Research Suggests More Focus Needed on Women Veterans Especially
ATLANTA — New research is adding to the evidence that veterans are at increased risk for cardiometabolic conditions and poor cardiovascular outcomes.
Based on presentations at the virtual American Heart Association’s 2021 Scientific Sessions conference recently, better and more comprehensive screening and interventions for veterans, particularly female veterans, appear to be necessary to improve cardiovascular health in this population.
Within the VA healthcare system, cardiovascular disease is the leading cause of hospitalization, and—as highlighted in these and other studies—there are unique factors that put veterans at higher risk for developing cardiovascular disease.1
“For example, a history of trauma is associated with higher risk for metabolic abnormalities and clustering of cardiovascular risk factors like abnormal lipids, higher blood pressure and diabetes, which are all contributors to cardiovascular risk,” said Donald Lloyd-Jones, MD, volunteer president of the American Heart Association and professor of preventive medicine, medicine and pediatrics at Northwestern University’s Feinberg School of Medicine in Chicago.
The link between military service and cardiovascular disease is found among veterans outside of the United States, as well. One study presented by scientists from the United Kingdom investigated the relationship between combat-related traumatic injury and cardiovascular risk. The research found that British veterans deployed during the Afghanistan War who experienced severe injuries were significantly more likely to have metabolic syndrome than their noninjured counterparts. Metabolic syndrome, a cluster of conditions including high blood pressure, high cholesterol, high blood sugar and excess abdominal fat, increases a person’s risk for heart disease, diabetes and stroke.2
Cardiovascular disease also is the leading cause of death for women in the United States, and female veterans are at higher risk due to an increased prevalence of mental health issues such as post-traumatic stress, anxiety and depression. Yet one study presented by VA researchers examined the health records of more than 6,000 women veterans and found that, despite the fact that 35% of the women had diagnosed depression, less than 10%—28% of those with depression—had undergone a cardiovascular screening.
Although the study’s sample of women had more traditional risks for heart disease, the biggest drivers of cardiovascular screening within a primary care setting were obesity and post-traumatic stress disorder. Since PTSD is a major predictor for ischemic heart disease among female veterans, the researchers say that it’s critical to employ cardiovascular screening and interventions in this population.3
“Clinicians should consider veterans at risk for a number of chronic health conditions related to social determinants of health and be particularly sensitized to needs for screening and treating risk factors among veterans, as well as support for mental health issues,” said Lloyd-Jones. He also noted that more work remains in order to better understand the connection between veterans’ mental health and cardiovascular risk. “We need to understand the interplay of stressors and health behaviors in veterans over the long term and how they contribute to disease,” he said. “We also need to understand what factors contribute to resilience against physical and mental health issues and try to enhance these factors.”
Echoing similar concerns, a third study examined cardiovascular death rates among female veterans from 2000 to 2017. The researchers reviewed the electronic medical records of all women who visited any VAMC during that 17-year period and found that, despite that cardiovascular deaths were declining among women nationally, age-adjusted cardiac death among women veterans shot up by more than 49%. By 2017, the end of the study period, the age-adjusted cardiac death rate for women veterans was more than twice the rate for U.S. women overall.4
Women Veterans
“I think these findings were the most surprising and concerning, [because], during that same period, cardiovascular death rates for U.S. women nationally were declining sharply, especially from 2000 to 2010,” said Lloyd-Jones. “These data indicate that we must focus specifically on improving cardiovascular health, and identifying and controlling risk factors, among women veterans.”
Yet another study of female veterans focused on chronic hypertension during pregnancy—maternal chronic hypertension—which has recently become more widespread among civilians. The study used data from the Surgical Treatment Outcomes for Patients with Psychiatric Disorders (STOPP) project, which includes 11 million veterans.
Researchers identified more than 43,000 women who had chronic hypertension prior to becoming pregnant and found that nearly 10% had maternal chronic hypertension. Almost two-thirds of those with MCH had uncontrolled blood pressure in the year prior to pregnancy, and nearly 20% received an antihypertensive medication that was not recommended for pregnant women during the pregnancy. The researchers say the study underscores the need for interventions to decrease MCH among women veterans, improve management of hypertension before pregnancy and ensure that appropriate medications are used during pregnancy.5
Obesity/overweight also has increased steadily among the U.S. civilian population, and researchers examined trends in body mass index among adult veterans over a 14-year period (from 2002 to 2016). The team examined the VHA medical records of one million men and women and calculated prevalence of obesity by race and geographic region. They found that obesity increased among all racial groups except for Asian men and women, who also had the lowest prevalence of obesity. Morbid obesity increased the most among Hawaiian/Pacific Islander and American Indian veterans. Geographically, obesity was most prevalent among men and women in the Midwest, while morbid obesity declined among women in the Northeast.6
Lastly, a group of researchers sought to learn more about the genetic factors associated with dilated cardiomyopathy, a disease in which the heart muscle becomes weakened or enlarged. The team leveraged data from the Million Veterans Program, a research database that includes questionnaires, VA electronic health records, and blood samples for genomic and other testing. This database allows researchers to discover new genetic or environmental risk factors associated with disease.7
The study of nearly 500,000 veterans of European and African ancestry identified five novel, common gene locations associated with dilated cardiomyopathy. The study’s findings may help scientists develop more precise tools to improve diagnosis and treatment for people with the disease. Importantly, the findings also show the potential to scale this type of research using data from additional biobank populations.
- “VA Research on Cardiovascular Disease.” VA Office of Research & Development. https://www.research.va.gov/topics/cardio.cfm
- Boos, CJ, et al. The Relationship Between Combat-related Traumatic Injury and Cardiometabolic Risk. American Heart Association’s Scientific Sessions 2021.
- Bean-Mayberry B, et al. What Predicts the Use of Cardiovascular Screeners in Primary Care Among Women Veterans With Depression? American Heart Association’s Scientific Sessions 2021.
- Ebrahimi R, et al. Trends in Cardiovascular Death Rates Among Women Veterans. American Heart Association’s Scientific Sessions 2021.
- Harding, CC, et al. Management of Chronic Hypertension Prior to Pregnancy Among Women Veterans. American Heart Association’s Scientific Sessions 2021.
- Imran TF, et al. Prevalence and Trends of Overweight and Obesity Among United States Veterans From 2002 to 2016. American Heart Association’s Scientific Sessions 2021.
- Aragam KG, et al. Genome-Wide Association Study of Dilated Cardiomyopathy in the VA Million Veteran Program. American Heart Association’s Scientific Sessions 2021.