The research team, led by investigators including Ramin Ebrahimi, Paul A. Dennis, and Jennifer A. Sumner, drew on national electronic health records spanning 2000 to 2019, a period covering multiple military service eras. Women veterans represent the fastest-growing group within the Veterans Health Administration, nearly tripling in number from roughly 160,000 in 2000 to nearly 440,000 in 2015, and they are projected to account for nearly 18 percent of all living US veterans by 2040. Yet despite carrying a heavier burden of both psychiatric and traditional cardiovascular risk factors than civilian women or male veterans—and experiencing higher cardiovascular mortality—they have been strikingly underrepresented in research on the PTSD-heart disease connection.

Methodologically, the study was designed to guard against the confounding that has plagued earlier work in this field. The investigators identified 622,312 women veterans with at least one VHA healthcare encounter, then excluded anyone with pre-existing cardiovascular disease. From this pool, 140,210 women with documented PTSD were matched to 101,448 women without the disorder using propensity score methods. Rather than relying on conventional statistical matching, the team employed extreme gradient boosting, a machine learning algorithm that iteratively models residuals to capture complex interactions among dozens of variables, including demographics, traditional risk factors such as hypertension and smoking, female-specific risks like preeclampsia, and a range of mental health conditions from depression to substance use disorders.

The matching process achieved excellent balance across all measured covariates, with standardized mean differences falling below the conventional threshold of 0.10. The resulting cohort had a mean age of 39.1 years, with fewer than 5 percent aged 60 or older, and was notably diverse: just over half were non-Hispanic White, roughly 30 percent non-Hispanic Black, and more than 9 percent Hispanic/Latina. Cardiovascular outcomes were identified using strict diagnostic code criteria—requiring at least one inpatient or two outpatient records for each condition—an approach validated in prior Department of Veterans Affairs research with reported sensitivity and specificity above 0.95 for PTSD identification.

Over an average follow-up of roughly six years, 7.5 percent of women with PTSD developed at least one of the cardiovascular conditions in the composite outcome, compared with 5.5 percent of women without PTSD—a 36 percent relative increase in crude cumulative incidence. In survival models accounting for the competing risk of death, PTSD was associated with a 24 percent higher rate of incident cardiovascular disease overall. The association held for ischemic heart disease, with a hazard ratio of 1.30, and for stroke and transient ischemic attack, with a hazard ratio of 1.29, consistent with meta-analytic estimates from earlier studies that had reported pooled hazard ratios of approximately 1.6 for coronary heart disease and stroke.

What distinguishes this study is its reach beyond the familiar territory of heart attacks and strokes. The researchers found significant associations between PTSD and heart failure, venous thromboembolism, pulmonary hypertension, and aortic valve stenosis. The link with venous thromboembolism was among the strongest observed, with a hazard ratio of 1.34, while aortic stenosis showed a hazard ratio of 1.23 and pulmonary hypertension 1.17. Associations with atrial fibrillation and peripheral arterial disease were elevated but did not reach statistical significance, possibly because these conditions remain rare in a cohort of women in their late thirties followed for only about six years.

Perhaps the most striking findings emerged from stratified analyses. The PTSD-cardiovascular connection was strongest in the youngest women: those aged 30 to 39 showed a hazard ratio of 1.52, and those aged 18 to 29 a hazard ratio of 1.42, compared with more modest elevations in older age groups. Racial and ethnic disparities were equally pronounced. American Indian/Alaska Native women with PTSD had a 58 percent higher rate of cardiovascular disease, and Hispanic/Latina women a 50 percent higher rate, compared with their counterparts without PTSD. The authors caution that small sample sizes for some subgroups produced wide confidence intervals, but the pattern suggests that certain populations may bear a disproportionate share of PTSD-related cardiovascular risk.

The biological plausibility of these associations rests on well-characterized pathways. PTSD has been linked to unhealthy behaviors including physical inactivity, poor diet, disrupted sleep, and smoking, as well as to comorbid depression and substance use disorders that independently elevate cardiovascular risk. Beyond behavior, the disorder involves dysregulation of the hypothalamic-pituitary-adrenal axis and hyperreactivity of the sympathetic nervous system, particularly in response to trauma-related reminders. These stress-system disturbances can drive vasoconstriction, endothelial dysfunction, arterial stiffness, and increased cardiac afterload—mechanisms that plausibly contribute to ischemic heart disease and stroke. Immune dysregulation and chronic systemic inflammation, also documented in PTSD, may underlie connections to heart failure and pulmonary hypertension specifically.

Notably, prior work by the same research group found that traditional and nontraditional risk factors together explained less than half of the association between PTSD and incident ischemic heart disease in women veterans, implying that much of the excess risk operates through pathways not yet captured in electronic health records. The authors call for mechanism-focused research into modifiable factors such as sleep patterns, physical activity, and trauma-related processes, which could open new avenues for prevention tailored to this high-risk population.

The clinical implications are difficult to ignore. Current cardiology guidelines have historically categorized women under 45 as low-risk for cardiovascular events, and the most recent VA/Department of Defense dyslipidemia guidelines recommend screening only from age 40, with no mention of PTSD status. Yet this study found the strongest PTSD-related risk precisely in women under 40, and earlier research showed that ten-year cardiovascular risk rises steadily from age 30 in women veterans. The findings argue for earlier and more tailored cardiovascular risk assessment in women veterans with PTSD, and the Veterans Health Administration has begun developing a Cardiovascular Toolkit aimed at improving risk identification and patient education for women veterans. The researchers also emphasize the need to determine whether similar early risk elevation exists in non-veteran women and men with PTSD, to verify the novel associations with aortic stenosis and pulmonary hypertension, and to test whether targeted interventions can blunt the cardiovascular toll of trauma-related illness.

Subject of Research: The association between posttraumatic stress disorder and incident cardiovascular disease in women veterans

Article Title: Impact of posttraumatic stress disorder on incident cardiovascular outcomes in women veterans: a retrospective longitudinal study

Article References: Ebrahimi, R., Dennis, P. A., Alvarez, C. A., Shroyer, A. L., Beckham, J. C., & Sumner, J. A. (2026). Impact of posttraumatic stress disorder on incident cardiovascular outcomes in women veterans: a retrospective longitudinal study. eClinicalMedicine, 100, Article 104197. https://doi.org/10.1016/j.eclinm.2026.104197

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104197

Keywords: PTSD, cardiovascular disease, women veterans, heart failure, venous thromboembolism, aortic stenosis, pulmonary hypertension, stroke, ischemic heart disease, propensity score matching, Veterans Health Administration, health disparities