United States Women Veterans and Cardiovascular Disease Primary Prevention

Women have served in the US Armed Forces since 1901 and represent the fastest-growing demographic within the Veterans Administration (VA).1,2 The current women veteran (WV) demographic trend is trimodal, with the largest group representing middle-aged women (45–64 years), followed by a growth in the number of older WVs (65+ years) and younger WVs (18–44 years).1 Compared with civilian women, WVs have higher rates of cardiovascular disease (CVD) (7.3% vs 8.9%) and CVD mortality (26.4% higher in WVs).3,4 In addition, WVs have poorer general health, including traditional CVD risk factors, and a greater incidence of nontraditional risk factors, such as mental health and chronic health conditions, compared with civilian women.3 Traditional and Nontraditional Cardiovascular Disease Risk Factors Traditional risk factors for CVD include hypertension (HTN), hyperlipidemia, diabetes, obesity, and smoking. These risk factors are high in all WVs, but most concerning perhaps is the increase in traditional risk factors among younger WVs. Nearly 60% of younger WVs (18–44 years) have at least 1 major CVD risk factor.1 Cardiovascular disease risk factor prevalence increases to 75% in middle age (45–64 years) and over 80% in WVs older than 65 years.5 An analysis of VA billing codes found that HTN is the third leading diagnosis among WVs aged 45 to 64 years and the leading diagnosis among WVs older than 65 years.1 Nontraditional risk factors for CVD include mental health diagnoses such as posttraumatic stress disorder and depression. A study of post-9/11 veterans found that 45% of WVs had been given a diagnosis of depression and 56% were given a diagnosis of posttraumatic stress disorder.6 Depression is the only leading CVD risk factor identified as higher among WVs than male veterans, an indication that the CVD profile of WVs differs from that of male veterans.6 Among WVs younger than 45 years, depression is the most common CVD risk factor.1 Additional veteran-specific risk factors that may impact CVD and its risk factors include military sexual trauma and homelessness.7 Women veterans are also a unique group in CVD risk due to their racial/ethnic makeup. Women veterans are more racially and ethnically diverse than both civilian women and male veterans, with 30% identifying as Black, 8% as Hispanic or Latina, and 2% as Asian.1 Racial disparities have consistently been recognized as important factors in CVD outcomes. Cardiovascular Disease and Reproductive Health The higher incidence of CVD and CVD risk factors found in younger WVs also has implications for reproductive health.8 Common contraceptive methods, such as combined hormonal contraception and Depo-Provera injections, are not recommended for women with CVD.9,10 Women veterans with HTN have an increased risk of developing gestational HTN, preeclampsia, and eclampsia compared with those without preexisting HTN.8 In turn, these pregnancy-related complications also increase the risk of developing CVD later in life.11 For WVs beyond childbearing age, menopause can also be concerning for CVD, especially when developed at earlier ages. Early menopause is more common among WVs compared with civilian women and has been linked to CVD outcomes.12 Hormone therapies used to treat menopause symptoms and symptoms, such as hot flashes and night sweats, can also lead to CVD.13 Challenges in Cardiovascular Disease Care and Prevention Veterans Affairs healthcare utilization among WVs has doubled over the last 15 years.1 Despite this increase in WVs accessing care through the VA, barriers persist. A national sample of WVs cited feeling disrespected in healthcare settings, lack of affordability, and the perception of not needing preventative CVD care from clinicians as leading factors for not seeking CVD preventative care.14 In addition to a perception of not being at risk for CVD, WVs endorsed a lack of confidence, stress, and depression as factors for low engagement in CVD-preventative behaviors.15 Nurses' Influence in Cardiovascular Disease Prevention With rising numbers of women in the military and VA, there is an urgent need to address both traditional and nontraditional risk factors for CVD, and nurses are uniquely positioned to address CVD prevention in WVs by leveraging their roles in direct care, patient education, and advocacy. Nurses play a pivotal role in implementing early screening and education initiatives for CVD prevention, particularly in tailoring interventions to address mental health conditions, lifestyle factors, and reproductive health challenges unique to WVs. Nurses can use health literacy tools to assess patients' understanding of CVD risk factors and tailor communication to improve disease knowledge. Incorporating teach-back methods and interactive education, such as simulated scenarios, can help reinforce practical skills such as monitoring blood pressure or making heart-healthy dietary choices. Future Directions for Cardiovascular Disease Prevention Cardiovascular disease risk in WVs is multifactorial, and risks are often compounded by one another (ie, racial/ethnic minority WVs with posttraumatic stress disorder have a higher risk of CVD).16 Addressing the complex factors that contribute to the unique CVD risk profile in WVs will require a collaborative approach across VA and community care. Increasing numbers of WVs who choose to receive mental health treatment and primary care at the VA means multiple touchpoints for CVD surveillance and education. All VA medical centers have Health Promotion and Disease Prevention Program Managers, Women Veteran Program Managers, and VA Maternity Care Coordinators, roles often filled by nurses. Coordinated CVD prevention efforts should be made among these roles to ensure communication across the continuum of WVs' care, including primary care and mental health services. Communication should also be enhanced between community and VA care, especially for preconception visits for younger WVs (<45 years), to inform the risks during and after pregnancy, a task well suited for nurses. In addition, interventional programs are necessary to build on the education components. The authors of the Enhancing Mental and Physical Health of Women through Engagement and Retention 2.0 QUERI study are taking steps to expand telehealth preventative and mental health services to WVs and offer a promising approach to CVD prevention.17 Community-based programs, such as heart-healthy cooking classes, community fitness classes, and mental health support groups, are additional practical ways for nurses to engage WVs and empower them to adopt healthier lifestyles. Prevention efforts should also be expanded to educate younger WVs and active-duty and reserve military members. A VA and Department of Defense partnership for targeting CVD prevention in younger female military members could help kick-start education and prevention efforts before women become veterans. Enhanced early identification of risk for CVD in WVs will be critical to preventing worsening CVD and CVD mortality. A new CVD risk calculator has already shown improvements in predicting CVD risk among White and Hispanic WVs by including depression as a component.18 Nurses can incorporate this tool into primary care visits or as a previsit screener available through the patient portal, which offers a low-cost and low-effort measure that could reduce CVD burden. By leveraging their positions in primary care and community settings, nurses can foster stronger engagement in preventive measures and advocate for integrating innovative tools, such as the new CVD risk calculator, into routine care practices. The growing body of literature over the past decade to enhance knowledge of WVs and CVD risk as well as the increasing WV population make now an optimal time to start shifting the focus from information gathering to addressing how to prevent future CVD incidence through intervention trials for tailored WV CVD prevention.