Cardiovascular disease, bone fracture, and all-cause mortality risks among postmenopausal women by arthritis and veteran status: A multistate Markov transition analysis

Abstract

Arthritis, a chronic inflammatory condition linked to cardiovascular disease (CVD) and bone fracture, is more frequent among military veterans and postmenopausal women. This study examined correlates of arthritis and relationships of arthritis with risks of developing CVD, bone fractures, and mortality among postmenopausal veteran and non-veteran women. We analyzed longitudinal data on 135,790 (3,436 veteran and 132,354 non-veteran) postmenopausal women from the Women’s Health Initiative who were followed-up for an average of 16 years between enrollment (1993–1998) and February 17, 2024. Regression and multistate Markov modeling were applied to meet study objectives. The prevalence of arthritis at enrollment (1993–1998) did not differ by veteran status in a fully adjusted logistic model. Variable selection yielded 5 key predictors of prevalent arthritis among veterans and 15 key predictors among non-veterans. In fully-adjusted Cox models, prevalent arthritis was associated with CVD (hazard ratio [HR] = 1.08, 95% confidence interval [CI]: 1.05, 1.10) and all-cause mortality (HR = 1.03, 95% CI: 1.01, 1.05) risks among non-veterans only, but was not associated with bone fracture risk irrespective of veteran status. Transition probabilities between health and CVD and between bone fracture and death were higher among women with vs. without arthritis. The latter transition was more strongly related to arthritis among non-veteran vs. veteran women. In conclusion, among postmenopausal women, prevalent arthritis was associated with greater probabilities of transitioning from a healthy state to CVD and from bone fracture to death, with worse prognosis after bone fracture among those who did not serve in the military.