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Publication Briefs

Study Suggests Traumatic Brain Injury May Be a Potentially Novel Risk Factor for Cardiovascular Disease in Veterans

Traumatic brain injury (TBI) is considered the ‘signature injury’ of the wars in Iraq and Afghanistan. Prior work has demonstrated associations between TBI and both hemorrhagic and ischemic stroke. However, these studies examined older, civilian populations and may not be generalizable to post-9/11 era Veterans. This retrospective cohort study sought to determine the association between TBI and subsequent cardiovascular disease (CVD) in post-9/11 era Veterans (defined as service from FY2000 to 2016). Using VA and Department of Defense (DoD) data, investigators identified 1,559,928 Veterans who had at least two years of VA care; of these Veterans, 301,169 had a history of TBI. Variables examined in this study included: age, sex, race/ethnicity, education, component, rank, deployment history, and combat exposure. The primary outcome was CVD, defined as a composite of CAD (coronary artery disease), stroke, PAD (peripheral artery disease), and CVD death. Secondary outcomes were the individual components of the composite outcome.


  • Traumatic brain injury is a potentially novel risk factor for cardiovascular disease in Veterans.
  • In adjusted models, post-9/11 Veterans with mild TBI, moderate to severe TBI, and penetrating TBI were more likely to develop CVD compared to Veterans without TBI.
  • Although the risk was highest shortly after injury, TBI remained significantly associated with CVD for years after the initial injury.
  • All TBI categories increased the risk of stroke, CAD, and PAD after adjustment. Mild and moderate to severe TBI categories were also associated with an increased risk of CVD mortality.
  • Veterans with TBI were more likely to have a history of smoking, substance use disorder, obesity, obstructive sleep apnea, insomnia, PTSD, depression, and anxiety. Conversely, hyperlipidemia, kidney disease, hypertension, and diabetes were more common in Veterans without TBI.


  • Given the relatively young age of the study cohort (<35 years at index), results suggest there may be an increased burden of CVD as 9/11-era Veterans age and develop additional CVD risk factors.
  • Further studies are needed to determine if the increased risk of CVD is modifiable.


  • Investigators did not have access to data from private healthcare systems.

This project was supported by HSR&D and RR&D under the Long-term Impact of Military-relevant Brain Injury Consortium (LIMBIC). Dr. Pugh is supported by an HSR&D Research Career Scientist Award. Ms. Amuan and Drs. Tate, Wright, Wilde, and Pugh are part of HSR&D’s Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, Salt Lake, UT; Dr. Carlson is part of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR; Dr. Pogoda is with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA; and Dr. Dismuke-Greer is part of HSR&D’s Health Economics Resource Center (HERC), Palo Alto, CA.

Stewart I, Amuan M, Wang C-P, Kennedy E, Kenney K, Werner JK, Carlson K, Tate D, Pogoda T, Dismuke-Greer C, Wright WS, Wilde E, and Pugh MJ. Association between Traumatic Brain Injury and Subsequent Cardiovascular Disease among Post-9/11 Era Veterans. JAMA Neurology. September 6, 2022; online ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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