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.
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