitivity, and impaired endothelial function in arteries resulting from circulating stress hormones.14 The stress from IPV continuously triggers immune-inflammatory responses, making female survivors more susceptible to the deleterious effects of biochemical marker production (eg, proinflammatory cytokines) and inducing the subsequent breakdown of the cardiovascular system.15,16 Another proposed pathway by which experiencing IPV may increase cardiovascular risk is through the survivors' adoption of unhealthy lifestyles.10 Notably, these maladaptive stress-coping behaviors—for instance, smoking, alcohol use, and physical inactivity—are not only considered the most prominent behavioral risk factors of CVD but also found to influence other cardiovascular risk indicators or conditions such as BP, lipid levels, oxidative stress, or inflammation.17

Whereas authors of extensive research studies have documented a consistent relationship between childhood violence exposure and CVD, less research has focused on the cardiovascular health in adults with a history of IPV victimization.4,10,11 This is an important area of inquiry given adulthood exposure to violence may operate under different biological mechanisms that differ from childhood exposure.4 Understanding vulnerability in CVD among female IPV survivors is essential for healthcare providers to initiate targeted interventions and prevent further development of CVD. As of 2015, Suglia and colleagues4 published a systematic review of the association of interpersonal violence with cardiovascular outcomes in adults. Their focus was centered on violence perpetrated by both strangers from wider communities and nonstrangers (eg, family members). In addition, their search criteria were limited to studies in which authors assessed CVD end points, excluding studies in which authors evaluated cardiovascular risk factors such as biomarkers of CVD. Indeed, cardiovascular risk factors have critical implications for disease prevention. Evidence has supported that some leading modifiable risk factors (eg, hypercholesterolemia, diabetes, hypertension, obesity, smoking) are responsible for more than half of cardiovascular mortality in American adults aged from 45 to 79 years.18 Cardiovascular disease biomarkers, particularly, have been increasingly recognized as valuable instruments for early prevention and treatment of CVD.19 Because the cardiovascular risk and outcomes specifically for IPV survivors have not been well addressed, synthesizing current research on this topic may fill a gap in the literature and further our understanding about the relationship between IPV and CVD. Therefore, the purpose of our integrative review is to examine whether IPV is associated with cardiovascular risk and outcomes among female adults.

Methods

The analysis was guided by Whittemore and Knafl's20 updated integrative review framework, using a systematic approach to synthesize rigorous evidence from empirical resources. Activities involved in the current review included a literature search, data evaluation and extraction, data synthesis and comparison, and interpretation. With the assistance of a university librarian, the researchers used 3 electronic databases—PubMed, CINAHL, and Web of Science. The databases were thoroughly searched for the topics of IPV and CVD using the Medical Subject Headings and keywords, namely, “intimate partner violence,” “domestic violence,” “family violence,” “partner abuse,” “spouse abuse,” “exposure to violence,” “battered women,” “cardiovascular diseases,” “cardiovascular outcomes,” “cardiovascular health,” “cardiovascular risk,” “coronary diseases,” “blood pressure,” and “CVD.” The researchers combined the terms for each topic using “OR” and between the topics using “AND.” The search was initially limited to studies that met the following criteria: peer-reviewed studies, written in English language, published from 1998 to 2019, and included adults 18 years or older. This yielded 223 articles retrieved from the data sources described previously. Hand searching and reference tracing were also carried out, which yielded 6 additional articles. After removing 30 duplicates, the researchers examined the titles and abstracts of the remaining articles and excluded 162 articles for other reasons (see Figure). This process left 37 articles for a full review. After the full review, 18 articles were removed because they did not meet our search criteria. Consequently, 19 articles were included for analysis. Data were extracted from each study based on the following categories: author and year, study aim, sample characteristics, study methods, main CVD measures, IPV measures, and key findings (see Table).

FIGURE
FIGURE:
Preferred Reporting Items for Systematic Review and Meta-Analyses flowchart of search process.
TABLE
TABLE:
Summary of Included Studies

Results

Study Design and Sample Characteristics

Given the nature of the research topic, authors of all 19 articles included in this review used a quantitative method to examine cardiovascular health in IPV female survivors. The studies varied in research designs: in 13 studies,10,12,13,21–30 authors used secondary data analyses; in 5 studies,11,15,16,31,32 prospective cross-sectional designs were included; and in 1 study,33 authors used a prospective longitudinal design. Across the included studies, 14 included women who lived in the United States,12,13,15,16,21–24,28–33 whereas the remaining focused on women from Canada (n = 1),10 Norway (n = 1),11 Mexico (n = 1),25 Spain (n = 1),27 and South Africa (n = 1).26 The targeted study population in 16 studies was women, whereas the other 3 studies13,22,24 included men and women. Most studies included female samples who were in midadulthood, with the mean age ranging from 2222,24 to 5516 years.

Study Measures

Approximately 79% of the studies (n = 15) compared cardiovascular health between individuals exposed to IPV and their nonabused counterparts with variations in the type and timing of abuse examined.11–13,15,21,22,24–31,33 Both physical and sexual abuse were the most commonly evaluated forms of IPV among female survivors. Lifetime history of abuse was frequently used as a measure to assess the timing of IPV. Because CVD is a complex, multifaceted condition, the operationalization of this concept varied significantly across the studies. Thus, we reported the findings based on 2 categories: cardiovascular risk and cardiovascular outcomes.

Cardiovascular Risk

Cardiovascular Disease Risk Factors

High BP is one of the strongest risk factors for nearly all types of CVD. Of the 9 studies10,12,13,15,24,26–28,31 reviewed that explored the relationship between BP outcomes and IPV, seven12,13,15,26–28,31 relied on self-reported measures, whereas two10,24 used objective measures. Among the studies reviewed, the prevalence of hypertension ranged from 12.21%24 to 50.7%,15 and only 1 study28 found a statistically significant finding. Breiding and colleagues13 analyzed the 2005 Behavioral Risk Factor Surveillance System, showing that 22.6% of the female IPV sample was diagnosed with hypertension and that lifetime IPV was significantly associated with hypertension after controlling for sociodemographic variables (adjusted odds ratio [aOR], 1.11; 95% confidence interval [CI], 1.01–1.23); however, the relationship was attenuated after adjusting for other health variables such as high cholesterol, stroke, and tobacco and alcohol use (aOR, 0.97; 95% CI, 0.86–1.10). Although the studies did not demonstrate a significant association between IPV and high BP, some evidence suggested that the effect of psychological abuse in contributing to hypertension might be greater than any other forms of abuse. Analyzing a longitudinal data set that followed female nurses for 6 years (N = 51 434), Mason and colleagues28 demonstrated that women who were exposed to severe psychological IPV had a 24% increased risk of developing hypertension in comparison with their counterparts who were not exposed to emotional abuse after adjusting for history of childhood abuse, race, parental education, somatogram score at the age of 5 years, and body mass index (BMI) at the age of 18 years (adjusted hazard ratio, 1.24; 95% CI, 1.02–1.53). Thus, the research that has examined the relationship between IPV and BP is mixed.

Diabetes, disorders of lipid metabolism, and obesity are also well-established risk factors for the development of CVD. Authors of a total of 6 studies examined how these risk factors were linked to IPV.11–13,21,26,31 Authors of 3 studies12,13,26 who assessed IPV and diabetes did find a relationship, and authors of another 3 studies11,13,31 documented mixed findings regarding the association of IPV with cholesterol and lipid metabolism. In the study carried out by Breiding et al,13 female survivors of IPV were 13% more likely to have high cholesterol than their nonabused counterparts (aOR, 1.13; 95% CI, 1.01–1.27). In a population-based study that compared cardiovascular risks and medication use in 5593 Oslo women with or without the experience of IPV, Stene and colleagues11 noted that those who reported lifetime IPV exhibited lower high-density lipoprotein and higher triglyceride levels (P = .031 and P = .003, respectively), yet the level of total cholesterol did not significantly differ between the 2 groups. Bonomi et al31 did not find an association between IPV and lipid metabolism disorder in 272 of 1928 women who reported a past-year history of abuse after adjusting for age (adjusted relative risk, 0.86; 95% CI, 0.46–1.62). Furthermore, 4 studies did not note a significant relationship between IPV and obesity, as measured by BMI.11–13,21 However, when waist-to-hip ratio was used to measure obesity, Stene and colleagues11 found that women victimized by physical and/or sexual violence (n = 415) exhibited a higher likelihood of abdominal obesity than the control group (P = .001). Taken together, the researchers examining the associations of diabetes, lipid metabolism, and obesity with experiences of IPV have shown mixed results.

Behavioral Risk Factors

Unhealthy behaviors are adopted by some women as coping mechanisms to deal with IPV-induced stress. These behaviors, such as smoking, alcohol use, and physical inactivity, may confer adverse consequences on cardiovascular health. Of the 6 studies that included measures of smoking and alcohol use, five revealed significant results.10,11,13,21,26 The overall prevalence of smoking and alcohol use among the IPV samples was 33.8%13 to 54.8%12 and 14.5%13 to 89.6%,11 respectively. In 3 studies that included nationally representative samples, abused women were 1.68 to 2.80 times more likely to smoke and 1.39 to 2.37 times more likely to use alcohol as compared with nonabused women.13,21,26 Limited researchers have examined specific characteristics of IPV and the association between tobacco and alcohol use. Among a sample of 309 Canadian female survivors of IPV, Scott-Storey et al10 hypothesized that current smoking status had a positive relationship with both severity of past IPV and ongoing abuse. The investigators noted a significant correlation between smoking and severity of past abuse (t = 3.586, P ≤ .001), yet their results showed that women who experienced ongoing abuse were more likely to be nonsmokers, which was contrary to their original hypothesis. Stene and colleagues11 found that women who were exposed to physical or sexual IPV had higher adoption rates of smoking (P < .001) and drinking (P = .014) than their counterparts who only reported psychological IPV or no abuse history. However, Vijayaraghavan and colleagues12 did not find significant differences in the rate of smoking (54.8% vs 46.4%, P = .30) or alcohol use (61.8% vs 54.2%, P = .20) among 329 homeless women with and without history of IPV. This finding could be explained by the unique characteristics of the homeless population, a group that has a strikingly high rate of smoking according to the past literature.34 Taken together, smoking and alcohol use are negative health behaviors that are more prevalent among women with previous experiences of IPV.

In addition to the 2 maladaptive coping strategies discussed previously, physical inactivity can also play a critical role in the development of CVD.35 In this review, authors of 3 studies assessed the relationship between IPV and physical activity using the Behavioral Risk Factor Surveillance System data set and did not yield significant findings.11,13,21 For example, researchers reported that nearly half of their female sample who had a lifetime experience of IPV performed weekly moderate or vigorous exercise, and the level of physical activity did not differ when comparing abused versus nonabused women (aOR, 1.00; 95% CI, 0.92–1.09).13 In another study by Dichter et al,21 a sample of 21 162 women was analyzed, and the investigators were unable to find an association between lifetime IPV and physical inactivity after adjusting for demographic characteristics and veteran status (aOR, 0.90; 95% CI, 0.80–1.10). In summary, IPV status does not have a direct association with physical inactivity.

Cardiovascular Disease Biomarkers

Intimate partner violence may overactivate the immune system and cause elevated levels of biomarkers such as inflammatory cytokines (eg, IL-6) and acute-phase proteins (eg, C-reactive protein [CRP]), which have been shown to accelerate the pathogenesis of CVD.9 Authors of 5 studies examined the association between IPV victimization and CVD biomarkers.15,16,23,25,33 Among the studies reviewed, four15,16,23,33 used serum and/or salivary samples, and one25 used an ultrasound technique to compute the subclinical marker carotid intima-media thickness (IMT).

Despite their nascency in IPV research, IL-6 and CRP were 2 of the most frequently examined biomarkers among the studies; overall, the evidence showed their close association with IPV victimization, particularly when female survivors were severely assaulted or exposed to significant psychological trauma. Newton and colleagues16 examined CVD biomarkers in a sample of 68 women who underwent divorce or separation resulting from stressful relationships—finding that severe physical abuse remained a significantly negative correlation with phytohemagglutinin-stimulated IL-6 production after adjusting for BMI, current posttraumatic stress, and depressive symptoms (β = −0.08, P = .005). In another pilot cross-sectional study by Halpern et al,15 they found that IPV was correlated with salivary CVD biomarkers, such as CRP/IL-6, among a sample of women presenting to an oral surgery clinic (51% vs 49%, P < .01, N = 37). Yet, the results need to be interpreted cautiously given the small sample size. In addition to the biomarkers IL-6 and CRP, authors of 1 study25 used carotid IMT to predict adverse cardiovascular function in female victims. Carotid IMT is a novel biomarker of CVD that predicts subclinical carotid atherosclerosis.36 In their study, Flores-Torres and colleagues25 found that the adjusted mean percentage difference in carotid IMT between women who were exposed to either sexual or physical violence and their nonabused counterparts to violence was 2.4% (95% CI, 0.50–4.30). The investigators also found that women who reported physical violence by their family members had 1.3% higher mean carotid IMT, and this population was 1.48 times more likely to have subclinical carotid atherosclerosis when compared with those without a history of violence (aOR, 1.48; 95% CI, 0.78–2.83). Taken together, there is strong evidence showing that IPV victimization is related to higher levels of CVD biomarkers.

Cardiovascular Outcomes

Cardiovascular symptoms and diagnosis are important indicators of adverse cardiovascular outcomes. The most commonly reported symptoms in this review were chest pain, palpitations, and shortness of breath.10,15,31 Scott-Storey et al10 analyzed a sample of 309 female IPV survivors living in Canadian communities, hypothesizing that chronic stress (operationalized by severity of past experience of IPV and ongoing abuse) was positively associated with cardiovascular symptoms (chest pain, shortness of breath, palpitations, and symptoms of hypertension). Notably, they found that neither severity of IPV nor current abuse was a significant predictor of those cardiovascular symptoms (χ22[n = 271] = 0.85, P = .655). It was also noted that half of the abused sample reported cardiovascular symptoms that were important indicators of ischemic heart disease, yet only 17.2% of the women received a diagnosis of CVD. This implied that healthcare providers might overlook the presentation of cardiovascular symptoms among female IPV survivors and fail to diagnose and treat CVD in this population.

Authors of 4 studies documented several CVD diagnoses that were frequently reported by abused women: coronary heart disease (CHD), heart attack, cardiac dysrhythmia, chronic ischemic heart disease, and cardiac valve disorders.10,13,26,27 The likelihood of developing CHD in this population was particularly striking. Vives-Cases et al27 conducted a secondary analysis of a sample that included 13 094 women from Spain. They found that 0.98% of their sample experienced IPV within the past 12 months and that this population was 5.28 times more likely to develop CHD in comparison with those who were never abused (aOR, 5.28; 95% CI, 1.45–19.25) after controlling for sociodemographic characteristics, social support, smoking, and BMI. Similarly, another study conducted by Breiding et al26 showed that female IPV survivors (26.4%) were nearly 1.5 times (aOR, 1.43; 95% CI, 1.06–1.94) more likely to develop CHD as compared with their nonabused counterparts.

In addition, authors of 5 studies reviewed used the Framingham Risk Score to assess long-term cardiovascular health for a 10- or 30-year time frame.11,22,29,30,32 This comprehensive measure has been widely considered as a validated instrument of estimating future CVD events in asymptomatic individuals because it takes into account multiple important risk factors of CVD, including age, gender, systolic BP, total cholesterol, high-density lipoprotein, use of antihypertensive medications, and smoking status.37,38 Stene and colleagues11 reported that women who disclosed physical or sexual IPV had a slightly higher risk of CVD in 10 years than those without IPV histories (P = .033). For example, the percentages of women who had more than 5.54% risk of 10-year estimated risk of CVD were 27.5% and 24.7% in those with and without IPV histories, respectively. Authors of the remaining 4 studies22,29,30,32 used the 30-year risk prediction model, and the results consistently showed higher CVD scores among female IPV survivors. In a study of 7392 young women that included female survivors (n = 1161), Wright et al29 found that those who experienced past-year IPV had a small yet significant increase in the mean score of 30-year CVD risk when compared with the nonabused group (9.6% vs 8.7%, P < .01). However, the relationship was no longer significant after adjusting for other important predictors in the model including race and ethnicity, education, pregnancy status, health insurance, and financial stress. These findings highlight the necessity of considering other contextual factors that may affect cardiovascular outcomes in IPV survivors. The same investigators subsequently used the same sample to conduct another analysis, assessing whether depressive symptoms, alcohol dependence, and perceived stress were potential mediators of the relationship between IPV and 30-year CVD risk. They found that stress (total indirect effect, 0.047; SE = 0.010, P < .01) and depression (total indirect effect, 0.054; SE = 0.012, P < .01) played contributing roles in the context of IPV and cardiovascular health. In summary, the evidence shown previously has indicated a potential correlation between IPV and long-term negative cardiovascular outcomes in female survivors.

Discussion

This literature review summarized evidence from 19 articles to investigate cardiovascular health in women with experiences of IPV. Although research in this area is limited, our findings suggest that IPV may be an important risk factor for the development of CVD. Compared with their nonabused counterparts, abused women are more likely to engage in unhealthy behaviors, experience cardiovascular symptoms, and have long-term cardiovascular complications. However, the overall mixed findings limit our ability to definitively establish the relationship between IPV and CVD. There are several factors that may help explain the inconsistent findings. First, the sample size widely ranged from 34 to 70 156, which could affect power and introduce great variability in the study results. Second, the differences among sample sociodemographics may influence women's responses toward IPV, coping strategies, and their knowledge about cardiovascular health and management. Finally, the researchers used different measures of both IPV and cardiovascular outcomes, which may contribute to mixed findings.

One of the major findings identified from this review is the high adoption rate of smoking and alcohol use among abused women, both of which are risk factors for CVD. Although it is unclear whether IPV experience is a direct cause of those unhealthy behaviors, this type of exposure to violence may precipitate maladaptive behaviors, and their relationship has been theoretically grounded in previous investigations on stress and coping.39,40 According to Lazarus and Folkman,41 an individual's coping strategies are often developed through an interplay between one's internal resources and external demands that are created by the stressful transaction. Those researchers found that people who appraised their problems as changeable tended to use more problem-focused strategies, whereas they were more likely to use emotion-focused strategies when the situation was appraised as not or less changeable.42 Hence, it is likely that many abused women select conflict-specific, maladaptive coping strategies with respect to the form, severity, or chronicity of IPV they experience.43 Therefore, fostering behavioral change should be considered as a top priority for CVD prevention among those women. Healthcare providers should incorporate the evaluation of coping skills and mental distress into their routine health assessment. Focus can be placed on identifying high-risk situations that most likely trigger tobacco or alcohol use and empower this vulnerable population with effective coping strategies and emotion regulation skills. In addition, further research is warranted to better understand how IPV characteristics might affect women's choice of unhealthy behaviors and how the engagement of those behaviors might change over time throughout IPV trajectories.10

Our review highlights the importance of using a total risk approach rather than using single risk factors to estimate the overall cardiovascular health among female IPV survivors. As the study results indicated, the assessment of BP, diabetes, cholesterol, or BMI has shown either an insignificant or mixed correlation with IPV. This could be partially explained by the cardioprotective effect of estrogen in women because most of the study participants were premenopausal women. Authors of growing research suggest the use of total risk approach to predict cardiovascular outcomes. Many researchers have recognized that the single risk factor approach may cause individuals with a low cardiovascular risk to receive unnecessary treatments while leaving the truly high-risk populations—those who present with high total cardiovascular risk resulting from multiple slightly elevated risk factors—neglected for timely medical interventions. Because many CVD factors tend to coexist and act multiplicatively,44 the total risk approach uses scoring prediction models that are centered on the profile of all essential cardiovascular risk factors, appearing to be a logical and effective means to predict negative cardiovascular consequences in the abused population. Indeed, our review showed that female IPV survivors generally had higher Framingham risk scores than nonabused women. This evidence not only suggests the long-term influence of IPV on one's cardiovascular health but also underscores that the total cardiovascular risk assessment approach could become a routine clinical instrument to identify high-risk individuals and reduce premature morbidity and mortality among abused women.

In addition, this review explored the association between IPV and cardiovascular biomarkers, a relatively new focus of linking IPV to health outcomes. The findings of elevated levels of IL-6 and CRP in abused women are consistent with the emerging literature on stress, inflammatory responses, and CVD.45 The changes of those biomarkers signal an early indication of systemic inflammation and endothelial dysfunction and may subsequently lead to atherosclerosis and promote the development of CVD.46 In our review, 2 studies15,23 tested the feasibility of using salivary specimen to measure cardiovascular biomarkers in the IPV population. Both suggested that this less invasive approach could potentially provide prognostic indication for cardiovascular risk in the IPV population. However, because research on IPV and cardiovascular biomarkers is still quite limited, it is important to explore the validity and clinical utility of using these novel biomarkers in large study samples before introducing them into the routine clinical assessment.

There are several limitations in this review that should be addressed. First, authors of the included studies predominantly used cross-sectional or secondary data analysis approaches to examine CVD. Although the use of a cross-sectional method is an efficient way to conduct a study, the data collected from each participant cannot be used to infer a causal relationship between IPV and CVD.47 Similarly, carrying out secondary data analysis enables existing data to be fully and appropriately explored, but this method limits the ability to measure all variables salient to CVD.10 Future research should include population-based and longitudinal studies, in an effort to observe cardiovascular change over and beyond the trajectory of violence. Second, authors of a vast majority of the studies reviewed used self-report to measure cardiovascular outcomes. Clinical information obtained by self-report may introduce bias to the results.11 Therefore, objective measures of CVD risk and outcomes are suggested for future studies. Finally, IPV is a complicated issue that takes various forms of abuse, timing, and severity. Most studies had limited measures of IPV that may not adequately capture the magnitude of the issue. It would be beneficial for future researchers to conduct a more comprehensive review of this problem and explore how the different types, severity, and chronicity of IPV have an impact on women's cardiovascular health.

Nurses, who are ideally positioned to identify women with experiences of IPV, can play a pivotal role to help this vulnerable population to prevent CVD occurrence and achieve optimal health outcomes. The 2019 American College of Cardiology/American Heart Association guideline48 has provided several recommendations for healthcare providers to improve primary prevention of CVD in clinical practice. Some essential ones are changing lifestyle behaviors (eg, diet and physical activity) and using traditional risk factors to estimate 10-year cardiovascular risk every 4 to 6 years among individuals who are 20 to 79 years old and free from CVD. Other recommendations include promoting patient-centered approaches (eg, team-based care, shared decision making, assessment of social determinants of health such as environmental and psychosocial factors) and initiating cost-effectiveness of prevention. Such strategies can be instrumental for nurses in guiding targeted interventions to meet individual needs and promote the overall population health outcomes.

Conclusion

Overall, this review demonstrates that the experience of IPV could increase women's risk for developing CVD. Intimate partner violence not only serves as a stressor affecting cardiovascular health through modifying women's lifestyle behaviors but also triggers a cascade of biological changes that pose long-lasting detrimental influences on one's health. To address cardiovascular risks in abused women, it is extremely vital to prevent IPV from occurring in the first place or avoid this problem from continuing. Healthcare providers are encouraged to adopt routine IPV screening and counseling in both primary care and community settings and refer female survivors for specialty services as early as possible. Once IPV is identified, healthcare providers should consider initiating early recognition of CVD in this vulnerable population through a comprehensive assessment of lifetime experiences of victimization, coping strategies, and total risk factors. Targeted interventions need to be timely implemented at the individual and community levels simultaneously to mitigate the effects of violence in this large vulnerable group of women.

What’s New and Important

  • Women with experiences of IPV are at risk for developing adverse cardiovascular consequences. More research studies are needed to investigate this important yet overlooked problem.
  • Routine assessment of CVD risk factors and symptoms may be beneficial to improve cardiovascular outcomes among female IPV survivors. In particular, evidence has suggested that CVD biomarkers could potentially be used as an instrument to detect CVD in this population.
  • Healthcare providers are recommended to recognize the importance of screening IPV in clinical practice. Individualized interventions, such as teaching effective coping strategies, should be implemented in a timely manner.

REFERENCES

1. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137(1):e67–e492. doi:10.1161/CIR.0000000000000558.
2. Centers for Disease Control and Prevention. Women and heart disease fact sheet. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_women_heart.htm. Accessed June 1, 2019.
3. Scott-Storey KA. Abuse as a gendered risk factor for cardiovascular disease: a conceptual model. J Cardiovasc Nurs. 2013;28(6):E1–E8. doi:10.1097/JCN.0b013e318279e372.
4. Suglia SF, Sapra KJ, Koenen KC. Violence and cardiovascular health: a systematic review. Am J Prev Med. 2015;48(2):205–212. doi:10.1016/j.amepre.2014.09.013.
5. Black MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.
6. Department of Justice. Domestic Violence. https://www.justice.gov/ovw/domestic-violence. Accessed April 2, 2018.
7. Smith SG, Zhang X, Basile KC, et al. The National Intimate Partner and Sexual Violence Survey: 2015 Data Brief—Updated Release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2018.
8. Association of Women's Health, Obstetric and Neonatal Nurses. Intimate partner violence. J Obstet Gynecol Neonatal Nurs. 2019;48(1):112–116. doi:10.1016/j.jogn.2018.11.003.
9. Kendall-Tackett KA. Inflammation, cardiovascular disease, and metabolic syndrome as sequelae of violence against women: the role of depression, hostility, and sleep disturbance. Trauma Violence Abuse. 2007;8(2):117–126. doi:10.1177/1524838007301161.
10. Scott-Storey K, Wuest J, Ford-Gilboe M. Intimate partner violence and cardiovascular risk: is there a link? J Adv Nurs. 2009;65(10):2186–2197. doi:10.1111/j.1365-2648.2009.05086.x.
11. Stene LE, Jacobsen GW, Dyb G, Tverdal A, Schei B. Intimate partner violence and cardiovascular risk in women: a population-based cohort study. J Womens Health (Larchmt). 2013;22(3):250–258. doi:10.1089/jwh.2012.3920.
12. Vijayaraghavan M, Tochterman A, Hsu E, Johnson K, Marcus S, Caton CLM. Health, access to health care, and health care use among homeless women with a history of intimate partner violence. J Community Health. 2012;37(5):1032–1039. doi:10.1007/s10900-011-9527-7.
13. Breiding MJ, Black MC, Ryan GW. Chronic disease and health risk behaviors associated with intimate partner violence—18 U.S. states/territories, 2005. Ann Epidemiol. 2008;18(7):538–544. doi:10.1016/j.annepidem.2008.02.005.
14. Steptoe A, Kivimäki M. Stress and cardiovascular disease. Nat Rev Cardiol. 2012;9(6):360–370. doi:10.1038/nrcardio.2012.45.
15. Halpern LR, Shealer ML, Cho R, et al. Influence of intimate partner violence (IPV) exposure on cardiovascular and salivary biosensors: is there a relationship? J Natl Med Assoc. 2017;109(4):252–261. doi:10.1016/j.jnma.2017.08.001.
16. Newton TL, Fernandez-Botran R, Miller JJ, Lorenz DJ, Burns VE, Fleming KN. Markers of inflammation in midlife women with intimate partner Violence histories. J Womens Health (Larchmt). 2011;20(12):1871–1880. doi:10.1089/jwh.2011.2788.
17. Mozaffarian D, Wilson PWF, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031–3038. doi:10.1161/CIRCULATIONAHA.107.738732.
18. Patel SA, Winkel M, Ali MK, Narayan KMV, Mehta NK. Cardiovascular mortality associated with 5 leading risk factors: national and state preventable fractions estimated from survey data. Ann Intern Med. 2015;163(4):245–253. doi:10.7326/M14-1753.
19. Sun X, Jia Z. A brief review of biomarkers for preventing and treating cardiovascular diseases. J Cardiovasc Dis Res. 2012;3(4):251–254. doi:10.4103/0975-3583.102688.
20. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–553. doi:10.1111/j.1365-2648.2005.03621.x.
21. Dichter ME, Cerulli C, Bossarte RM. Intimate partner violence victimization among women veterans and associated heart health risks. Womens Health Issues. 2011;21(suppl 4):S190–S194. doi:10.1016/j.whi.2011.04.008.
22. Clark CJ, Alonso A, Everson-Rose SA, et al. Intimate partner violence in late adolescence and young adulthood and subsequent cardiovascular risk in adulthood. Prev Med. 2016;87:132–137. doi:10.1016/j.ypmed.2016.02.031.
23. Out D, Hall RJ, Granger DA, Page GG, Woods SJ. Assessing salivary c-reactive protein: longitudinal associations with systemic inflammation and cardiovascular disease risk in women exposed to intimate partner violence. Brain Behav Immun. 2012;26(4):543–551. doi:10.1016/j.bbi.2012.01.019.
24. Clark CJ, Everson-Rose SA, Alonso A, et al. Effect of partner violence in adolescence and young adulthood on blood pressure and incident hypertension. PLoS ONE. 2014;9(3):e92204. doi:10.1371/journal.pone.0092204.
25. Flores-Torres MH, Lynch R, Lopez-Ridaura R, et al. Exposure to violence and carotid artery intima-media thickness in Mexican women. J Am Heart Assoc. 2017;6(8):e006249. doi:10.1161/JAHA.117.006249.
26. Gass JD, Stein DJ, Williams DR, Seedat S. Intimate partner violence, health behaviours, and chronic physical illness among south African women. S Afr Med J. 2010;100(9):582–585.
27. Vives-Cases C, Ruiz-Cantero MT, Escribà-Agüir V, Miralles JJ. The effect of intimate partner violence and other forms of violence against women on health. J Public Health (Oxf). 2011;33(1):15–21. doi:10.1093/pubmed/fdq101.
28. Mason SM, Wright RJ, Hibert EN, Spiegelman D, Forman JP, Rich-Edwards JW. Intimate partner violence and incidence of hypertension in women. Ann Epidemiol. 2012;22(8):562–567. doi:10.1016/j.annepidem.2012.05.003.
29. Wright EN, Hanlon A, Lozano A, Teitelman AM. The association between intimate partner violence and 30-year cardiovascular disease risk among young adult women. J Interpers Violence. 2018. doi:10.1177/0886260518816324.
30. Wright EN, Hanlon A, Lozano A, Teitelman AM. The impact of intimate partner violence, depressive symptoms, alcohol dependence, and perceived stress on 30-year cardiovascular disease risk among young adult women: a multiple mediation analysis. Prev Med. 2019;121:47–54. doi:10.1016/j.ypmed.2019.01.016.
31. Bonomi AE, Anderson ML, Reid RJ, Rivara FP, Carrell D, Thompson RS. Medical and psychosocial diagnoses in women with a history of intimate partner violence. Arch Intern Med. 2009;169(18):1692–1697. doi:10.1001/archinternmed.2009.292.
32. Renner LM, Spencer RA, Morrissette J, et al. Implications of severe polyvictimization for cardiovascular disease risk among female survivors of violence. J Interpers Violence. 2017. doi:10.1177/0886260517728688.
33. Symes L, McFarlane J, Frazier L, et al. Exploring violence against women and adverse health outcomes in middle age to promote women's health. Crit Care Nurs Q Crit Care Lifesp. 2010;33(3):233–243. doi:10.1097/CNQ.0b013e3181e6d7c4.
34. Baggett TP, Lebrun-Harris LA, Rigotti NA. Homelessness, cigarette smoking and desire to quit: results from a US national study. Addiction. 2013;108(11):2009–2018. doi:10.1111/add.12292.
35. Prasad DS, Das BC. Physical inactivity: a cardiovascular risk factor. Indian J Med Sci. 2009;63(1):33–42.
36. Polak JF, O'Leary DH. Carotid intima-media thickness as surrogate for and predictor of CVD. Glob Heart. 2016;11(3):295–312.e3. doi:10.1016/j.gheart.2016.08.006.
37. D'Agostino RB Sr., Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117(6):743–753. doi:10.1161/CIRCULATIONAHA.107.699579.
38. Pencina MJ, D'Agostino RB Sr., Larson MG, Massaro JM, Vasan RS. Predicting the 30-year risk of cardiovascular disease: the Framingham heart study. Circulation. 2009;119(24):3078–3084. doi:10.1161/CIRCULATIONAHA.108.816694.
39. Jun HJ, Rich-Edwards JW, Boynton-Jarrett R, Wright RJ. Intimate partner Violence and cigarette smoking: association between smoking risk and psychological abuse with and without co-occurrence of physical and sexual abuse. Am J Public Health. 2008;98(3):527–535. doi:10.2105/AJPH.2003.037663.
40. Flanagan JC, Jaquier V, Overstreet N, Swan SC, Sullivan TP. The mediating role of avoidance coping between IPV victimization, mental health, and substance abuse among women experiencing bidirectional IPV. Psychiatry Res. 2014;220(1–2):391–396. doi:10.1016/j.psychres.2014.07.065.
41. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York, NY: Springer; 1984.
42. Folkman S, Lazarus RS. An analysis of coping in a middle-aged community sample. J Health Soc Behav. 1980;21(3):219–239. doi:10.2307/2136617.
43. Sullivan TP, Schroeder JA, Dudley DN, Dixon JM. Do differing types of victimization and coping strategies influence the type of social reactions experienced by current victims of intimate partner violence? Violence Against Women. 2010;16(6):638–657. doi:10.1177/1077801210370027.
44. World Health Organization. Prevention of Cardiovascular Disease: Guidelines for Assessment and Management of Cardiovascular Risk. Geneva, Switzerland: World Health Organization; 2007.
45. Liu YZ, Wang YX, Jiang CL. Inflammation: the common pathway of stress-related diseases. Front Hum Neurosci. 2017;11:316. doi:10.3389/fnhum.2017.00316.
46. Upadhyay RK. Emerging risk biomarkers in cardiovascular diseases and disorders. J Lipids. 2015;2015:971453. doi:10.1155/2015/971453.
47. Sedgwick P. Ecological studies: advantages and disadvantages. BMJ. 2014;348:g2979. doi:10.1136/bmj.g2276.
48. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2019;140(11):e596–e646. doi:10.1161/CIR.0000000000000678.
Keywords:

cardiovascular diseases; intimate partner violence; review literature; risk factors; women's health

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.