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. 2026 Jul 1;39(5):983–990. doi: 10.1002/jts.70103

Sex‐specific associations between potentially traumatic events and cardiovascular disease in middle‐aged and older adults

Jeanine I Nasser 1,2, Sophie M Selbe 1,2, Kelsey N Serier 3,4, Brian Shiner 5,6, Jennifer A Sumner 7, Jaimie L Gradus 1,2,4,✉
PMCID: PMC13639218  PMID: 42383422

Abstract

Potentially traumatic events (PTEs) are associated with cardiovascular disease (CVD) in aging populations. Despite sex differences in PTE exposure and CVD incidence, no study has examined sex‐specific associations between PTEs and CVD in the same sample of middle‐aged and older adults. Using data from the Health and Retirement Study, we examined lifetime exposure to 18 PTEs across three domains: early life adversity, lifetime trauma, and perceived discrimination and CVD (stroke or heart disease). We used Cox proportional hazards regression to calculate crude and adjusted (race/ethnicity, age, and educational attainment) hazard ratios (aHRs) and 95% confidence intervals (CI). Among 12,272 HRS participants, nearly 80% reported experiencing at least one PTE. Within domains, child abuse and serious accident or illness had the strongest associations with CVD for men, aHR = 1.26, 95% CI [1.04, 1.52], aHR = 1.68, 95% CI [1.53, 1.85], respectively, and women, aHR = 1.35, 95% CI [1.17, 1.56], aHR = 1.80, 95% CI [1.64, 1.97], respectively. Sex differences were noted for perceived discrimination—for men, the strongest association was between being prevented from moving into other housing and CVD, aHR = 1.52, 95% CI [1.08, 2.14], and for women, the strongest association was between being denied health care and CVD, aHR = 1.43, 95% CI [1.08, 1.90]. For both sexes, experiencing a higher number of PTEs was associated with an increased rate of CVD. Differences among men and women in these results offer insight into opportunities for prevention and targeted clinical interventions in this age group.

Exposure to potentially traumatic events (PTEs; e.g., adverse childhood events, sexual assault, combat, experiencing discrimination) increases the risk of cardiovascular disease (CVD; (Sumner et al., 2023), and sex and gender differences in the associations between PTEs and CVD have been noted (Galli et al., 2021; Padhi et al., 2024; Sumner et al., 2023; Thurston et al., 2022). Prior longitudinal studies of women have shown that intimate partner violence and child abuse are associated with CVD among women (Rich‐Edwards et al., 2012; Sumner et al., 2015; Thurston et al., 2022), as are war‐related traumatic experiences (Glaesmer et al., 2011). Among men, disasters (Remch et al., 2018) and combat exposure increase the risk of CVD (Olff, 2017). Sex differences in the associations between PTEs and CVD also extend beyond conventionally defined PTEs. Workplace discrimination is associated with increased hypertension in women across all races, but this association is weaker among men (Lewis et al., 2014; Mezuk et al., 2011).

Sex‐specific associations between PTEs and CVD are particularly relevant because patterns of PTE exposure and CVD risk vary by sex and across the life course (Betai et al., 2024) especially during the menopause transition, in which women's risk of CVD increases in part due to the decline of cardioprotective female sex hormones (Ryczkowska et al., 2022; Uddenberg et al., 2024). However, no studies of which we are aware have examined sex‐specific associations between PTEs and CVD within a single sample. This is a limitation of the existing literature, as sex‐specific results from different samples can have differences that are explained by methodological choices, like variability in PTE measurement, confounder selection and control, and participant selection. In addition, adults who are 50 years of age and older have an increased risk of CVD and are a population in which a wide range of PTEs across the life course can be examined. Despite this, most prior longitudinal research on PTEs and CVD has included participants in their 40s or younger at baseline (Jansen van Vuren et al., 2025; Sumner et al., 2015; Thurston et al., 2022). Thus, additional research is needed from larger samples of middle‐aged and older adults to better understand sex‐specific associations between PTE exposure and CVD in this population.

To address these gaps, this study used data from the Health and Retirement Study (HRS), a nationally representative sample of middle‐aged and older adults across the United States, to examine the sex‐specific associations between lifetime PTE exposure across three domains (early childhood adversity, traumatic events, and perceived discrimination) and CVD.

METHOD

Participants

The HRS is a longitudinal panel study that began in 1992, with over 43,000 participants aged 50 years and older enrolled to date in the United States. The HRS study design and sampling methods have been described elsewhere (Heeringa & Connor, 1995; Juster & Suzman, 1995). Briefly, the HRS follows participants biennially to collect information on demographic characteristics, housing, economic well‐being, cognition, and physical health. Using a multistage area probability design, the HRS recruited participants in 1992, 2004, and 2010, with oversampling of certain demographic groups—especially Black and Hispanic populations—to ensure a nationally representative sample (Sonnega et al., 2014). The HRS is sponsored by the National Institute of Aging (Grant No. NIA U01AG009740) and is conducted by the University of Michigan. All participants provided informed consent, and Institutional Review Board (IRB) approval was granted through the University of Michigan; the current study was approved by the Boston University Medical Campus IRB.

Procedure

Data on lifetime PTE exposure in the HRS were collected between 2006 and 2012. Starting in 2006, the HRS began conducting “enhanced face‐to‐face interviews” in addition to the main questionnaires. Participants were selected for these enhanced face‐to‐face interviews based on a rotating 50% subsample design such that half of the sample was selected to be interviewed at one wave, and those who were not part of this subsample completed the enhanced interviews in the following wave (i.e., Subsample A completed these interviews in 2006, 2010, 2014, and so on, and Subsample B completed these interviews in 2008, 2012, 2016, and so on). To maximize the broad scope of lifetime PTEs captured in our analyses, our analytic sample included HRS participants who specifically responded to the 2010 or 2012 questionnaires (n = 16,614), as these were the years with the most comprehensive PTE assessments. We removed participants under 50 years of age in the analytic sample (n = 4,342), yielding a final sample size of 12,272 people.

Measures

Lifetime adverse events

Three domains of lifetime adverse events were included in this analysis: adverse early life events, lifetime traumatic experiences, and perceived discrimination. For early life adverse events, participants answered dichotomous questions about experiences that occurred prior to 18 years of age, including trouble with police, parental drinking or drug use, physical abuse, and repeating a year of school (Krause et al., 2004). Lifetime adverse experiences were assessed using seven dichotomous items: death of a child, major natural disaster, fired a weapon or was fired upon in combat, spouse or child who was addicted to drugs, victim of a serious attack, experiencing a life‐threatening illness or accident, and close family member experiencing a life‐threatening illness or accident. Finally, lifetime experiences of perceived discrimination were assessed via seven dichotomous items: unfairly dismissed from a job, unfairly denied a promotion, unfairly prevented from moving into another neighborhood, unfairly denied a loan, unfairly stopped and searched by police, and unfairly denied health care (Williams et al., 1997). Questions asked respondents about unfair treatment (e.g., “Were you ever unfairly prevented from moving into new housing?”) and, as such, may encompass different forms of discrimination (e.g., race‐based discrimination, gender‐based discrimination).

Cardiovascular outcomes

CVD was assessed via self‐report responses biennially between 2012 and 2022. For all participants, ascertainment of CVD diagnoses began at the next assessment time following their PTE assessment in either 2010 or 2012. Participants dichotomously reported whether they had a stroke or were diagnosed with heart disease within the last year.

Covariates

Confounders were recorded in 2010 and included race, ethnicity, age (in years), and educational attainment (identified using a directed acyclic graph approach; (Digitale et al., 2022). Race (White, Black/African American, or other) and ethnicity (Hispanic or non‐Hispanic) were combined to create a composite race/ethnicity variable for: non‐Hispanic White, non‐Hispanic Black, non‐Hispanic other, and Hispanic. Educational attainment consisted of the following categories: less than high school, high school graduate/GED, some college, and college or above. Finally, we included a dichotomous (yes/no) variable for lifetime history of psychiatric problems, which was captured in 2008 by asking, “Have you ever had a history of psychiatric problems?”

Data analysis

We conducted sex‐stratified descriptive analyses to examine the distribution of demographic characteristics in the sample. We used Cox proportional hazards regression to compute crude and adjusted hazard ratios (HRs and aHRs, respectively) and 95% confidence intervals (CI) to evaluate the sex‐stratified associations between exposure to each lifetime PTE and the number of lifetime PTEs (0, 1, 2, 3, or ≥ 4) and CVD. Given our assessment of PTEs at any point in the life course, including childhood, we were unable to adjust for potential confounding due to psychiatric problems before PTE exposure, as confounders must occur prior to exposure (Rothman et al., 2008). To better understand the influence of a lifetime history of psychiatric problems on the association between lifetime PTE exposure and CVD, we performed secondary analyses further stratifying our regression analyses by lifetime history of psychiatric problems, as collected in 2008. Analyses were conducted in RStudio (Version 2024.12.1 + 563) using R (Version 4.5.0).

RESULTS

Table 1 presents the sex‐specific demographic characteristics of the sample. Most participants were female (n = 7,334, 59.8%), were non‐Hispanic White (n = 9,322, 76.0%), did not have a lifetime history of psychiatric problems (n = 10,462, 85.3%), and were approximately 71 years old. A slightly higher proportion of male participants reported CVD during follow‐up (n = 2,657, 53.8%), and most participants experienced at least one PTE in their lifetime. The most common PTEs among men and women were experiencing a serious accident or illness (n = 1,604, 32.5%) and having a significant other experience a serious accident or illness (n = 2,236, 30.5%), respectively.

TABLE 1.

Sociodemographic characteristics of Health and Retirement Study participants in the analytic sample, stratified by gender

Variable Men Women
(n = 4,938) (n = 7,334)
M SD M SD
Age (years) 70.7 8.9 70.5 9.7
n % n %
Race/ethnicity
Non‐Hispanic White 3,858 78.1 5,464 74.5
Non‐Hispanic Black 539 10.9 1,031 14.1
Non‐Hispanic other 116 2.3 164 2.2
Hispanic 424 8.6 674 9.2
Educational attainment a (collapsed)
Less than high school 867 17.6 1,371 18.7
High school graduate/GED 1,618 32.8 2,818 38.4
Some college 1,074 21.7 1,750 23.9
College and above 1,378 27.9 1,394 19.0
Age group (years)
50–64 1,681 34.0 2,722 37.1
65–74 1,996 40.4 2,694 36.7
≥ 75 1,261 25.6 1,918 26.2
Adverse early life experiences b
Repeated school year 1,027 20.8 741 10.1
Trouble with police 487 9.9 88 1.2
Parents used drugs 757 15.3 1,168 15.9
Child physical abuse 288 5.8 555 7.6
PTE exposure
Death of a child 762 15.4 1,432 19.5
Experienced disaster 904 18.3 1,166 15.9
Combat exposure 677 13.7 25 0.3
Spouse or child addicted to drugs 650 13.2 1,509 20.6
Physical attack 273 5.5 443 6.0
Serious accident or illness 1,604 32.5 1,718 23.4
Significant other accident or illness 1,250 25.3 2,236 30.5
Experiences of perceived discrimination
Dismissed from job 938 19.0 1,043 14.2
Not hired for a job 413 8.4 466 6.4
Denied promotion 508 10.3 514 7.0
Prevented housing move 79 1.6 144 2.0
Denied loan 278 5.6 295 4.0
Unfair treatment by police 394 8.0 196 2.7
Denied health care 93 1.9 148 2.0
Number of lifetime PTEs
0 873 17.7 1,792 24.4
1 1,193 24.2 1,870 25.5
2 1,006 20.4 1,485 20.2
3 742 15.0 1,000 13.6
≥ 4 1,124 22.8 1,187 16.2
Lifetime psychiatric problems before 2010 492 10.0 1,318 18.0
Any CVD between 2012 and 2022 2,657 53.8 3,273 44.6
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Note: N = 12,272. PTE = potentially traumatic event; CVD = cardiovascular disease.

a

Collapsed.

b

Before 18 years of age.

The results of our regression analyses are presented in Table 2. For men, experiencing child physical abuse was associated with CVD, aHR = 1.26, 95% CI [1.04, 1.52]. For women, the strongest associations were for child physical abuse, aHR = 1.35, 95% CI [1.17, 1.56], and repeating a year of school, aHR = 1.33, 95% CI [1.17, 1.51]. Within the domain of lifetime adverse experiences, having a life‐threatening illness or serious accident demonstrated the strongest association with CVD among men, aHR = 1.68, 95% CI [1.53, 1.85]. Among women, having a serious illness or accident, aHR = 1.80, 95% CI [1.64, 1.97], and experiencing a physical attack, aHR = 1.54, 95% CI [1.32, 1.79], demonstrated the strongest associations with CVD. There was some evidence of association with CVD for most perceived discrimination items. Among men and women, being unfairly prevented from moving into housing, aHR = 1.52, 95% CI [1.08, 2.14], and being denied health care, aHR = 1.43, 95% CI [1.08, 1.90], were most strongly associated with CVD, respectively.

TABLE 2.

Sex‐specific associations between potentially traumatic event (PTE) exposure and cardiovascular disease (CVD) from 2010 to 2022

Variable Men Women
HR 95% CI aHR 95% CI HR 95% CI aHR 95% CI
Early life experiences (before age 18 years)
Repeat year of school 1.14 [1.02, 1.27] 1.16 [1.03, 1.30] 1.30 [1.14, 1.47] 1.33 [1.17, 1.51]
Trouble with police 0.97 [0.84, 1.13] 1.13 [0.97, 1.32] 0.79 [0.53, 1.17] 1.00 [0.67, 1.48]
Parents drank or used drugs 1.04 [0.92, 1.18] 1.12 [0.99, 1.26] 1.04 [0.94, 1.16] 1.16 [1.04, 1.30]
Child physical abuse 1.15 [0.95, 1.38] 1.26 [1.04, 1.52] 1.17 [1.01, 1.35] 1.35 [1.17, 1.56]
Lifetime Adverse Experiences
Death of a child 1.25 [1.10, 1.41] 1.09 [0.96, 1.24] 1.40 [1.27, 1.54] 1.17 [1.06, 1.30]
Experienced natural disaster 1.09 [0.97, 1.22] 1.09 [0.98, 1.23] 1.09 [0.98, 1.22] 1.15 [1.04, 1.28]
Combat exposure a 1.30 [1.14, 1.48] 1.18 [1.03, 1.34]
Spouse or child addicted to drugs 1.14 [1.00, 1.30] 1.14 [1.00, 1.30] 1.26 [1.14, 1.38] 1.31 [1.19, 1.44]
Physical attack 1.04 [0.86, 1.26] 1.23 [1.02, 1.50] 1.31 [1.12, 1.52] 1.54 [1.32, 1.79]
Respondent experienced serious illness/ accident 1.79 [1.63, 1.96] 1.68 [1.53, 1.85] 1.77 [1.62, 1.93] 1.80 [1.64, 1.97]
Significant other experienced serious illness/accident 1.19 [1.08, 1.32] 1.08 [0.98, 1.20] 1.23 [1.13, 1.34] 1.17 [1.08, 1.28]
Experiences of perceived discrimination
Dismissed from job 0.90 [0.80, 1.01] 0.99 [0.88, 1.11] 1.10 [0.99, 1.23] 1.29 [1.15, 1.44]
Not hired for a job 0.94 [0.80, 1.11] 1.08 [0.91, 1.27] 0.91 [0.77, 1.07] 1.05 [0.89, 1.24]
Denied promotion 1.14 [0.99, 1.31] 1.24 [1.08, 1.44] 0.95 [0.82, 1.11] 1.08 [0.93, 1.27]
Prevented housing move 1.30 [0.93, 1.82] 1.52 [1.08, 2.14] 1.12 [0.85, 1.46] 1.25 [0.95, 1.64]
Denied loan 1.16 [0.96, 1.40] 1.28 [1.06, 1.55] 1.27 [1.05, 1.54] 1.39 [1.15, 1.69]
Unfair treatment by police 0.90 [0.76, 1.07] 1.08 [0.91, 1.28] 1.11 [0.88, 1.39] 1.38 [1.09, 1.74]
Denied health care 1.09 [0.77, 1.56] 1.22 [0.86, 1.75] 1.12 [0.85, 1.47] 1.43 [1.08, 1.90]
Number of PTEs
0 Ref Ref Ref Ref Ref Ref Ref Ref
1 1.18 [1.02, 1.37] 1.22 [1.05, 1.42] 1.11 [0.98, 1.26] 1.17 [1.03, 1.32]
2 1.32 [1.13, 1.54] 1.31 [1.12, 1.53] 1.28 [1.13, 1.45] 1.34 [1.18, 1.53]
3 1.46 [1.24, 1.72] 1.48 [1.25, 1.74] 1.49 [1.30, 1.71] 1.54 [1.35, 1.77]
≥ 4 1.52 [1.30, 1.76] 1.60 [1.38, 1.86] 1.65 [1.45, 1.87] 1.89 [1.66, 2.15]
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Note: Adjusted hazard ratios (aHRs) account for age at baseline, race/ethnicity, and educational attainment. HR = hazard ratio; CI = confidence interval.

a

Due to the small sample size for women who experienced combat, no results are shown.

Experiencing a higher number of PTEs was associated with a higher rate of CVD compared to experiencing no PTEs. For men, experiencing four or more lifetime PTEs was associated with a 1.60‐times higher rate of CVD, 95% CI [1.38, 1.86]; for women, this PTE exposure level was associated with a 1.89‐times higher rate, 95% CI [1.66, 2.15]. Finally, the results of our analyses examining associations when additionally stratified by history of psychiatric problems (Supplementary Table S1) revealed few differences in the pattern of associations.

DISCUSSION

This study is the first of which we are aware to examine sex‐specific associations between lifetime PTEs and CVD in a large single sample of middle‐aged and older men and women. Consistent with the existing literature (Beristianos et al., 2016; Coughlin, 2011; Edmondson & Cohen, 2013; Jordan et al., 2011; Kim et al., 2022; Lenane et al., 2019; O'Donnell et al., 2021; Scott et al., 2013) we found that different types of lifetime PTEs from the domains of early life adversity, traumatic events, and perceived discrimination increased the rate of CVD in older adults. In general, our results were consistent with the overall PTE and CVD literature from sex‐specific samples, providing evidence that methodological differences between studies may not readily explain previously observed sex differences. Biological, behavioral, and/or social mechanisms may explain these associations, including hypothalamic–pituitary–adrenal axis dysregulation and inflammation (Sumner et al., 2023); unhealthy behaviors (e.g., smoking, alcohol use;(Powell‐Wiley et al., 2022) and structural factors (e.g., policy), which can compound these behavioral and biological mechanisms and influence CVD risk through social isolation and exclusion, marginalization, and stigmatization. Given that prior work suggests that older adults present with different patterns of trauma‐related distress and might be reluctant to disclose or are not asked about PTEs in health care contexts (Cations et al., 2020; de la Perrelle et al., 2022), these findings highlight the importance of using approaches like trauma‐informed care in both screening and treating posttraumatic symptoms and psychological distress in this population.

Our findings related to perceived discrimination and CVD contribute to a growing understanding of how PTEs that may not be considered traumatic under the conventional definition of posttraumatic stress disorder Criterion A in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM‐5; (American Psychiatric Association, 2013) but can have comparable consequences to Criterion A events. Our findings corroborate prior literature examining the associations between exposure to certain types of perceived discrimination and CVD, including race‐based discrimination (Lewis et al., 2014). Further work examining the effects of PTEs that may not be considered traumatic under the conventional definition is warranted.

The findings from this study should be interpreted in consideration of several limitations. First, although the longitudinal data used for this study confers some degree of temporality, the precise timing and chronicity of PTE exposure are unknown, so temporal ordering with CVD is not guaranteed. Second, data were not available for other PTEs that are strongly associated with negative outcomes (e.g., sexual assault, intimate partner abuse); however, the exclusion of this type of PTE likely means that our results for overlapping items that were queried (e.g., experiencing a physical attack) are underestimates of true, stronger associations. Third, our exposure and outcome measures were self‐reported, single‐item dichotomous indicators, which are limited in their ability to capture the nuance and depth of these constructs. As such, future work should leverage more objective measures of CVD, such as diagnostic codes from health records, to minimize these measurement‐related concerns. Fourth, our results may be influenced by uncontrolled confounding from various sources, such as a history of psychiatric problems. Our supplementary analysis demonstrated that prior psychiatric problems had little impact on our observed associations, but psychiatric problems were measured using a single item, and these results should be interpreted with this limitation in mind. Finally, our data are composed of a majority‐White sample, limiting generalizability. Future research should include studies of middle‐aged and older adults from racially and ethnically diverse groups.

Notwithstanding these limitations, this study expands on the existing literature by examining sex‐specific associations between 18 different PTEs and CVD in a single sample of middle‐aged and older adults. Knowledge that different types of PTEs are important to CVD risk among men and women may have implications for prevention and intervention efforts, as well as future research aimed at better understanding mechanisms.

AUTHOR CONTRIBUTIONS

Jeanine I. Nasser: conceptualization, methodology, data curation, formal analysis, writing—original draft, writing—review and editing. Sophie M. Selbe: data curation, writing—review and editing. Kelsey N. Serier: writing—review and editing, funding acquisition. Brian Shiner: writing—review and editing, funding acquisition. Jennifer A. Sumner: writing—review and editing, funding acquisition. Jaimie L. Gradus: conceptualization, supervision, project administration, methodology, writing—original draft, writing—review and editing, funding acquisition.

AUTHOR NOTE

This work was supported by grants from the National Heart, Lung, and Blood Institute (R01HL160850, R01HL176899) and the National Institute of Diabetes and Digestive and Kidney Diseases (K08DK138296).

OPEN PRACTICES STATEMENT

The data used for this study are publicly available at https://doi.org/10.7826/AFUA5287 (no reference number available) and https://www.rand.org/health/surveys/hrs/hrs‐data.html (no reference number available); more information can be found on the Health and Retirement Study website (https://hrs.isr.umich.edu/).

Supporting information

Supplsementary materials

JTS-39-983-s001.docx (22.3KB, docx)

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