Insomnia, Sleep Apnea, and Incidence of Hypertension and Cardiovascular Disease Among Men and Women US Veterans

Background Comorbid insomnia and obstructive sleep apnea (COMISA) is associated with cardiovascular disease (CVD) in older adults. The associations of COMISA with cardiovascular risk among military veterans, who show a greater risk for hypertension and CVD than non‐Veterans, and whether associations differ by sex are unknown. Thus, we examined associations of COMISA with incident hypertension and CVD risk in post‐9/11 Veterans. Methods This retrospective cohort included patients who enrolled in Veterans Health Administration care from 2001 to 2021. Insomnia and obstructive sleep apnea were defined by ≥2 outpatient diagnoses. Hypertension was defined by ≥2 outpatient‐coded diagnoses or ≥1 antihypertensive medication fill; CVD by ≥1 inpatient or ≥2 outpatient diagnoses. Time‐varying Cox proportional hazard models adjusted for demographics, behavioral, and clinical factors were conducted overall and by sex. Sensitivity analyses accounted for health care use, a 180‐day washout, sleep study–confirmed diagnoses, outpatient blood pressure data, and inclusion of patients deceased during follow‐up. Results Among 937 598 veterans (12% women; median age, 41 years), COMISA was associated with increased hypertension risk overall (adjusted hazard ratio [aHR], 2.43 [95% CI, 2.36–2.50]), in men (aHR, 2.09 [95% CI, 2.02–2.16]) and in women (aHR, 2.20 [95% CI, 2.00–2.42]). Insomnia alone (aHR, 1.27–1.44) and obstructive sleep apnea only (aHR, 2.00–2.26) were also associated with elevated risk. COMISA was similarly associated with CVD risk overall (aHR, 3.81 [95% CI, 3.64–3.99]), in men (aHR, 3.81 [95% CI, 3.63–4.00]) and women (aHR, 3.44 [95% CI, 2.98–3.98]), as were insomnia (aHR, 1.36–1.37) and obstructive sleep apnea (aHR, 3.32–2.62). Sensitivity analyses were consistent. Conclusions COMISA conferred the greatest risk of hypertension and CVD among post‐9/11 Veterans. Identifying disordered sleep among men and women may be an important CVD prevention priority.