BACKGROUND:Veterans are at an increased cardiovascular risk compared to age- and sex-matched non-Veterans. Cardiac rehabilitation (CR) can improve outcomes in cardiovascular disease, but its use in men and women Veterans is not well understood. OBJECTIVES:This study aimed to examine CR participation by sex and socioeconomic status among Veterans. METHODS:The authors conducted a retrospective cohort study from January 1, 2021, to December 31, 2023, using a national electronic health record database. The primary outcome was participation in at least 1 CR session among patients within 1 year of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery. Multivariable logistic regression models accounted for patient-level (demographics, medical/psychiatric comorbidities) and community-level factors. Area deprivation indices (ADIs) (analyzed as quartiles) assessed socioeconomic status. RESULTS:Among 82,496 CR-eligible Veterans (3.6% women), CR participation was low (10.4%) and similar by sex (women = 10.2%, men = 10.4%). Women Veterans did not differ significantly in CR participation compared to men Veterans after adjusting for patient-level and community-level characteristics, including age, race, cardiac and comorbidities, mental health risk factors, rural-urban status, and ADI (adjusted OR: 0.90; 95% CI: 0.79-1.03; P = 0.121). Veterans in the most deprived ADI quartile were less likely to participate vs the least deprived quartile (adjusted OR: 0.82; 95% CI: 0.75-0.89; P < 0.001). CONCLUSIONS:CR participation among U.S. Veterans remains low, far below that of the Medicare population (10.4% vs 28%), with no significant differences in initiation by sex. However, low socioeconomic status is associated with decreased uptake. Further research is needed to explore innovative, Veteran-specific CR delivery models.

Introduction:Pregnancy is a critical test of women's cardiovascular risk. Structural factors may influence long-term cardiovascular health beyond individual, social experiences. We examined associations of neighborhood-level deprivation and individual-level social vulnerability (SV) during pregnancy with postpartum blood pressure (BP). Methods:This secondary analysis of a prospective cohort study used data from 3,728 nulliparous women in the nuMoM2b-HHS cohort followed from early pregnancy to 2-7 years post-delivery (Mage: 30.8 years, 65% non-Hispanic White, 14% with adverse pregnancy outcomes [APOs]). Multivariable linear and logistic regression models tested relations of the Area Deprivation Index (ADI) and SV (a composite of perceived stress, discrimination, pregnancy experiences, social support, health literacy, depression, and anxiety) with systolic BP (SBP), diastolic BP (DBP), and incident hypertension, adjusting for demographic and behavioral covariates. Effect modification by APO history was assessed. Results:In unadjusted models, both ADI and greater SV were positively associated with SBP and DBP (all ps<0.001). After adjustment, ADI remained positively associated with BP: each 10-unit increase in ADI was associated with 1.0 mmHg higher SBP (p=0.008) and 0.6 mmHg higher DBP (p=0.013). However, SV was no longer associated with BP after adjustment. ADI and SV were not associated with incident hypertension. No evidence of effect modification by APO history was observed (interactions p>0.20). Conclusions:Neighborhood deprivation during pregnancy was associated with higher BP up to seven years later, independent of individual social vulnerability. Structural context during pregnancy may contribute to early maternal cardiovascular risk.

Psychological distress (i.e., symptoms of depression, anxiety, posttraumatic stress disorder, chronic or acute stress, and negative emotions) is both a risk factor for acute coronary syndrome (ACS) and a common consequence of ACS, with important sex differences. Compared with men, women experience a disproportionate burden of psychological distress before and after ACS. Women with ACS also have longer treatment delays, receive fewer invasive interventions, and have higher mortality rates. Screening for psychological distress in patients with ACS may help identify those at increased risk for complications.

The contribution of behavioural and psychosocial factors (such as lifestyle behaviours, negative emotions and social connection) to incident cardiovascular disease and cardiovascular events is well recognized, and interventions to reduce the risk associated with these factors have been proved effective. Yet the implementation of these interventions in clinical settings has been slow, at best. In this Perspective, we review the literature to identify the elements and actions needed for a broad adoption of behavioural medicine interventions in routine cardiovascular care. We specifically discuss the need for a behavioural medicine clinical trials enterprise that is more pragmatic in approach, utilizing implementation science methods and extant clinical data sources, and prioritizing patient-reported and quality-of-life outcomes, along with offsets in cost of care. We furthermore discuss the need for the development and testing of integrated care models, engaging with institutional stakeholders, patients and families, and healthcare systems. Behavioural and psychosocial interventions can effectively reduce the risk of cardiovascular disease. In this Perspective, Burg et al. identify the elements and actions needed for a broad implementation of these interventions in standard cardiovascular care.

Background Hypertension prevalence, diagnosis, and treatment vary by age, sex, and race and ethnicity in the general US population and for veterans. Less is known about the youngest veterans (ie, discharged post‐9/11), including growing subsets of women and some racial and ethnic subgroups. Methods In this cross‐sectional study, national Veterans Health Administration data were used to identify post‐9/11 veterans receiving Veterans Health Administration care in 2001 to 2023. Proportions with clinical hypertension (patients with hypertension diagnostic code[s], antihypertensive medication fills, or blood pressure measurements ≥140/90), undiagnosed hypertension, and untreated hypertension were calculated. Crude and adjusted prevalence ratios for hypertension measures were presented by sex and by race and ethnicity, adjusting for demographics and comorbidities. Results Among 1 181 007 veterans (mean age, 33.5±9.4 years; 12.3% women), 44.9% had clinical hypertension, among them 49% undiagnosed and 26% untreated. Compared with men, women were associated with 5% lower risk of clinical hypertension (adjusted prevalence ratio, 0.95 [95% CI, 0.93–0.96]) and untreated hypertension (adjusted prevalence ratio, 0.61 [95% CI, 0.60–0.63]) but had higher risk of undiagnosed hypertension (adjusted prevalence ratio, 1.17 [95% CI, 1.16–1.18]). Compared with White veterans, Black veterans were associated with 9% higher risk of hypertension but 26% lower risk of undiagnosed and 19% lower risk of untreated hypertension. Conclusions Nearly half of post‐9/11 veterans met hypertension criteria, and among them 49% were undiagnosed and 26% were untreated. Tailored screening and self‐measured blood pressure monitoring to reduce prevalence and improve management might curb potential differences among these veterans.

BACKGROUND:Adverse pregnancy outcomes (APOs) are associated with a higher risk of developing chronic hypertension. The objectives of this study were to determine whether patterns of perceived stress during and after pregnancy were associated with blood pressure and incident hypertension 2 to 7 years after delivery, and whether having an APO modified this association. METHODS:Analyses utilized data from the prospective nuMoM2b-HHS cohort (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study). Perceived stress was assessed using the Perceived Stress Scale in the first and third trimester and 2 to 7 years after delivery. Latent class trajectory analysis characterized subgroups with similar patterns of perceived stress over time. APOs were abstracted from medical charts and included hypertensive disorders of pregnancy, preterm birth, small-for-gestational-age, and stillbirth. Multivariable regression models evaluated the independent effects of perceived stress on systolic and diastolic blood pressure and incident hypertension and 2 to 7 years after delivery. RESULTS:Three distinct stress trajectory groups emerged, delineated by persistently low, moderate, and high stress levels. No associations between stress trajectory group and blood pressure or incident hypertension were observed after adjustment for covariates. However, there was a significant interaction between stress trajectory group and APO on blood pressure (P for interaction=0.04). Stress trajectory group was associated with higher blood pressure only among those with APO (β=1.991±0.819 mm Hg; P=0.02) but not without APO (β=0.040±0.471 mm Hg, P=0.93). CONCLUSIONS:These findings suggest that elevated perceived stress may contribute to higher blood pressure, specifically among women who had an APO.

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.

Significant inequities persist in hypertension detection and control, with minoritized populations disproportionately experiencing organ damage and premature death due to uncontrolled hypertension. Remote blood pressure monitoring combined with telehealth visits (RBPM) is proving to be an effective strategy for controlling hypertension. Yet there are challenges related to technology adoption, patient engagement and social determinants of health (SDoH), contributing to disparities in patient outcomes. This review summarizes the evidence to date for RBPM, focusing on the potential to advance health equity in blood pressure control and the existing levers for largescale implementation. Several studies demonstrate the promise of RBPM programs to address health disparities through: (1) the use of cellular-enabled blood pressure machines that do not require internet access or smart devices to connect readings into the medical record; (2) emphasis on home blood pressure monitoring to illuminate the daily factors that influence blood pressure control, thereby increasing patient empowerment; (3) adoption of standardized algorithms for hypertension management; and (4) integration of services to address SDoH. Multidisciplinary, non-physician care teams that include nurses, pharmacists, and community health workers are integral to this model. However, most studies have not embraced all aspects of RBPM, and implementation is challenging as current payment models do not support the digital components of RBPM or a diverse workforce of hypertension providers. To address hypertension disparities, RBPM programs need to integrate digital technology that is accessible to all users as well as multidisciplinary care teams that attend to the medical and social needs of populations experiencing health inequities.

Unique characteristics and service exposures of the post-9/11 cohort of U.S. Veterans can influence their sleep health and associated comorbidities. The objectives of this study were to learn about men and women post-9/11 Veterans' and "front line" VA providers' knowledge about sleep and experiences with Veterans Health Administration (VA) sleep management. One sample included post-9/11 Veterans who received VA care (n=23; 60% women; Mage: 45 y). To complement those views, primary care and mental health providers were recruited from VA medical centers (n=27). Semistructured qualitative interviews were conducted using Microsoft Teams. Questions pertained to sleep knowledge, care practices, and perceived barriers to sleep-related VA care. Interview data were synthesized with content analysis and inductive coding to characterize major themes. Four main themes emerged: (1) Sleep is viewed as foundational but Veterans and providers often have limited related knowledge and more routine education is needed. (2) Men and women have distinct sleep management needs. Relative to men, women are more likely to advocate for sleep assessment and for behavioral versus pharmacological treatment. (3) Sleep management practices vary considerably between clinics and providers. (4) Veterans and their providers each experience unique barriers to sleep management. Post-9/11 Veterans and providers view sleep as critical. Yet, VA sleep management needs to be more uniform. Providers are motivated to assess sleep but require standardized education and low-burden opportunities to incorporate sleep into their practice, perhaps with mental health screening. Ultimately, more specialized care is required to meet the responsibility of Veterans' sleep health.

This review summarizes the psychological effects of consumer wearables in patients with established cardiovascular disease (CVD) and helps to identify remaining challenges that must be resolved to support the appropriate implementation of wearables. Consumer wearables (e.g., smartwatches, portable rhythm devices, rings, fitness bands, skin-surface patches) are increasingly used “off label” by patients and healthcare providers for ambulatory CVD monitoring and lifestyle modification. Emerging research suggests that while these technologies can motivate some patients to engage in healthy behaviors, they can also provoke adverse psychological reactions in others. Additionally, there are unintended, downstream consequences for clinicians and healthcare systems. Wearables show great promise for enhancing CVD management by providing patients and clinicians with continuous data on key health metrics that can be used for diagnostic and therapeutic purposes. Yet, the potential risks associated with their use must be acknowledged, rigorously investigated, and appropriately managed. Findings from this review emphasize the need for large, well-designed prospective studies and randomized trials to evaluate a broad range of wearable technologies and their influence on patients’ mental health, quality of life, and CVD self-management over longer time periods and in high-risk groups (e.g., women, minorities, and children), and to determine their impact on patient outcomes, provider burden, healthcare utilization and costs. Addressing these challenges is crucial for fully integrating wearable health technologies into clinical practice.

PURPOSE:Cardiac rehabilitation (CR) is a valuable secondary preventive intervention for Veterans given their increased risk of cardiovascular disease. Adults cared for in the Veterans Affairs (VA) healthcare system are a unique population that receives healthcare from the largest integrated care network in the United States. Yet, this group faces distinct challenges in utilizing CR. In this review, we evaluated the existing data regarding CR utilization and outcomes among U.S. Veterans. REVIEW METHODS:A literature search was conducted using PubMed and Scopus for cardiac rehabilitation and U.S. Veterans. SUMMARY:Veterans have 3 potential options for attending CR: in-person at their local VA medical centers, home-based CR through their local VA medical centers, and in-person at community CR centers. However, participation remains low. A significant barrier to participation is transportation to in-person CR. Home-based CR shows promise in addressing this barrier and has demonstrated resilience in the face of pandemic restrictions. Cardiac rehabilitation outcomes among Veterans who participate include improved exercise capacity, fewer depressive symptoms, and decreased mortality. Despite its benefits for secondary prevention among Veterans, there remains a paucity of data about the current uptake of CR, the impact of mental health on uptake, possible sex-based or racial disparities, and long-term outcomes.

Introduction:Comorbid insomnia and obstructive sleep apnea (OSA, i.e., COMISA) are associated with cardiovascular disease (CVD) among older adults. It is unknown how the comorbidity is related to cardiovascular risk among younger military Veterans, who show a greater risk for hypertension and CVD than non-Veterans, and if associations differ by sex. Thus, we examined whether COMISA is associated with incident hypertension and CVD risk in younger men and women Veterans. Methods:The cohort included post-9/11 Veterans who enrolled in Veterans Health Administration care from 2001 to 2021. Administrative and electronic health record data were merged. Insomnia and OSA were defined by 2 outpatient International Classification of Diseases, 9 or 10 diagnoses. Hypertension was defined by ≥2 outpatient-coded diagnoses or ≥1 antihypertensive medication fill. CVD was defined by 1≥ inpatient or ≥2 outpatient diagnoses. Time-varying Cox proportional hazard models were adjusted for demographics, behavioral, and clinical factors and conducted overall and by sex. Results:Analyses included 937,598 Veterans (12% women; median age: 41 years). Greater hypertension risk was observed overall (adjusted hazard ratio [aHR]:2.43: 95%CI:2.36-2.50), for men (aHR:2.09, 95%CI:2.02-2.16) and women with COMISA (aHR:2.20, 95%CI:2.00-2.42), insomnia only (aHRs:1.27-1.44), and OSA only (aHRs:2.00-2.26) versus no sleep disorder. For incident CVD, COMISA was again associated with 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 (aHRs:1.36-1.37) and OSA (aHRs:3.32-2.62). Conclusions:For post-9/11 Veterans, COMISA was associated with the greatest risk of hypertension and CVD. Identifying disordered sleep among men and women should be a cardiovascular prevention priority.

Purpose:Cardiac rehabilitation (CR) is a valuable secondary preventive intervention for Veterans given their increased risk of cardiovascular disease. Adults cared for in the Veterans Affairs (VA) healthcare system are a unique population that receives healthcare from the largest integrated care network in the United States. Yet, this group faces distinct challenges in utilizing CR. In this review, we evaluated the existing data regarding CR utilization and outcomes among U.S. Veterans.Review methods:A literature search was conducted using PubMed and Scopus for cardiac rehabilitation and U.S. Veterans.Summary:Veterans have 3 potential options for attending CR: in-person at their local VA medical centers, home-based CR through their local VA medical centers, and in-person at community CR centers. However, participation remains low. A significant barrier to participation is transportation to in-person CR. Home-based CR shows promise in addressing this barrier and has demonstrated resilience in the face of pandemic restrictions. Cardiac rehabilitation outcomes among Veterans who participate include improved exercise capacity, fewer depressive symptoms, and decreased mortality. Despite its benefits for secondary prevention among Veterans, there remains a paucity of data about the current uptake of CR, the impact of mental health on uptake, possible sex-based or racial disparities, and long-term outcomes.

The increasing popularity of consumer-grade wearable (CGW) devices for everyday use has prompted discussions within learning healthcare systems (LHSs) about the integration of patient-generated health data (PGHD) into clinical workflow. To report findings from interviews with healthcare professionals (HCPs) about the potential role of CGWs and PGHD in clinical workflow, which in turn informed recommendations for health systems to consider when integrating PGHD from CGWs. Mixed methods. Clinical care providers and holistic/wellness providers with various training and expertise from the largest integrated health system in the USA (i.e., Veterans Health Administration). A purposive sample of 29 individuals who were knowledgeable informants were invited to complete a survey focused on CGW feasibility and usability of PGHD. Those who completed the survey were invited to participate in a semi-structured interview to elicit their perceptions of the barriers and facilitators for PGHD utilization. Survey data were analyzed descriptively and rapid qualitative analysis techniques were used to identify themes from interview data. Twenty-one HCPs were included in this study. Quantitative and qualitative findings revealed significant interest in PGHD integration in clinical workflow and patient interactions. Clinical care providers focused on the value of PGHD as a complement to traditional clinical data, whereas holistic/wellness providers emphasized using CGWs and PGHD for behavioral change. Their interest levels were tempered by concerns about workload implications and apprehension about having to distill the vast amount of PGHD of varying validity into clinically actionable information. Integrating CGWs and PGHD can enable an LHS to improve patient outcomes, particularly to promote health access and equity. Yet, concerns were raised regarding staffing and workload issues, data interpretation, expectations, access, privacy, and educational needs. Therefore, harnessing the benefits of CGWs will require investing in health systems’ infrastructure to optimally integrate PGHD into clinical workflow.