Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications

Perinatal depression and risk of mortality: nationwide, register based study in Sweden

OBJECTIVE

To determine whether women with perinatal depression are at an increased risk of death compared with women who did not develop the disorder, and compared with full sisters.

DESIGN

Nationwide, register based study.

SETTING

Swedish national registers, 1 January 2001 to 31 December 2018.

PARTICIPANTS

86 551 women with a first ever diagnosis of perinatal depression ascertained through specialised care and use of antidepressants, and 865 510 women who did not have perinatal depression were identified and matched based on age and calendar year at delivery. To address familial confounding factors, comparisons were made between 270 586 full sisters (women with perinatal depression (n=24 473) and full sisters who did not have this disorder (n=246 113)), who gave at least one singleton birth during the study period.

MAIN OUTCOME MEASURES

Primary outcome was death due to any cause. Secondary outcome was cause specific deaths (ie, unnatural and natural causes). Multivariable Cox regression was used to estimate hazard ratios of mortality comparing women with perinatal depression to unaffected women and sisters, taking into account several confounders. The temporal patterns of perinatal depression and differences between antepartum and postpartum onset of perinatal depression were also studied.

RESULTS

522 deaths (0.82 per 1000 person years) were reported among women with perinatal depression diagnosed at a median age of 31.0 years (interquartile range 27.0 to 35.0) over up to 18 years of follow-up. Compared with women who did not have perinatal depression, women with perinatal depression were associated with an increased risk of death (adjusted hazard ratio 2.11 (95% confidence interval 1.86 to 2.40)); similar associations were reported among women who had and did not have pre-existing psychiatric disorder. Risk of death seemed to be increased for postpartum than for antepartum depression (hazard ratio 2.71 (95% confidence interval 2.26 to 3.26) v 1.62 (1.34 to 1.94)). A similar association was noted for perinatal depression in the sibling comparison (2.12 (1.16 to 3.88)). The association was most pronounced within the first year after perinatal depression but remained up to 18 years after start of follow up. An increased risk was associated with both unnatural and natural causes of death among women with perinatal depression (4.28 (3.44 to 5.32) v (1.38 (1.16 to 1.64)), with the strongest association noted for suicide (6.34 (4.62 to 8.71)), although suicide was rare (0.23 per 1000 person years).

CONCLUSIONS

Even when accounting for familial factors, women with clinically diagnosed perinatal depression were associated with an increased risk of death, particularly during the first year after diagnosis and because of suicide. Women who are affected, their families, and health professionals should be aware of these severe health hazards after perinatal depression.

Impact of adverse pregnancy outcomes on brain vascular health and cognition

A State of the Art lecture titled "Impact of Adverse Pregnancy Outcomes on Brain Vascular Health and Cognition" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Adverse pregnancy outcomes, encompassing conditions such as gestational hypertension, eclampsia, preeclampsia, preterm birth, fetal growth restriction, stillbirth, and gestational diabetes, may form part of an underrecognized pathway from early adulthood reproductive health factors to later-life vascular cognitive impairment and dementia in women. Adverse pregnancy outcomes are caused by dysregulated vascular and metabolic adaptations during pregnancy, and these pathophysiological changes may persist after delivery. Adverse pregnancy outcomes may contribute to the increased risk of cognitive impairment and dementia directly through vascular and metabolic dysregulation and subsequent development of cardiovascular diseases, or other biological processes may be at play, such as shared maternal risk factors. Extensive epidemiologic evidence has shown that many cognitive impairment and dementia cases may be prevented or delayed by strategies targeting midlife cardiovascular health. Despite the recognized importance of adverse pregnancy outcomes for cardiovascular health, the literature on associated long-term health outcomes is limited. In this State of the Art review article, we summarize the current epidemiologic evidence on the relationship between adverse pregnancy outcomes and cognitive impairment and dementia and provide an overview of the potential pathophysiological mechanisms. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.

Breastfeeding Associated with Lower Prevalence of Metabolic Syndrome in Women with Gestational Diabetes in the Very Early Postpartum Period

OBJECTIVE

 The aim of this study is to examine the association of breastfeeding with metabolic syndrome (MetS) in women with recent gestational diabetes mellitus (GDM) in the very early postpartum (PP) period.

STUDY DESIGN

 We performed a secondary analysis of the Balance After Baby Intervention (BABI) study which enrolled women with recent GDM. Data collected during an early (~8 weeks) PP visit were used in this analysis. At this visit, weight, height, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG), and lipids were obtained. MetS was classified per National Cholesterol Education Program Adult Treatment Program III (NCEP-ATP III) criteria. We defined breastfeeding as currently breastfeeding or not currently breastfeeding for the main analysis.

RESULTS

 Of 181 women enrolled in BABI, 178 were included in this analysis (3 excluded for missing lipids). Thirty-four percent were Hispanic. Of non-Hispanics, 31.5% were White, 18.5% Asian, and 12.9% Black/African American. The prevalence of MetS was 42.9% in women not breastfeeding versus 17.1% in women breastfeeding (p < 0.001; adjusted odds ratio [aOR] = 0.16 [95% confidence interval (CI): 0.06-0.41]). Breastfeeding women had significantly lower odds of FPG ≥100 mg/dL (aOR = 0.36 [95% CI: 0.14-0.95], p = 0.039), HDL < 50 mg/dL (aOR = 0.19 [95% CI: 0.08-0.46], p < 0.001), and triglycerides (TG) ≥ 150 mg/dL (aOR = 0.26 [95% CI: 0.10-0.66], p = 0.005). When evaluated as continuous variables, WC, FPG, and TG were significantly lower and HDL significantly higher in women breastfeeding in the very early PP period (vs. not breastfeeding).

CONCLUSION

 In a diverse population of women with recent GDM, there was lower prevalence of MetS in women breastfeeding compared with those not breastfeeding in the very early PP period. This study extends the findings of an association of breastfeeding with MetS previously reported at time points more remote from pregnancy to the very early PP period and to an ethnically and racially diverse population.

KEY POINTS

· MetS prevalence in women with recent GDM was lower in breastfeeding than not breastfeeding women.. · FPG, HDL, WC, and TG were improved in the breastfeeding group.. · This study extends prior findings to the very early PP period and to a diverse population..

Improvement in Clinical Features of L-NAME-Induced Preeclampsia-like Rats through Reduced SERPINA5 Expression

Pre-eclampsia (PE) is a severe pregnancy disorder that poses a significant health risk to both mother and fetus, with no preventive or therapeutic measures. Our previous research suggested an association between elevated SERPINA5 levels and PE features. This study investigated whether SERPINA5 could be a potential therapeutic target for PE. We established PE-like features in pregnant rats using L-NAME (75 mg/kg/d) treatment. Adenoviruses carrying overexpressed or suppressed SERPINA5 genes were intravenously injected into these PE rats on the fifth and seventh days of pregnancy. We evaluated the rats' systolic blood pressure, urine protein concentration, and placental and fetal metrics and histology. Placental gene expression following SERPINA5 overexpression was evaluated using mRNA sequencing. The L-NAME-induced PE rat model observed a significant increase in placental and peripheral SERPINA5 levels. The overexpression of SERPINA5 exacerbated L-NAME-induced hypertension and proteinuria in pregnant rats. A histology examination revealed a smaller placental junctional zone in L-NAME + overexpressing rats. Placental gene expression analysis in the L-NAME + overexpressing group indicated increased coagulation activation. L-NAME-induced hypertension and proteinuria were mitigated when SERPINA5 expression was suppressed. Additionally, placental development was improved in the SERPINA5-suppressed group. Our findings suggested that SERPINA5 may worsen L-NAME-induced PE-like features by promoting the activation of the coagulation cascade. Therefore, reducing SERPINA5 expression could potentially serve as a therapeutic strategy for PE.

US County-Level Variation in Preterm Birth Rates, 2007-2019

Importance

Preterm birth is a leading cause of preventable neonatal morbidity and mortality. Preterm birth rates at the national level may mask important geographic variation in rates and trends at the county level.

Objective

To estimate age-standardized preterm birth rates by US county from 2007 to 2019.

Design, Setting, and Participants

This serial cross-sectional study used data from the National Center for Health Statistics composed of all live births in the US between 2007 and 2019. Data analyses were performed between March 22, 2022, and September 29, 2022.

Main Outcomes and Measures

Age-standardized preterm birth (<37 weeks' gestation) and secondarily early preterm birth (<34 weeks' gestation) rates by county and year calculated with a validated small area estimation model (hierarchical bayesian spatiotemporal model) and percent change in preterm birth rates using log-linear regression models.

Results

Between 2007 and 2019, there were 51 044 482 live births in 2383 counties. In 2007, the national age-standardized preterm birth rate was 12.6 (95% CI, 12.6-12.7) per 100 live births. Preterm birth rates varied significantly among counties, with an absolute difference between the 90th and 10th percentile counties of 6.4 (95% CI, 6.2-6.7). The gap between the highest and lowest counties for preterm births was 20.7 per 100 live births in 2007. Several counties in the Southeast consistently had the highest preterm birth rates compared with counties in California and New England, which had the lowest preterm birth rates. Although there was no statistically significant change in preterm birth rates between 2007 and 2019 at the national level (percent change, -5.0%; 95% CI, -10.7% to 0.9%), increases occurred in 15.4% (95% CI, 14.1%-16.9%) of counties. The absolute and relative geographic inequalities were similar across all maternal age groups. Higher quartile of the Social Vulnerability Index was associated with higher preterm birth rates (quartile 4 vs quartile 1 risk ratio, 1.34; 95% CI, 1.31-1.36), which persisted across the study period. Similar patterns were observed for early preterm birth rates.

Conclusions and Relevance

In this serial cross-sectional study of county-level preterm and early preterm birth rates, substantial geographic disparities were observed, which were associated with place-based social disadvantage. Stability in aggregated rates of preterm birth at the national level masked increases in nearly 1 in 6 counties between 2007 and 2019.

Considering gestational diabetes and gestational hypertension history across two pregnancies in relationship to cardiovascular disease development: A retrospective cohort study

AIMS

Gestational diabetes (GDM) and hypertension (GHTN) occurrences signal elevated cardiovascular disease (CVD) risk. There is little study of occurrence and recurrence of these conditions in relationship to CVD. Among women with two singleton pregnancies, we aimed to quantify CVD risk in relationship to the number of GDM/GHTN occurrences.

METHODS

In this Quebec-based retrospective cohort study (n = 431,980), we ascertained the number of GDM/GHTN occurrences over two pregnancies and assessed for CVD over a median of 16.4 years (cohort inception 1990-2012, outcomes 1990-2019). We defined CVD as a composite of myocardial infarction, stroke, and angina, requiring hospitalization and/or causing death. We adjusted Cox proportional hazards models for offspring size, preterm/term birth status, maternal age group, time between deliveries, ethnicity, deprivation level, and co-morbid conditions.

RESULTS

Compared to absence of GDM/GHTN in either pregnancy, one GDM/GHTN occurrence increased CVD hazards by 47% (hazard ratio [HR] = 1.47, 95% confidence interval [CI] 1.35-1.61), two occurrences nearly doubled hazards (HR = 1.91, 95% CI 1.68-2.17), and three or more approximately tripled CVD hazards (HR = 2.93, 95% CI 2.20-3.90). Individual components of the composite demonstrated similar findings.

CONCLUSIONS

Health care providers and mothers should consider a complete history of GDM/GHTN occurrences to ascertain the importance and urgency of preventive action.

Association between preterm delivery and subsequent maternal risk of hypertension and type 2 diabetes mellitus in a UK population-based retrospective cohort study

OBJECTIVES

Women with a history of preterm delivery (PTD) are at higher risk of developing cardiovascular diseases (CVD) later in life. However, it is not well established whether PTD is associated with CVD risk factors, hypertension and type 2 diabetes mellitus (T2DM). Therefore, in this study, we examined the associations between PTD compared with term delivery and subsequent risk of hypertension and T2DM.

DESIGN

Retrospective matched population-based open cohort study.

SETTING

Clinical Practice Research Datalink GOLD data in the UK.

PARTICIPANTS

A total of 3335 18-49-year-old women with preterm delivery were matched by age and region to 12 634 without a record of preterm delivery.

PRIMARY OUTCOME MEASURES

Outcomes of interest were newly diagnosed hypertension or T2DM at least 6 months after delivery. During the study period (January 2000-December 2019), hypertension or T2DM events in the medical records of women with (exposed) and without (unexposed) preterm delivery were compared. HR and 95% CI were estimated using Cox proportional hazards models adjusted for potential confounders.

RESULTS

Over a median follow-up period of 5.11 (IQR 2.15-9.56) years, the HRs for hypertension in women who delivered preterm compared with women who delivered at term were 1.42 (95%CI 1.09 to 1.80) and 1.18 (95%CI 0.90 to 1.56) in the unadjusted and adjusted models, respectively. For T2DM, over a median follow-up period of 5.17 (IQR 2.18-9.67) years, the HRs in women who delivered preterm compared with those who delivered at term were 1.67 (95%CI 1.12 to 2.48) and 1.10 (95%CI 0.72 to 1.68) in the unadjusted and adjusted models, respectively.

CONCLUSION

We found no independent effect of preterm delivery on risk of hypertension or type 2 diabetes in this study. While significant associations were observed in unadjusted analyses, associations were lost after adjustment and may be attributable to other reproductive complications. Additional studies are needed to confirm these findings.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Postpartum Lifestyle Behaviors among Women with Hypertensive Disorders of Pregnancy: Data from the HUNT Study

Hypertensive disorders of pregnancy (HDP) are associated with an increased risk of cardiovascular disease later in life. Clinical guidelines for postpartum follow-up after HDP often recommend lifestyle counseling to reduce this risk. However, knowledge about lifestyle behaviors and perceptions among women with a history of HDP is limited. We linked data from the fourth survey of the population-based Trøndelag Health Study (HUNT4) with data from the Medical Birth Registry of Norway. The associations between HDP and postpartum lifestyle behaviors and perceptions were examined using multivariable logistic regression. In a secondary analysis, HUNT4 participants with a recent history of pre-eclampsia were compared with women with a recent history of pre-eclampsia participating in a postpartum pilot intervention study. Lifestyle behaviors and perceptions were self-reported and included diet (intake frequency of fruits, vegetables, meat, fish, and sugar-sweetened beverages), alcohol intake, physical activity, sleep, smoking, lifestyle satisfaction, and the importance of a healthy lifestyle. Among 7551 parous HUNT4 participants, 610 had a history of HDP. We found no differences in lifestyle behaviors between women with and without a history of HDP. However, women with HDP had higher odds of being unsatisfied with their lifestyle. Women with pre-eclampsia participating in a postpartum lifestyle intervention study tended to have a healthier lifestyle at baseline than women participating in HUNT4. Future studies should explore how lifestyle intervention programs could be adapted to the needs of women who have experienced HDP or other pregnancy complications that are associated with an increased risk of CVD.

Atherosclerotic Cardiovascular Disease in Women: Providing Protection With Lipid-altering Agents

PURPOSE

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in women, yet it remains underdiagnosed, undertreated, and understudied in women compared with men. Although estrogen has provided observational evidence of cardioprotection, randomized controlled trials using hormone replacement therapy have generally produced unfavorable results.

METHODS

For this narrative review, a literature search was performed using the key words cardiovascular disease, women, and dyslipidemia in PubMed and Google Scholar with no date limitations. References within each article were also reviewed for additional relevant articles.

FINDINGS

Sex-specific risk factors and underrecognized conditions more predominant in women elevate ASCVD risk, creating further clinical challenges, such as the need for accurate risk stratification, compared with in men. Dyslipidemia frequently manifests or worsens during the menopausal transition. Therefore, identification during midlife and implementing lipid-lowering strategies to reduce ASCVD risk is imperative. Women have historically been poorly represented in cardiovascular (CV) outcome trials. However, more recent studies and meta-analyses have indicated that lipid-lowering therapies are equally effective in women and produce similar reductions in CV events and total mortality. Major cholesterol guidelines address many of the challenges that clinicians face when assessing ASCVD risk in women. Key points specific to women include obtaining a detailed history of pregnancy-related conditions, identification of common autoimmune disorders associated with systemic inflammation, and use of 10-year ASCVD risk calculators and imaging modalities (coronary artery calcium) to optimize ASCVD assessment. In terms of treatment, similar to men, women with existing ASCVD or high-risk primary prevention patients should be treated aggressively to achieve ≥50% LDL-C reductions and/or LDL-C goals as low as <55 mg/dL. Appropriate lipid-lowering therapies include high-intensity statins with or without ezetimibe and proprotein convertase subtilisin kexin/type 9 inhibitors. Women with lower ASCVD risk may be considered for low- to moderate-intensity statin therapy (approximately 30%-50% LDL-C reduction). All women, regardless of ASCVD risk category, should implement therapeutic lifestyle changes, which improve many common age-related cardiometabolic conditions.

IMPLICATIONS

Although ASCVD and current risk factor trends in women are concerning, numerous evidence-based approaches are available to protect women with ASCVD risk from life-changing CV events.

Long-term maternal mortality risk following spontaneous preterm birth: A retrospective cohort study

OBJECTIVE

To determine whether women with spontaneous preterm birth (PTB) have increased risks for long-term mortality.

DESIGN

Retrospective cohort.

SETTING

Births in Utah between 1939 and 1977.

POPULATION

We included women with a singleton live birth ≥20 weeks who survived at least 1 year following delivery. We excluded those who had never lived in Utah, had improbable birthweight/gestational age combinations, underwent induction (except for preterm membrane rupture) or had another diagnosis likely to cause PTB.

METHODS

Exposed women had ≥1 spontaneous PTB between 20+0  weeks and 37+0  weeks. Women with >1 spontaneous PTB were included only once. Unexposed women had all deliveries at or beyond 38+0  weeks. Exposed women were matched to unexposed women by birth year, infant sex, maternal age group and infant birth order. Included women were followed up to 39 years after index delivery.

MAIN OUTCOME MEASURES

Overall and cause-specific mortality risks were compared using Cox regression.

RESULTS

We included 29 048 exposed and 57 992 matched unexposed women. There were 3551 deaths among exposed (12.2%) and 6013 deaths among unexposed women (10.4%). Spontaneous PTB was associated with all-cause mortality (adjusted hazard ratio [aHR] 1.26, 95% confidence interval [CI] 1.21-1.31), death from neoplasms (aHR 1.10, 95% CI 1.02-1.18), circulatory disease (aHR 1.35, 95% CI 1.25-1.46), respiratory disease (aHR 1.73, 95% CI 1.46-2.06), digestive disease (aHR 1.33, 95% CI 1.12-1.58), genito-urinary disease (aHR 1.60, 95% CI 1.15-2.23) and external causes (aHR 1.39, 95% CI 1.22-1.58).

CONCLUSIONS

Spontaneous PTB is associated with modestly increased risks for all-cause and some cause-specific mortality.

Sex-specific differences in cardiovascular risk factors and implications for cardiovascular disease prevention in women

Cardiovascular disease (CVD) is the leading cause of mortality for women globally. Sex differences exist in the relative risks conferred by traditional CVD risk factors, including diabetes, hypertension, obesity, and smoking. Additionally, there are female-specific risk factors, including age of menarche and menopause, polycystic ovary syndrome, infertility and the use of assisted reproductive technology, spontaneous pregnancy loss, parity, and adverse pregnancy outcomes, as well as female-predominant conditions such as autoimmune diseases, migraines, and depression, that enhance women's cardiovascular risk across the lifespan. Along with measurement of traditional risk factors, these female-specific factors should also be ascertained as a part of cardiovascular risk assessment to allow for a more comprehensive overview of the risk for developing cardiometabolic disorders and CVD. When present, these factors can identify women at elevated cardiovascular risk, who may benefit from more intensive preventive interventions, including lifestyle changes and/or pharmacotherapy such as statins. This review describes sex differences in traditional risk factors and female-specific/female-predominant risk factors for CVD and examines the role of coronary artery calcium scores and certain biomarkers that can help further risk stratify patients and guide preventive recommendations.

Validation of parental recall questionnaire to classify preterm delivery subtypes: Spontaneous preterm labour, preterm premature rupture of membranes and clinician-initiated preterm delivery

BACKGROUND

Preterm delivery (PTD) includes three main presenting subtypes: spontaneous preterm labour (sPTL), preterm premature rupture of membranes (pPROM) and clinician-initiated preterm delivery (ciPTD). PTD subtype data are rarely available from birth registries and are onerous to derive from medical records.

OBJECTIVES

To develop and test the validity of a questionnaire to classify PTD subtype based on birthing parent recall of labour and delivery events.

METHODS

The questionnaire was sent in 2022 to 581 patients with PTD history documented in the LIFECODES study, a hospital-based birth cohort in Boston, Massachusetts. Eighty-two respondents reported 94 PTDs that could be linked to medical records. Data on PTD subtype were extracted from medical records as the reference standard.

RESULTS

Medical records indicated 47 spontaneous (24 sPTL, 23 pPROM) and 47 ciPTD deliveries occurring a median eight years earlier. The sensitivity and specificity of the recall questionnaire were 88% (95% confidence interval: 68, 97%) and 89% (79, 95%) for sPTL; 96% (78, 100%) and 94% (86, 98%) for pPROM; and 83% (69, 92%) and 100% (92, 100%) for ciPTD, respectively. Greater time since pregnancy did not degrade the sensitivity or specificity of the parental recall questionnaire.

CONCLUSIONS

Although derived from a modest sample, the moderate-to-high sensitivity and specificity of the parental recall questionnaire to classify sPTL, pPROM and ciPTD demonstrates its potential for large studies of PTD and for correction of misclassification bias. Future studies are required to test the questionnaire in a variety of populations.

Body Mass Index, Adverse Pregnancy Outcomes, and Cardiovascular Disease Risk

BACKGROUND

Obesity is a well-established risk factor for both adverse pregnancy outcomes (APOs) and cardiovascular disease (CVD). However, it is not known whether APOs are mediators or markers of the obesity-CVD relationship. This study examined the association between body mass index, APOs, and postpartum CVD risk factors.

METHODS

The sample included adults from the nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be) Heart Health Study who were enrolled in their first trimester (6 weeks-13 weeks 6 days gestation) from 8 United States sites. Participants had a follow-up visit at 3.7 years postpartum. APOs, which included hypertensive disorders of pregnancy, preterm birth, small-for-gestational-age birth, and gestational diabetes, were centrally adjudicated. Mediation analyses estimated the association between early pregnancy body mass index and postpartum CVD risk factors (hypertension, hyperlipidemia, and diabetes) and the proportion mediated by each APO adjusted for demographics and baseline health behaviors, psychosocial stressors, and CVD risk factor levels.

RESULTS

Among 4216 participants enrolled, mean±SD maternal age was 27±6 years. Early pregnancy prevalence of overweight was 25%, and obesity was 22%. Hypertensive disorders of pregnancy occurred in 15%, preterm birth in 8%, small-for-gestational-age birth in 11%, and gestational diabetes in 4%. Early pregnancy obesity, compared with normal body mass index, was associated with significantly higher incidence of postpartum hypertension (adjusted odds ratio, 1.14 [95% CI, 1.10-1.18]), hyperlipidemia (1.11 [95% CI, 1.08-1.14]), and diabetes (1.03 [95% CI, 1.01-1.04]) even after adjustment for baseline CVD risk factor levels. APOs were associated with higher incidence of postpartum hypertension (1.97 [95% CI, 1.61-2.40]) and hyperlipidemia (1.31 [95% CI, 1.03-1.67]). Hypertensive disorders of pregnancy mediated a small proportion of the association between obesity and incident hypertension (13% [11%-15%]) and did not mediate associations with incident hyperlipidemia or diabetes. There was no significant mediation by preterm birth or small-for-gestational-age birth.

CONCLUSIONS

There was heterogeneity across APO subtypes in their association with postpartum CVD risk factors and mediation of the association between early pregnancy obesity and postpartum CVD risk factors. However, only a small or nonsignificant proportion of the association between obesity and CVD risk factors was mediated by any of the APOs, suggesting APOs are a marker of prepregnancy CVD risk and not a predominant cause of postpartum CVD risk.

Hypertensive Disorders of Pregnancy and Risk of Stroke in U.S. Black Women

BACKGROUND: Black women have a disproportionately higher burden of both preeclamptic pregnancy and stroke compared with White women, but virtually all existing evidence on this possible association has been generated from women of European ancestry. METHODS: In the Black Women’s Health Study, a prospective cohort of U.S. Black women who enrolled in 1995, 42,924 participants were parous and free of cardiovascular disease at baseline. Biennial questionnaires included questions on preeclampsia, gestational hypertension, and stroke. We sought the medical records for participants who reported a stroke, and we reviewed them blinded to reproductive history. Cox proportional-hazards models, with control for potential confounders, were used to estimate hazard ratios and 95% confidence intervals (CIs). RESULTS: Over a median of 22 years of follow-up, there were 1555 incident strokes, including 310 among 4938 women with a history of hypertensive disorders of pregnancy (HDOP). The multivariable hazard ratio for stroke for women with any HDOP compared with those who had never experienced HDOP was 1.66 (95% CI, 1.46 to 1.89). Comparable hazard ratios were 1.53 (95% CI, 1.29 to 1.82) for preeclampsia and 1.81 (95% CI, 1.53 to 2.13) for gestational hypertension only. Associations were similar among women under age 55 years and those aged 55 years and older. CONCLUSIONS: In this prospective study of Black women, a history of HDOP was associated with an estimated 66% increased long-term risk of stroke. This association may contribute to the disproportionately higher stroke incidence in Black women given the higher prevalence of HDOP in this population. (Funded by the U.S. National Institutes of Health.)

Parity and Risk of Dementia in Women: The Atherosclerosis Risk in Communities Study

Objective: Reproductive factors, including parity, may contribute to dementia risk, due to hormonal, physiological, social, and demographic factors. We hypothesized that higher parity would be associated with increased dementia risk. Materials and Methods: We utilized data from the Atherosclerosis Risk in Communities (ARIC) community-based cohort study. Participants were recruited in 1987-1989 and followed through 2017. Participants, all born between 1921 and 1945, were from four U.S. communities in Forsyth County, NC; Jackson, MS; Minneapolis, MN; and Washington County, MD. We included all female participants seen at ARIC visit three or five for whom parity and dementia outcomes were available (N = 7,921). The primary exposure was self-reported number of live births. Our primary outcome was dementia, diagnosed via neurocognitive assessments, informant interviews, and expert adjudication. We created Cox proportional hazards models to evaluate the association between parity and incident dementia, adjusting for demographic factors, education level, apolipoprotein E allele status, and vascular risk factors. We tested for interactions by race and birth cohort. Results: The adjusted hazard ratio was 0.82 (95% confidence intervals [CI] 0.69-0.99) for dementia in women with 0-1 births and 0.85 (95% CI 0.72-0.99) for women with 5+ births, compared to women with 2 births (reference group). This association was present in women born from 1924 to 1934, but not in women born in 1935 or later (p-interaction <0.001). Conclusion: We found an inverted U-shaped association of parity with dementia risk. This effect was modified by birth cohort, suggesting that the association may depend on demographic and sociocultural factors.

Sensitivity and specificity of alternative screening methods for systematic reviews using text mining tools

OBJECTIVES

To evaluate the impact of text mining (TM) on the sensitivity and specificity of title and abstract screening strategies for systematic reviews (SRs).

STUDY DESIGN AND SETTING

Twenty reviewers each evaluated a 500-citation set. We compared five screening methods: conventional double screen (CDS), single screen, double screen with TM, combined double screen and single screen with TM, and single screen with TM. Rayyan, Abstrackr, and SWIFT-Review were used for each TM method. The results of a published SR were used as the reference standard.

RESULTS

The mean sensitivity and specificity achieved by CDS were 97.0% (95% confidence interval [CI]: 94.7, 99.3) and 95.0% (95% CI: 93.0, 97.1). When compared with single screen, CDS provided a greater sensitivity without a decrease in specificity. Rayyan, Abstrackr, and SWIFT-Review identified all relevant studies. Specificity was often higher for TM-assisted methods than that for CDS, although with mean differences of only one-to-two percentage points. For every 500 citations not requiring manual screening, 216 minutes (95% CI: 169, 264) could be saved.

CONCLUSION

TM-assisted screening methods resulted in similar sensitivity and modestly improved specificity as compared to CDS. The time saved with TM makes this a promising new tool for SR.

Hypertensive Disorders of Pregnancy in Black Women - Where Do We Go from Here?

In this issue of NEJM Evidence, Sheehy et al.1 report the results of a prospective cohort study that examined the association between hypertensive disorders of pregnancy (HDOP) and the risk of stroke among Black women in the United States. Using data from 42,924 participants in the Black Women's Health Study (BWHS) who were free of cardiovascular disease at baseline, they compared the rates of stroke between women with HDOP and those who did not have HDOP over a median follow-up of 22 years.

Lipid Profile Variations in Pregnancies with and without Cardiovascular Risk: Consequences for Both Mother and Newborn

Background: Maternal cardiovascular risk and its implications can have significant repercussions for both the mother and the child. This study compares the lipid profiles of two distinct groups of pregnant women, those with and without cardiovascular risk, to shed light on its effects on maternal and outcomes for newborns. Materials and Methods: This study enrolled 86 pregnant women, dividing them into two groups: Group 1 (n = 46, healthy pregnancies) and Group 2 (n = 40, pregnancies with cardiovascular risk factors). The data collected included maternal demographics, smoking history, pre-existing pathologies, and a range of laboratory measures. Neonatal outcomes were also recorded. Results: Group 2 showed a significant increase in the percentage of newborns with abnormal APGAR scores (p-value < 0.0001), congenital abnormalities (p-value < 0.0001), severe prematurity (p-value < 0.0001), and neonatal mortality rates (p-value < 0.0001), as well as differences in birth weight (p-value = 0.0392) and therapy usage (surfactant: p-value < 0.001, steroids p-value = 0.004, and antibiotics p-value < 0.001). Regarding laboratory measures, Group 2 exhibited significantly elevated levels of total cholesterol, LDL-C (p-value < 0.0001), ApoB (p-value < 0.0001), Lp(A) (p-value = 0.0486), triglycerides (p-value < 0.0001), and hs-CRP (p-value = 0.0300). Discussion: These results underscore the elevated risk associated with pregnancies complicated by cardiovascular risk factors. Group 2 demonstrated a more concerning clinical profile, with a higher prevalence of detrimental neonatal outcomes and different lipid and inflammatory profiles, signifying a potential pathophysiological link. Conclusions: The differential lipid profiles and adverse neonatal outcomes in pregnancies with cardiovascular risks highlight the urgency of effective risk stratification and management strategies in this population.

Postpartum cardiovascular function in patients with hypertensive disorders of pregnancy: a longitudinal study

BACKGROUND

Women with a history of hypertensive disorders of pregnancy are at increased risk of cardiovascular diseases, which are usually mediated by the development of cardiovascular risk factors, such as chronic hypertension, metabolic syndrome, or subclinical myocardial dysfunction. Increasing evidence has been showing that little time elapses between the end of pregnancy and the development of these cardiovascular risk factors.

OBJECTIVE

This study aimed to assess the persistence of hypertension and myocardial dysfunction at 4 months postpartum in a cohort of women with hypertensive disorders of pregnancy, and to compare the echocardiographic parameters between the peripartum and the postpartum period.

STUDY DESIGN

In a longitudinal prospective study, a cohort of women with preterm or term hypertensive disorders of pregnancy and an unmatched group of women with term normotensive pregnancy were recruited. Women with preexisting chronic hypertension (n=29) were included in the hypertensive disorders of pregnancy cohort. All participants underwent 2 cardiovascular assessments: the first was conducted either before or within 1 week of delivery (V1: peripartum assessment), and the second between 3 and 12 months following delivery (V2: postpartum assessment). The cardiovascular evaluation included blood pressure profile, maternal transthoracic echocardiography (left ventricular mass index, relative wall thickness, left atrial volume index, E/A, E/e', peak velocity of tricuspid regurgitation, ejection fraction, and left ventricular global longitudinal strain and twist), and metabolic assessment (fasting glycemia, insulin, lipid profile, and waist measurement). Echocardiographic data were compared between V1 and V2 using paired t test or McNemar test in hypertensive disorders of pregnancy and in the control groups.

RESULTS

Among 260 patients with pregnancies complicated by hypertensive disorders of pregnancy and 33 patients with normotensive pregnancies, 219 (84.2%) and 30 (90.9%) attended postpartum follow-up, respectively. Patients were evaluated at a median of 124 days (interquartile range, 103-145) after delivery. Paired comparisons of echocardiographic findings demonstrated significant improvements in cardiac remodeling rates (left ventricular mass index [g/m2], 63.4±14.4 vs 78.9±16.2; P<.001; relative wall thickness, 0.35±0.1 vs 0.42±0.1; P<.001), most diastolic indices (E/e', 6.3±1.6 vs 7.4±1.9; P<.001), ejection fraction (ejection fraction <55%, 9 [4.1%] vs 28 [13.0%]; P<.001), and global longitudinal strain (-17.3±2.6% vs -16.2±2.4%; P<.001) in the postpartum period compared with the peripartum. The same improvements in cardiac indices were observed in the normotensive group. However, at the postnatal assessment, 153 of 219 (69.9%) had either hypertension (76/219; 34.7%) or an abnormal global longitudinal strain (125/219; 57.1%), 13 of 67 (19.4%) had metabolic syndrome, and 18 of 67 (26.9%) exhibited insulin resistance.

CONCLUSION

Although persistent postpartum cardiovascular impairment was evident in a substantial proportion of patients given that more than two-thirds had either hypertension or myocardial dysfunction postpartum, cardiac modifications because of pregnancy-related overload and hypertension were more pronounced in the peripartum than in the postpartum period.

Hypertensive disorders of pregnancy and long-term risk of maternal stroke-a systematic review and meta-analysis

OBJECTIVE

Hypertensive disorders of pregnancy are associated with a long-term risk for cardiovascular disease among parous patients later in life. However, relatively little is known about whether hypertensive disorders of pregnancy are associated with an increased risk for ischemic stroke or hemorrhagic stroke in later life. This systematic review aimed to synthesize the available literature on the association between hypertensive disorders of pregnancy and the long-term risk for maternal stroke.

DATA SOURCES

PubMed, Web of Science, and CINAHL were searched from inception to December 19, 2022.

STUDY ELIGIBILITY CRITERIA

Studies were only included if the following criteria were met: case-control or cohort studies that were conducted with human participants, were available in English, and that measured the exposure of a history of hypertensive disorders of pregnancy (preeclampsia, gestational hypertension, chronic hypertension, or superimposed preeclampsia) and the outcome of maternal ischemic stroke or hemorrhagic stroke.

METHODS

Three reviewers extracted the data and appraised the study quality following the Meta-analyses of Observational Studies in Epidemiology guidelines and using the Newcastle-Ottawa scale for risk of bias assessment.

RESULTS

The primary outcome was any stroke (undifferentiated) and secondary outcomes included ischemic stroke and hemorrhagic stroke. The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews under identifier CRD42021254660. Of 24 studies included (10,632,808 study participants), 8 studies examined more than 1 outcome of interest. Hypertensive disorders of pregnancy were significantly associated with any stroke (adjusted risk ratio, 1.74; 95% confidence interval, 1.45-2.10). Preeclampsia was significantly associated with any stroke (adjusted risk ratio, 1.75; 95% confidence interval, 1.56-1.97), ischemic stroke (adjusted risk ratio, 1.74; 95% confidence interval, 1.46-2.06), and hemorrhagic stroke (adjusted risk ratio, 2.77; 95% confidence interval, 2.04-3.75). Gestational hypertension was significantly associated with any stroke (adjusted risk ratio, 1.23; 95% confidence interval, 1.20-1.26), ischemic stroke (adjusted risk ratio, 1.35; 95% confidence interval, 1.19-1.53), and hemorrhagic stroke (adjusted risk ratio, 2.66; 95% confidence interval, 1.02-6.98). Chronic hypertension was associated with ischemic stroke (adjusted risk ratio, 1.49; 95% confidence interval, 1.01-2.19).

CONCLUSION

In this meta-analysis, exposure to hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, seems to be associated with an increased risk for any stroke and ischemic stroke among parous patients in later life. Preventive interventions may be warranted for patients who experience hypertensive disorders of pregnancy to reduce their long-term risk for stroke.

Serum Cotinine and Adverse Cardiovascular Outcomes: A Cross-sectional Secondary Analysis of the nuMoM2b Heart Health Study

OBJECTIVE

We aimed to (1) compare serum cotinine with self-report for ascertaining smoking status among reproductive-aged women; (2) estimate the relative odds of adverse cardiovascular (CV) outcomes among women by smoking status; (3) assess whether the association between adverse pregnancy outcomes (APOs) and CV outcomes varies by smoking status.

STUDY DESIGN

We conducted a cross-sectional study of the nuMoM2b Heart Health Study. Women attended a study visit 2 to 7 years after their first pregnancy. The exposure was smoking status, determined by self-report and by serum cotinine. Outcomes included incident chronic hypertension (HTN), metabolic syndrome (MetS), and dyslipidemia. Multivariable logistic regression estimated odds ratios (ORs) for each outcome by smoking status.

RESULTS

Of 4,392 women with serum cotinine measured, 3,610 were categorized as nonsmokers, 62 as secondhand smoke exposure, and 720 as smokers. Of 3,144 women who denied tobacco smoke exposure, serum cotinine was consistent with secondhand smoke exposure in 48 (1.5%) and current smoking in 131 (4.2%) After adjustment for APOs, smoking defined by serum cotinine was associated with MetS (adjusted OR [aOR] = 1.52, 95% confidence interval [CI]: 1.21, 1.91) and dyslipidemia (aOR = 1.28, 95% CI: 1.01, 1.62). When stratified by nicotine exposure, nonsmokers with an APO in their index pregnancy had higher odds of stage 1 (aOR = 1.64, 95% CI: 1.32, 2.03) and stage 2 HTN (aOR = 2.92, 95% CI: 2.17, 3.93), MetS (aOR = 1.76, 95% CI: 1.42, 2.18), and dyslipidemia (aOR = 1.55, 95% CI: 1.25, 1.91) relative to women with no APO. Results were similar when smoking exposure was defined by self-report.

CONCLUSION

Whether determined by serum cotinine or self-report, smoking is associated with subsequent CV outcomes in reproductive-aged women. APOs are also independently associated with CV outcomes in women.

KEY POINTS

· Cotinine was detected in 5.7% of reported nonsmokers.. · Smoking and APOs were independently associated with CV health.. · Smoking was associated with MetS and dyslipidemia..

Cardio-Obstetrics: A Focused Review

PURPOSE OF REVIEW

Cardiovascular disease is the leading cause of maternal mortality in the USA. All cardiovascular care providers should have a foundational knowledge on the management of pregnant individuals with heart disease. This focused review touches on several key cardio-obstetric themes.

RECENT FINDINGS

Many individuals with cardiovascular disease can safely undergo pregnancy, but should have counseling preconception to optimize cardiac status. There are several cardiovascular conditions that are high risk for maternal mortality and morbidity. These individuals should be adequately counseled preconception and offered reliable birth control. The approach to a high-risk pregnant patient with cardiac disease is best managed by a multidisciplinary team to address potential maternal and fetal complications. Identification of at risk individuals can be estimated preconception with several risk scores. The development of risk scores to stratify and identify those at elevated risk during pregnancy is an area of continued research and development.

Long-Term Impacts of Preeclampsia on the Cardiovascular System of Mother and Offspring

Preeclampsia is a pregnancy-specific complication that is associated with an increased postpartum risk of cardiovascular disease (CVD) in both women and their offspring, although the underlying mechanisms have yet to be fully elucidated. Nevertheless, differential methylation of cytosine-phosphate-guanosine islands and alterations in the expression of microRNA, associated with an elevated risk of CVD, have been observed in women and their children following preeclampsia. Among this specific population, genetic and epigenetic factors play crucial roles in the development of CVD in later life. A series of biomolecules involved in inflammation, oxidative stress, and angiogenesis may link pregnancy vascular bed disorders in preeclampsia to the pathogenesis of future CVD and thus could be valuable for the prediction and intervention of long-term CVD in women with a history of preeclampsia and their offspring. Here, we present insights into the cardiovascular structure and functional changes of women with a history of preeclampsia and their offspring. With a focus on various underlying mechanisms, the conclusions from this review are expected to provide more potential diagnostics and treatment strategies for clinical practice.

Placental syndromes and maternal cardiovascular health

The placental syndromes gestational hypertension, preeclampsia and intrauterine growth restriction are associated with an increased cardiovascular risk to the mother later in life. In this review, we argue that a woman's pre-conception cardiovascular health drives both the development of placental syndromes and long-term cardiovascular risk but acknowledge that placental syndromes can also contribute to future cardiovascular risk independent of pre-conception health. We describe how preclinical studies in models of preeclampsia inform our understanding of the links with later cardiovascular disease, and how current pre-pregnancy studies may explain relative contributions of both pre-conception factors and the occurrence of placental syndromes to long-term cardiovascular disease.

Birth Weight in Consecutive Pregnancies and Maternal Cardiovascular Disease Mortality Among Spontaneous and Iatrogenic Term Births: A Population-Based Cohort Study

Knowledge on the association between offspring birth weight and long-term risk of maternal cardiovascular disease (CVD) mortality is often based on firstborn infants without consideration of women's consecutive births. We studied long-term CVD mortality according to offspring birth weight patterns among women with spontaneous and iatrogenic term deliveries in Norway (1967-2020). We constructed birth weight quartiles (Qs) by combining standardized birth weight with gestational age in quartiles (Q1, Q2/Q3, and Q4) for the women's first 2 births. Mortality was estimated using Cox regression and expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). Changes in offspring birth weight quartiles were associated with long-term maternal CVD mortality. Compared with women who had 2 term infants in Q2/Q3, women with a first offspring in Q2/Q3 and a second in Q1 had higher mortality risk (HR = 1.33, 95% CI: 1.18, 1.50), while risk was lower if the second offspring was in Q4 (HR = 0.78, 95% CI: 0.67, 0.91). The risk increase associated with having a first infant in Q1 was eliminated if the second offspring was in Q4 (HR = 0.99, 95% CI: 0.75, 1.31). These patterns were similar for women with iatrogenic and spontaneous deliveries. Inclusion of information from subsequent births revealed heterogeneity in maternal CVD mortality which was not captured when using only information based on the first offspring.

Placental syndromes and long-term risk of hypertension

Higher blood pressure prior to pregnancy is associated with increased risk of placental abruption, hypertension and preeclampsia, preterm delivery and fetal growth restriction. These conditions are jointly termed placental syndromes as they are characterised by impaired placentation and early placental vascularization. Placental syndromes are associated with an increased maternal risk of progression to hypertension and cardiovascular disease (CVD) in later life. Women affected by both a clinical placental syndrome and with evidence of placental maternal vascular malperfusion (MVM) have a particularly high risk of hypertension and CVD. Yet whether placental impairment and clinical syndromes are causes or consequences of higher blood pressure in women remains unclear. In this review, we address the relationship between blood pressure and maternal health in pregnancy. We conclude that there is a pressing need for studies with a range of detailed measures of cardiac and vascular structure and function taken before, during and after pregnancy to solve the 'chicken and egg' puzzle of women's blood pressure and pregnancy health, and to inform effective precision medicine prevention and treatment of both placental syndromes and chronic hypertension in women.

Sex, Racial, and Ethnic Disparities in Acute Coronary Syndrome: Novel Risk Factors and Recommendations for Earlier Diagnosis to Improve Outcomes

In this review, sex, racial, and ethnic differences in acute coronary syndromes on a global scale are summarized. The relationship between disparities in presentation and management of acute coronary syndromes and effect on worse clinical outcomes in acute coronary syndromes are discussed. The effect of demographic, geographic, racial, and ethnic factors on acute coronary syndrome care disparities are reviewed. Differences in risk factors including systemic inflammatory disorders and pregnancy-related factors and the pathophysiology underlying them are discussed. Finally, breast arterial calcification and coronary calcium scoring are discussed as methods to detect subclinical atherosclerosis and start early treatment in an attempt to prevent clinical disease.

Correlation Between Breast Arterial Calcifications and Higher Cardiovascular Risk: Awareness and Attitudes Amongst Canadian Radiologists Who Report Mammography

Background: Breast arterial calcification (BAC) on mammography correlates with increased cardiovascular risk. Reporting BAC is not standard practice. Our study evaluates the awareness of Canadian radiologists who report mammography of the clinical significance of BAC and their attitudes towards reporting BAC compared to their European and American counterparts. Methods: Following local institutional ethics approval, a 25 question survey (SurveyMonkey) was disseminated to Canadian radiologists via provincial and national society email lists. Responses were collected over 5 weeks (April-June 2022). Results: One hundred and eighty-six complete responses were collected. Sixty percent (112/186) were aware of the association between BAC and cardiovascular risk and 16% (29/186) document its presence in mammogram reports. Thirty five percent (65/186) occasionally document BAC if severe or in a young patient. Four percent (7/186) had local departmental guidelines on BAC reporting and 82% (153/186) agreed there is a need for national BAC reporting guidelines. Fewer Canadian radiologists were aware of the association between BAC and cardiovascular risk compared to European radiologists (60% vs 81%), report the presence of BAC compared to both European (15% vs 62%) and American (15% vs 35%) radiologists, and inform the patient of the presence of BAC compared to European radiologists (1% vs 46%). Conclusion: Canadian radiologists who report mammography were less aware of the association between BAC and cardiovascular risk than their European and American counterparts and were less likely to document the presence of BAC. Given the correlation of BAC with increased cardiovascular event risk, there is increased need for awareness as well as national BAC reporting guidelines.

Pregnancy complications in last pregnancy and mothers' long-term cardiovascular mortality: does the relation differ from that of complications in first pregnancy? A population-based study

BACKGROUND

Women who experience complications in first pregnancy are at increased risk of cardiovascular disease (CVD) later in life. Little corresponding knowledge is available for complications in later pregnancies. Therefore, we assessed complications (preeclampsia, preterm birth, and offspring small for gestational age) in first and last pregnancies and the risk of long-term maternal CVD death, taking women´s complete reproduction into account.

DATA AND METHODS

We linked data from the Medical Birth Registry of Norway to the national Cause of Death Registry. We followed women whose first birth took place during 1967-2013, from the date of their last birth until death, or December 31st 2020, whichever occurred first. We analysed risk of CVD death until 69 years of age according to any complications in last pregnancy. Using Cox regression analysis, we adjusted for maternal age at first birth and level of education.

RESULTS

Women with any complications in their last or first pregnancy were at higher risk of CVD death than mothers with two-lifetime births and no pregnancy complications (reference). For example, the adjusted hazard ratio (aHR) for women with four births and any complications only in the last pregnancy was 2.85 (95% CI, 1.93-4.20). If a complication occurred in the first pregnancy only, the aHR was 1.74 (1.24-2.45). Corresponding hazard ratios for women with two births were 1.82 (CI, 1.59-2.08) and 1.41 (1.26-1.58), respectively.

CONCLUSIONS

The risk for CVD death was higher among mothers with complications only in their last pregnancy compared to women with no complications, and also higher compared to mothers with a complication only in their first pregnancy.

Assisted reproductive technology: what are the cardiovascular risks for women?

INTRODUCTION

Infertility affects 15% of women of reproductive age in the United States. The use of assisted reproductive technology (ART) has been rising globally, as well as a growing recognition of reproductive factors that increase risk for cardiovascular disease (CVD).

AREAS COVERED

Women with infertility who use ART are more likely to have established CVD risk factors, such as obesity, dyslipidemia, hypertension, and diabetes. They are also more likely to experience adverse pregnancy outcomes, which are associated with both peripartum and long-term cardiovascular complications. ART may lead to increased cardiometabolic demands due to ovarian stimulation, pregnancy itself, and higher rates of multifetal gestation. Preeclampsia risk appears greater with frozen rather than fresh embryo transfers.

EXPERT OPINION

The use of ART and its association with long term CVD has not been well-studied. Future prospective and mechanistic studies investigating the association of ART and CVD risk may help determine causality. Nevertheless, CVD risk screening is critical pre-pregnancy and during pregnancy to reduce pregnancy complications that elevate future CVD risk. This also offers a window of opportunity to connect patients to longitudinal care for early management of cardiometabolic risk profile and initiation of preventive lifestyle and pharmacotherapy interventions tailored toward patient-specific risk factors.

Gender differences in efficacy and safety of antiplatelet strategies for acute coronary syndromes

INTRODUCTION

Dual antiplatelet therapy (DAPT) represents the cornerstone of secondary prevention in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention. Despite its undisputed efficacy in reducing thrombotic events, DAPT increases the risk of bleeding, which is associated with higher morbidity and mortality. Novel antiplatelet strategies (i.e. in terms of timing, selection of drugs and their combinations, and modulation strategies) have been tested in randomized trials, suggesting the utility of tailored approaches in selected populations (i.e. patients at high bleeding or ischemic risk). It remains uncertain whether the effect of these strategies is influenced by sex.

AREAS COVERED

This narrative review provides an overview of available evidence surrounding sex differences in the efficacy and safety of antiplatelet strategies for ACS and analyzes the potential reasons behind these findings. Relevant content was searched for in PubMed.

EXPERT OPINION

Significant differences between women and men exist in terms of clinical presentation, pharmacotherapies, interventional management, and prognosis of ACS. However, these observations do not appear to be attributed to different pharmacodynamic effects of antiplatelet therapies between women and men. Unfortunately, a critical issue depends on women being often underrepresented in clinical trials, leading to a substantial lack of sex-specific evidence.

Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.

Rationale, Design, and Methods for the Sedentary Behavior Reduction in Pregnancy Intervention (SPRING): Protocol for a Pilot and Feasibility Randomized Controlled Trial

BACKGROUND

Adverse pregnancy outcomes (APOs) identify cardiovascular disease risk, but few effective interventions are available. High sedentary behavior (SED) has recently been associated with APOs, but very few randomized controlled trials (RCTs) have tested SED reduction in pregnancy.

OBJECTIVE

The Sedentary Behavior Reduction in Pregnancy Intervention (SPRING) pilot and feasibility RCT addresses this gap by testing the feasibility, acceptability, and preliminary pregnancy health effects of an intervention to reduce SED in pregnant women. The objective of this manuscript is to describe the rationale and design of SPRING.

METHODS

Pregnant participants (n=53) in their first trimester, who are at risk for high SED and APO and without contraindications, are randomized in a 2:1 ratio to an intervention or control group. SED (primary outcome) and standing durations, and steps per day, are measured objectively in each trimester for 1 week with a thigh-mounted activPAL3 accelerometer. SPRING also seeks to demonstrate feasibility and acceptability while estimating preliminary effects on maternal-fetal health outcomes assessed during study visits and abstracted from medical records. The pregnancy-customized intervention promotes daily behavioral targets of less than 9 hours of SED and at least 7500 steps, achieved via increased standing and incorporating light-intensity movement breaks each hour. The multicomponent intervention provides a height-adjustable workstation, a wearable activity monitor, behavioral counseling every 2 weeks (through videoconference), and membership in a private social media group. Herein, we review the rationale, describe recruitment and screening processes, and detail the intervention, assessment protocols, and planned statistical analyses.

RESULTS

This study was funded by the American Heart Association (20TPA3549099), with a funding period of January 1, 2021, and until December 31, 2023. Institutional review board approval was obtained on February 24, 2021. Participants were randomized between October 2021 and September 2022, with final data collection planned for May 2023. Analyses and submission of results are expected for winter of 2023.

CONCLUSIONS

The SPRING RCT will provide initial evidence on the feasibility and acceptability of an SED-reduction intervention to decrease SED in pregnant women. These data will inform the design of a large clinical trial testing SED reduction as a strategy to reduce APO risk.

TRIAL REGISTRATION

ClincialTrials.gov NCT05093842; https://clinicaltrials.gov/ct2/show/NCT05093842.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48228.

Pregnancy as an Early Cardiovascular Moment: Peripartum Cardiovascular Health

Pregnancy is commonly referred to as a window into future CVH (cardiovascular health). During pregnancy, physiological adaptations occur to promote the optimal growth and development of the fetus. However, in approximately 20% of pregnant individuals, these perturbations result in cardiovascular and metabolic complications, which include hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and small-for-gestational age infant. The biological processes that lead to adverse pregnancy outcomes begin before pregnancy with higher risk of adverse pregnancy outcomes observed among those with poor prepregnancy CVH. Individuals who experience adverse pregnancy outcomes are also at higher risk of subsequent development of cardiovascular disease, which is largely explained by the interim development of traditional risk factors, such as hypertension and diabetes. Therefore, the peripartum period, which includes the period before (prepregnancy), during, and after pregnancy (postpartum), represents an early cardiovascular moment or window of opportunity when CVH should be measured, monitored, and modified (if needed). However, it remains unclear whether adverse pregnancy outcomes reflect latent risk for cardiovascular disease that is unmasked in pregnancy or if adverse pregnancy outcomes are themselves an independent and causal risk factor for future cardiovascular disease. Understanding the pathophysiologic mechanisms and pathways linking prepregnancy CVH, adverse pregnancy outcomes, and cardiovascular disease are necessary to develop strategies tailored for each stage in the peripartum period. Emerging evidence suggests the utility of subclinical cardiovascular disease screening with biomarkers (eg, natriuretic peptides) or imaging (eg, computed tomography for coronary artery calcium or echocardiography for adverse cardiac remodeling) to identify risk-enriched postpartum populations and target for more intensive strategies with health behavior interventions or pharmacological treatments. However, evidence-based guidelines focused on adults with a history of adverse pregnancy outcomes are needed to prioritize the prevention of cardiovascular disease during the reproductive years and beyond.

Pre-eclampsia and Cardiovascular Disease: From Pregnancy to Postpartum

Hypertensive disorders of pregnancy (HDP) complicate approximately 10% of pregnancies. In addition to multiorgan manifestations related to endothelial dysfunction, HDP confers an increased risk of cardiovascular disease during delivery hospitalisation, such as heart failure, pulmonary oedema, acute MI and cerebrovascular events. However, the cardiovascular legacy of HDP extends beyond birth since these women are significantly more likely to develop cardiovascular risk factors in the immediate postnatal period and major cardiovascular disease in the long term. The main mediator of cardiovascular disease in women with a history of HDP is chronic hypertension, followed by obesity, hypercholesterolaemia and diabetes. Therefore, optimising blood pressure levels from the immediate postpartum period until the first months postnatally could have beneficial effects on the development of hypertension and improve long-term cardiovascular health. Peripartum screening based on maternal demographic, and clinical and echocardiographic data could help clinicians identify women with HDP at highest risk of developing postpartum hypertension who would benefit from targeted primary cardiovascular prevention.

Invited Commentary: Beyond Barker-Mothers Are the Ones at Risk

Dr. David Barker hypothesized that low birth weight (LBW) is the result of inadequate fetal nutrition, leading to increased risk of cardiovascular disease (CVD) in the offspring. This hypothesis has stimulated thousands of reports on low birth weight (LBW) and CVD risk. One problem with this association is that many LBW infants are small because they are preterm, not growth-restricted. A second problem is that maternal CVD risk factors confound the association. In an accompanying article, Lu et al. (Am J Epidemiol. 2023;192(6):866-877) address both concerns. Using population data from Sweden and Denmark, the authors estimated CVD incidence among offspring born small for gestational age (SGA). The smallest 3% had a CVD hazard ratio of 1.44 (95% confidence interval: 1.38, 1.51). Even this moderate risk mostly evaporated in sibship analysis, which controlled for unmeasured maternal CVD risk factors (hazard ratio = 1.11, 95% confidence interval: 0.99, 1.25). The risk highlighted by Barker is negligible, especially when compared with a more urgent health issue-cardiovascular risk in women with pregnancy complications. Mothers of SGA infants have up to a 3-fold CVD risk, and mothers with preeclampsia and preterm delivery have up to a 9-fold risk. Pregnancy complications thus provide an early marker of a woman's propensity to develop CVD, and perhaps an opportunity for early intervention. From a public health perspective, Barker's hypothesis about CVD risk in LBW offspring is less compelling than the question of CVD risk among mothers with pregnancy complications. This article is part of a Special Collection on ABC.

Preventing Adverse Cardiovascular Outcomes in Pregnancy Complicated by Obesity

Purpose of review

Obesity is a chronic disease that is becoming increasingly prevalent, and more individuals of reproductive age have obesity prior to becoming pregnant. Obesity in pregnancy is associated with short- and long-term adverse consequences for both the birthing person and their offspring which have been associated with increased long-term cardiovascular morbidity and mortality. The goal of this review is to discuss what is currently understood about the relationship between maternal obesity and adverse pregnancy outcomes (APOs), the association between APOs and future cardiovascular disease (CVD) risk, and what evidence-based interventions can be implemented to prevent adverse outcomes in this population.

Recent findings

Maternal obesity has been associated with an increased risk of APOs such as gestational diabetes, hypertensive disorders of pregnancy, and preterm birth as well as an increased risk of future CVD, such as metabolic syndrome, chronic hypertension, coronary heart disease, and stroke. The impact of maternal obesity also extends beyond the pregnant individual to the offspring, increasing the risk of fetal, neonatal, and infant mortality, as well as of congenital malformations, prematurity, and long-term health problems such as insulin resistance and childhood obesity. Prevention guidelines are incorporating the increased risk of adverse outcomes from maternal obesity into formalized risk assessments to guide both prenatal and postpartum care. It is becoming evident that a multidisciplinary cardio-obstetrics team is an important part of providing comprehensive care for pregnant individuals with obesity and other cardiovascular risk factors, including preexisting CVD and a history of prior APOs. There remains a need for further studies to better understand the mechanisms underlying the relationship between maternal obesity and APOs, as well as the racial and ethnic disparities that have been noted in the prevalence of APOs and associated CVD risk and mortality.

Summary

There is increasing awareness that obesity in pregnancy is associated with various short- and long-term adverse maternal and offspring outcomes. There are multiple screening and prevention strategies that may be implemented before, during, and after pregnancy to prevent these adverse outcomes.

Rural-urban residence and sequelae of hypertensive disorders of pregnancy in the first year postpartum, 2007 - 2019

OBJECTIVES

To estimate the association between rural residence and sequelae of hypertensive disorders of pregnancy (HDP) in the first year postpartum.

STUDY DESIGN

We used the Maine Health Data Organization's All Payer Claims Data to identify women with HDP who delivered during 2007-2019 and did not have chronic hypertension or pre-pregnancy cardiac conditions (n = 8882). We used Cox proportional hazards modeling to estimate rural-urban hazard ratios (HR) and 95% confidence intervals (CI), adjusting for HDP subtype, age, insurance, nulliparity, and co-morbidities. Results were stratified by HDP subtype and timing of acute care visits.

MAIN OUTCOME MEASURES

Risk of at least one emergency room or inpatient visit related to hypertension or cardiovascular conditions in the first year postpartum and receipt of outpatient antihypertensive medications from 4 days to 1 year postpartum, separately.

RESULTS

Overall, risk of at least one acute care visit in the first year postpartum was not different between rural vs urban women (4.2% vs 4.2%; adjusted HR 0.98; 95% CI 0.79,1.21), and outpatient receipt of antihypertensive medication was not different (12.9% vs 12.8%; adjusted HR 0.99; 95% CI 0.87, 1.12). However, stratified analyses suggested some differences (e.g. preeclampsia with severe features: acute care visit adjusted HR 1.54; 95% CI 0.95, 2.49).

CONCLUSIONS

Rural and urban women do not differ in the risks of these common HDP sequelae, though rural women may have increased risk by HDP subtype or timing of acute care visit. Future research should investigate postpartum interventions for reducing HDP sequelae in rural and urban women.

Obstetric and Gynecologic Disorders and the Nervous System

OBJECTIVE

This article discusses obstetric and gynecologic associations with common neurologic disorders.

LATEST DEVELOPMENTS

Neurologic complications of obstetric and gynecologic disorders can arise throughout the lifespan. Caution should be exercised when prescribing fingolimod and natalizumab to patients with multiple sclerosis who are of childbearing potential because of the risk of disease rebound when they are discontinued. OnabotulinumtoxinA is considered safe in pregnancy and lactation based on long-term observational data. Hypertensive disorders of pregnancy are associated with higher subsequent cerebrovascular risk, likely via multiple mechanisms.

ESSENTIAL POINTS

Neurologic disorders may present in a variety of obstetric and gynecologic contexts, with meaningful implications for recognition and treatment. These interactions must be considered when treating women with neurologic conditions.

Number of prior live births is associated with higher arterial stiffness but not its change in older women: the atherosclerosis risk in communities study

Introduction

Although studies have demonstrated a J-shaped association between parity and cardiovascular disease (CVD), the association with arterial stiffness is not fully understood.

Methods

We examined the association between parity and carotid-femoral pulse wave velocity (cfPWV), a measure of central arterial stiffness. We conducted a longitudinal analysis of 1220 women (mean age 73.7 years) who attended the Atherosclerosis Risk in Communities Study visit 5 (2011-2013). At visit 2 (1990-1992), women self-reported parity (number of prior live births), which we categorized as: 0 (never pregnant or pregnant with no live births); 1-2 (referent); 3-4; and 5+ live births. Technicians measured cfPWV at visit 5 (2011-2013) and visit 6 or 7 (2016-2019). Multivariable linear regression modeled the associations of parity with visit 5 cfPWV and cfPWV change between visit 5 and 6/7 adjusted for demographics and potential confounding factors.

Results

Participants reported 0 (7.7%), 1-2 (38.7%), 3-4 (40.0%), or 5+ (13.6%) prior live births. In adjusted analyses, women with 5+ live births had a higher visit 5 cfPWV (β=50.6 cm/s, 95% confidence interval: 3.6, 97.7 cm/s) than those with 1-2 live births. No statistically significant associations were observed for other parity groups with visit 5 cfPWV or with cfPWV change.

Discussion

In later life, women with 5+ live births had higher arterial stiffness than those with 1-2 live births, but cfPWV change did not differ by parity, suggesting women with 5+ live births should be targeted for early primary prevention of CVD given their higher arterial stiffness at later-life.

Maternal glucose levels and future risk of developing cardiovascular disease: a systematic review and meta-analysis protocol

INTRODUCTION

Hyperglycaemia during pregnancy has been considered as one of the risk factors for cardiovascular diseases (CVDs) among women. Although the evidence regarding the association between gestational diabetes mellitus (GDM) and subsequent CVD has been synthesised, there are no systematic reviews covering the evidence of the association among the non-GDM population. This systematic review and meta-analysis, therefore, aim to fill the gap by summarising existing evidence on the association between maternal glucose levels and the risk of future CVD in pregnant women with or without a diagnosis of GDM.

METHODS AND ANALYSIS

This systematic review protocol was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. Comprehensive literature searches were performed in the following electronic databases: MEDLINE, EMBASE and CINAHL to identify relevant papers from inception to 31 December 2022. All observational studies (case-control studies, cohort studies and cross-sectional studies) will be included. Two reviewers will perform the abstract and full-text screening based on the eligibility criteria through Covidence. The Newcastle-Ottawa Scale will be used to assess the methodological quality of included studies. Statistical heterogeneity will be assessed by using the I² test and Cochrane's Q test. If the included studies are found to be homogeneous, pooled estimates will be calculated and meta-analysis will be performed using Review Manager 5 (RevMan) software. Random effects will be used to determine weights for meta-analysis, if needed. Pre-specified subgroup analysis and sensitivity analysis will be performed, if needed. The study results will be presented in the sequence of main outcomes, secondary outcomes and important subgroup analysis for each type of glucose level separately.

ETHICS AND DISSEMINATION

Given no original data will be collected, ethics approval is not applicable for this review. The results of this review will be disseminated by publication and conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42022363037.

Beyond sex differences: short- and long-term effects of pregnancy on the brain

Growing attention has been directed to the inclusion of females in neuroscience studies, and to the importance of studying sex as a biological variable. However, how female-specific factors such as menopause and pregnancy, affect the brain remains understudied. In this review, we use pregnancy as a case in point of a female-unique experience that can alter neuroplasticity, neuroinflammation, and cognition. We examine studies in both humans and rodents indicating that pregnancy can modify neural function in the short term, as well as alter the trajectory of brain aging. Furthermore, we discuss the influence of maternal age, fetal sex, number of pregnancies, and presence of pregnancy complications on brain health outcomes. We conclude by encouraging the scientific community to prioritize researching female health by recognizing and including factors such as pregnancy history in research.

How much does hypertension in pregnancy affect the risk of future cardiovascular events?

Hypertensive disorders in pregnancy (HDP) include essential (or secondary) hypertension occurring before 20 weeks of gestation or in women already on antihypertensive therapy prior to pregnancy, gestational hypertension, developing after 20 weeks of gestation without significant proteinuria, and pre-eclampsia or AH onset after 20 weeks of pregnancy in the presence of proteinuria. The development of HDP is associated with a higher incidence of long-term cardiovascular (CV) adverse events, such as myocardial infarction, heart failure, stroke, and CV death. Women who develop high blood pressure in their first pregnancy have an increased risk of complication in a subsequent pregnancy. In the years following delivery, pregnant women with hypertensive disorders develop subclinical atherosclerosis and alterations of cardiac structure and function that may lead to CV disease and heart failure. Thus, it is recommended to monitor these changes over time and subject in pregnant women with these characteristics to CV surveillance through structured and multidisciplinary interventions for CV prevention.

Pregnancy Complications and Long-Term Mortality in a Diverse Cohort

BACKGROUND

Pregnancy complications are associated with increased risk of development of cardiometabolic diseases and earlier mortality. However, much of the previous research has been limited to White pregnant participants. We aimed to investigate pregnancy complications in association with total and cause-specific mortality in a racially diverse cohort and evaluate whether associations differ between Black and White pregnant participants.

METHODS

The Collaborative Perinatal Project was a prospective cohort study of 48 197 pregnant participants at 12 US clinical centers (1959-1966). The Collaborative Perinatal Project Mortality Linkage Study ascertained participants' vital status through 2016 with linkage to the National Death Index and Social Security Death Master File. Adjusted hazard ratios (aHRs) for underlying all-cause and cause-specific mortality were estimated for preterm delivery (PTD), hypertensive disorders of pregnancy, and gestational diabetes/impaired glucose tolerance (GDM/IGT) using Cox models adjusted for age, prepregnancy body mass index, smoking, race and ethnicity, previous pregnancies, marital status, income, education, previous medical conditions, site, and year.

RESULTS

Among 46 551 participants, 45% (21 107 of 46 551) were Black, and 46% (21 502 of 46 551) were White. The median time between the index pregnancy and death/censoring was 52 years (interquartile range, 45-54). Mortality was higher among Black (8714 of 21 107 [41%]) compared with White (8019 of 21 502 [37%]) participants. Overall, 15% (6753 of 43 969) of participants had PTD, 5% (2155 of 45 897) had hypertensive disorders of pregnancy, and 1% (540 of 45 890) had GDM/IGT. PTD incidence was higher in Black (4145 of 20 288 [20%]) compared with White (1941 of 19 963 [10%]) participants. The following were associated with all-cause mortality: preterm spontaneous labor (aHR, 1.07 [95% CI, 1.03-1.1]); preterm premature rupture of membranes (aHR, 1.23 [1.05-1.44]); preterm induced labor (aHR, 1.31 [1.03-1.66]); preterm prelabor cesarean delivery (aHR, 2.09 [1.75-2.48]) compared with full-term delivery; gestational hypertension (aHR, 1.09 [0.97-1.22]); preeclampsia or eclampsia (aHR, 1.14 [0.99-1.32]) and superimposed preeclampsia or eclampsia (aHR, 1.32 [1.20-1.46]) compared with normotensive; and GDM/IGT (aHR, 1.14 [1.00-1.30]) compared with normoglycemic. P values for effect modification between Black and White participants for PTD, hypertensive disorders of pregnancy, and GDM/IGT were 0.009, 0.05, and 0.92, respectively. Preterm induced labor was associated with greater mortality risk among Black (aHR, 1.64 [1.10-2.46]) compared with White (aHR, 1.29 [0.97-1.73]) participants, while preterm prelabor cesarean delivery was higher in White (aHR, 2.34 [1.90-2.90]) compared with Black (aHR, 1.40 [1.00-1.96]) participants.

CONCLUSIONS

In this large, diverse US cohort, pregnancy complications were associated with higher mortality nearly 50 years later. Higher incidence of some complications in Black individuals and differential associations with mortality risk suggest that disparities in pregnancy health may have life-long implications for earlier mortality.

Women's Reproductive Milestones and Cardiovascular Disease Risk: A Review of Reports and Opportunities From the CARDIA Study

In 1985 to 1986, the CARDIA (Coronary Artery Risk Development in Young Adults) study enrolled 5115 Black or White participants, including 2788 women, aged 18 to 30 years. Over the following 35 years, the CARDIA study amassed extensive longitudinal data on women's reproductive milestones, spanning menarche to menopause. Although not initially conceived as a study of women's health, >75 CARDIA study publications address relationships between reproductive factors and events with cardiovascular and metabolic risk factors, subclinical and clinical cardiovascular disease, and social determinants of health. The CARDIA study was one of the earliest population-based reports to note Black-White differences in age at menarche and associations with cardiovascular risk factors. Adverse pregnancy outcomes, particularly gestational diabetes and preterm birth, have been assessed along with postpartum behaviors, such as lactation. Existing studies have examined risk factors for adverse pregnancy outcomes and lactation, as well as their relationship to future cardiovascular and metabolic risk factors, diagnoses, and subclinical atherosclerosis. Ancillary studies examining components of polycystic ovary syndrome and ovarian biomarkers, such as anti-Müllerian hormone, have facilitated examination of reproductive health in a population-based cohort of young adult women. As the cohort transitioned through menopause, examination of the importance of premenopausal cardiovascular risk factors along with menopause has improved our understanding of shared mechanisms. The cohort is now aged in the 50s to mid-60s, and women will begin to experience a greater number of cardiovascular events as well as other conditions, such as cognitive impairment. Thus, in the next decade, the CARDIA study will provide a unique resource for understanding how the women's reproductive life course epidemiology informs cardiovascular risk, as well as reproductive and chronological aging.