Female and Older Veterans Face Unique Cardiovascular Challenges

Highlights of Recent ACC Sessions

NEW ORLEANS — Women veterans face a constellation of cardiovascular risks that diverge sharply from their civilian counterparts, and older male veterans carry their own burdens of frailty, social isolation, and service-connected exposures that complicate cardiac care. Those were central themes at the American College of Cardiology’s 75th Annual Scientific Sessions in New Orleans March 28-30, where a session titled “Duty, Honor and Heart Health” brought together military and VA cardiologists to address the gaps in care for these populations.

The session also featured new research on cardiac rehabilitation uptake among veterans after heart attacks and on the cardiovascular consequences of mental health disorders — two areas where the veteran population continues to lag civilian benchmarks.

A Population at Accelerated Risk

Faith Kelly, MD, Lt. Col., USAF, director of the Cardiology Clinic at Brooke Army Medical Center, Fort Sam Houston, TX, and assistant professor of medicine at the Uniformed Services University in Bethesda, MD,, opened by challenging the common assumption that military service confers lasting health advantages.

“We start off in our service time with high physical fitness, ready access to medical care,” Kelly said, “but that advantage is quickly eroded by several exposures that come down the road during our service time, both mental and psychological exposures.”

The data she cited were sobering. A 2014 analysis found that service in and of itself functioned as an independent risk factor for cardiac events in women even two decades later. Several exposures specific to military environments compounded this baseline risk including oil well fires, smoke, chemical nerve agents, and chemical prophylaxis for nerve agents have all been associated with increased risk of cardiac events. The psychological burden was equally significant, with high rates of post-traumatic stress disorder (PTSD), sleep disorders, and military sexual trauma contributing to alterations in pathways that ultimately drive cardiovascular disease.

Among women specifically, polycystic ovary syndrome (PCOS) diagnoses doubled between 2014 and 2023 in the active duty population, adding another cardiovascular risk factor to an already burdened group. Gulf War Illness diagnoses carried a hazard ratio of 1.8 for heart disease development, and a PTSD diagnosis raised it 2.5-fold.

Kelly also highlighted findings from her own institution. “Out of Brooke Army Medical Center, we found that we had 2.5 to 3.5 times the risk of developing pre-eclampsia compared to the civilian population in that area,” she said. That finding has direct implications for long-term cardiovascular health, as pre-eclampsia is itself a recognized risk factor for future heart disease.

“Because women in the service have such a high incidence of PTSD, depression, and military sexual trauma exposure, this should really trigger us to start looking at them and screening them, because we have proved an accelerated trajectory of heart disease,” Kelly said, encouraging increased focus for both civilian and federal clinicians who treat women in or with a history of service.

The VA’s Growing Women’s Health Caseload

Elizabeth Le, MD, cardiologist at the VA Portland Health Care System and associate professor of medicine in the Division of Cardiovascular Medicine at Oregon Health & Science University School of Medicine, provided an epidemiological backdrop for the clinical discussion.

Women now make up 17.5% of the active military and 21.6% of the National Guard and Reserves. There are currently more than 2 million women veterans, and that number is projected to represent approximately 18% of the total veteran population by 2040, Le noted. That growth has direct implications for VA planning and resource allocation.

The VA’s own data reflect the complexity of this population. Among women veterans receiving VA care, the median age is 52, though roughly a quarter are 65 or older. While cardiovascular disease prevalence is higher in men across all age groups, Le emphasized that mental health conditions present differently by sex. Depression diagnoses are more common among women veterans than men. In the 45-to-64 age bracket, women carry a higher burden of PTSD diagnosis than their male counterparts.

“Women veterans are disproportionately affected by mental health conditions, including traumatic brain injury, PTSD, and depression,” Le said. Coronary artery disease remains the most prevalent cardiovascular condition, but she underscored that conditions such as microvascular disease, spontaneous coronary artery dissection, and peripartum cardiomyopathy deserve particular attention in this population, as these conditions are underrecognized and may present atypically.

Le also addressed structural barriers within the VA system. “One area for improvement is making VA care more accessible and comfortable for women, especially those who may avoid care due to past experiences,” such as military sexual trauma, Le said. She noted that specialized clinics and providers trained in women’s health would help address the gap.

Transition of Care and the Civilian-VA Interface

Rebecca Seifried, DO, RDN, chief of medicine and chief of cardiology at Fort Belvoir Community Hospital in Virginia, focused her remarks on the transition period from active duty to veteran status, often a critical and often poorly managed handoff.

Approximately 9 million of the 20 million U.S. veterans currently receive VA care, including about 1 million women. The Mission Act of 2014 created a community care pathway to address concerns about wait times and geographic access, and that mechanism has become essential to cardiovascular care delivery.

Seifried highlighted the earlier onset of cardiovascular disease in women veterans, attributing part of the risk to premature menopause, which occurs at about three times the rate seen in the general civilian population. About 50% of women veterans have at least one cardiovascular condition, compared to 37% of civilian women. Among women veterans under 45, 60% carry at least one cardiovascular risk factor, a figure that climbs above 80% in those older than 65.

She noted that while VA outcomes in areas such as heart failure mortality, readmission rates, and elective PCI are comparable to or better than community care benchmarks, access challenges persist. More than a third of patients still wait longer than 30 days for appointments, and women veterans face a four-fold higher risk of homelessness compared to civilian women, a social determinant with direct consequences for continuity of care.

Scott Hummel, MD, MS, section chief of cardiology and director of the Heart Failure Program at the VA Ann Arbor, MI, Healthcare System, and assistant professor of internal medicine at the University of Michigan Medical School, broadened the discussion to the geriatric veteran population, invoking the framework of the “five Ms” of geriatric medicine: multiple morbidity, medications, mind, mobility, and what matters most.

Frailty, Hummel noted, is strongly associated with increased cardiovascular mortality in this cohort, but it is far from alone in increasing risk. PTSD affects up to one-third of Vietnam-era veterans and 40% of veterans with heart failure experience food insecurity. Social isolation, which affects 44% of veterans over age 60, is independently linked to worse cardiovascular outcomes. Hearing impairment, which affects 3.6 million veterans and doubles dementia risk, adds further complexity. Agent Orange exposure, for which ischemic heart disease is a recognized service-connected condition, represents an additional layer of cardiovascular risk specific to this generation.

Cardiac Rehabilitation: Proven Benefit, Persistent Underuse

Kevin McConeghy, PharmD, a health services investigator at the Providence , RI, VAMC, presented findings from a target trial emulation examining cardiac rehabilitation (CR) after ST-elevation myocardial infarction in veterans in a separate presentation.

Among 5,403 veterans discharged alive after a ST-segment elevation myocardial infarction (STEMI) between October 2016 and December 2024, only 762 or approximately 14% initiated CR within 90 days of discharge. That figure stands in stark contrast to Medicare-eligible populations, where McConeghy noted roughly one in three beneficiaries released after STEMI undertake cardiac rehabilitation.

Using a cloning-censoring-weighting approach to control for baseline and time-varying confounders, his team found that cardiac rehabilitation initiation was associated with a 2.8 percentage point reduction in major adverse cardiovascular events or death at one year, a gap that widened to 7.9 percentage points at three years.

“CR appears quite effective for the people who get it,” McConeghy said, “but one of the key findings is that not that many people get CR in this population.”

When asked why uptake remains so low, he pointed to structural and patient-level factors. “The basic understanding is access to care, the ability of rural veterans to have access to a cardiac rehabilitation facility, plays a big role in it,” he said. In addition, “it’s a difficult population, with a high degree of mental health issues, substance abuse, and so on.”

He also acknowledged the absence of aggressive VA-wide policy requiring CR initiation for eligible patients following acute coronary syndromes, calling improvements in uptake an urgent priority.

Mental Health Disorders as Cardiovascular Drivers

Ramin Ebrahimi, MD, director of interventional cardiovascular research and co-director of the Cardiac Catheterization Laboratory at the Greater Los Angeles VA, and professor of medicine at the University of California, Los Angeles, provided a synthesis of the evidence linking psychiatric conditions to cardiac outcomes and emerging data on whether treatment of those conditions can mitigate cardiovascular risk.

Ebrahimi traced the research back more than four decades, to early nuclear imaging studies demonstrating that mental stress could produce reversible perfusion defects in patients with stable angina. The body of evidence has since expanded substantially, including studies showing PTSD and depression are each independently associated with cardiovascular disease, with shared genetic loci suggesting biological as well as behavioral pathways.

In a study from his institution examining more 800,000 women veterans, PTSD was associated with ischemic heart disease with a hazard ratio of 1.44. The association persisted across age groups and was even higher among Black and Hispanic women. A companion analysis found similarly elevated risks for stroke and TIA, though hemorrhagic stroke rates did not differ significantly between those with and without PTSD.

The question of whether treating mental health conditions reduces cardiovascular risk produced intriguing, if preliminary, findings. In a cohort of more than 600 women veterans, 40% had been exposed to at least one antidepressant. Compared to untreated patients, those receiving antidepressants showed significantly reduced rates of the composite outcome of heart attack, stroke, atrial fibrillation, heart failure, and pulmonary hypertension.

Ebrahimi was careful to note that antidepressants are prescribed for indications beyond depression including pain, sleep disorders, migraine, and menopausal symptoms and his team stratified the data accordingly. “It seems like you get a much better separation of the curves if they are used in those who actually have mental disorders,” he said, suggesting that the cardiovascular benefit may be greatest when treatment occurs for depression.

A Call for Civilian-VA Collaboration

Across the sessions, a unifying theme emerged: the VA cannot address these needs alone. Le put it plainly in her closing remarks.

“Women veterans are a special group … because they have these particular risks that we don’t think about,” she said. “We know that the veterans’ outcomes are lagging behind the civilian population. We have to depend on our community. But I think it’s our job also to educate our civilian providers who are partnering with us to provide care.”

Kelly echoed that call from an active-duty perspective, urging frontline providers and cardiologists, whether practicing within or outside the military health system, to develop fluency in the specific risk factors this population carries, many of which do not resolve with the end of service.

For cardiologists in community practice seeing veterans, the sessions emphasized that standard cardiovascular risk frameworks were not built with this population in mind, and closing the outcomes gap depends on closing the knowledge gap first.