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Tsulukidze M, Reardon DC, Craver C. Effects of prior reproductive losses on risk of cardiovascular diseases within six months of a first live birth. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 21:200260. [PMID: 38525098 PMCID: PMC10957406 DOI: 10.1016/j.ijcrp.2024.200260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
Objective There is emerging evidence suggesting that pregnancy loss (induced or natural) is associated with an increased risk of cardiovascular diseases (CVD). This prospective longitudinal study investigates the effect of prior pregnancy losses on CVD risk during the first six months following a first live birth. Methods Medicaid claims of 1,002,556 low-income women were examined to identify history of pregnancy losses, CVD, diabetes, and hyperlipidemia prior to first live birth. The study population was categorized into five groups: A: women with no pregnancy loss or CVD history prior to first live birth; B: women with pregnancy loss and no CVD prior to first live birth. C: women with a first CVD diagnosis after a first pregnancy ending in a loss and before their first live birth. D: women with CVD prior to first live birth and no history of pregnancy loss. E: women with both CVD and pregnancy loss prior to their first live birth. Results After controlling for age, race, state of residence, and history of diabetes and hyperlipidemia, the risk of CVD in the six-month period following a first live birth were 15%, 214%, 79% and 129% more common for Groups B, C, D and E, respectively, compared to Group A. Conclusions Pregnancy loss is an independent risk factor for CVD risk following a first live birth, both for women with and without a prior history of CVD. The risk is highest when CVD is first diagnosed after a pregnancy loss and prior to a first live birth.
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Affiliation(s)
| | - David C. Reardon
- Elliot Institute, Gulf Breeze, FL, USA
- Charlotte Lozier Institute, Arlington, VA, USA
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Wang M, Zhang J, Yuan L, Hu H, Li T, Feng Y, Zhao Y, Wu Y, Fu X, Ke Y, Gao Y, Chen Y, Huo W, Wang L, Zhang W, Li X, Liu J, Huang Z, Hu F, Zhang M, Sun L, Hu D, Zhao Y. Miscarriage and stillbirth in relation to risk of cardiovascular diseases: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 297:1-7. [PMID: 38554480 DOI: 10.1016/j.ejogrb.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/29/2024] [Accepted: 03/26/2024] [Indexed: 04/01/2024]
Abstract
INTRODUCTION The relationship between pregnancy loss and the risk of cardiovascular diseases (CVDs) remains a matter of debate. Our intention in conducting this meta-analysis was to analyze the relationship between miscarriage and stillbirth and risk of CVDs. METHODS PubMed, Embase, and Web of Science were systematically searched up to May 30, 2023 for all relevant studies. The random-effects model was applied to estimate the pooled relative risks (RRs) and 95% confidence intervals (95% CIs). We evaluated RR estimates for the risk of CVDs with each additional miscarriage and stillbirth through generalized least squares regression. RESULTS Twenty-three articles were incorporated into the meta-analysis. For women with a history of miscarriage, the pooled RRs for the risk of total CVDs, coronary heart disease (CHD), stroke, and total CVD deaths were 1.16 (95 % CI 1.10-1.22), 1.26 (1.12-1.41), 1.13 (1.03-1.24), and 1.20 (1.01-1.42), respectively. For women with a history of stillbirth, the pooled RRs for the risk of total CVDs, CHD, stroke, and total CVD deaths were 1.60 (1.34-1.89), 1.30 (1.12-1.50), 1.37 (1.06-1.78), and 1.95 (1.05-3.63), respectively. With each additional miscarriage, the risk increased for total CVDs (1.08, 1.04-1.13), CHD (1.08, 1.04-1.13), and stroke (1.05, 1.00-1.10). With each additional stillbirth, the risk increased for total CVDs (1.11, 1.03-1.21) and CHD (1.13, 1.07-1.19). CONCLUSION This meta-analysis indicates that both miscarriages and stillbirths are related to a higher risk of total CVDs, CHD, stroke, and total CVD deaths. The risk of total CVDs and CHD increased with the number of miscarriages or stillbirths.
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Affiliation(s)
- Mengmeng Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jinli Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Lijun Yuan
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Huifang Hu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Tianze Li
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yifei Feng
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yang Zhao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yuying Wu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Xueru Fu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yamin Ke
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yajuan Gao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yaobing Chen
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Weifeng Huo
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Longkang Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Wenkai Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Xi Li
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jiong Liu
- Department of Preventive Medicine, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Zelin Huang
- Department of Preventive Medicine, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Fulan Hu
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Ming Zhang
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Liang Sun
- Department of Social Medicine and Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan 450001, People's Republic of China
| | - Dongsheng Hu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China.
| | - Yang Zhao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China.
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Nguyen AH, Hurwitz M, Sullivan SA, Saad A, Kennedy JLW, Sharma G. Update on sex specific risk factors in cardiovascular disease. Front Cardiovasc Med 2024; 11:1352675. [PMID: 38380176 PMCID: PMC10876862 DOI: 10.3389/fcvm.2024.1352675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women.
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Affiliation(s)
- Andrew H. Nguyen
- Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, United States
| | - Madelyn Hurwitz
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Scott A. Sullivan
- Department of Maternal Fetal Medicine, Inova Fairfax Hospital, Falls Church, VA, United States
| | - Antonio Saad
- Department of Maternal Fetal Medicine, Inova Fairfax Hospital, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Garima Sharma
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
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Jung YM, Wi W, Cho KD, Hong SJ, Kim HY, Ahn KH, Hong SC, Kim HJ, Oh MJ, Cho GJ. The Risk of Hypertension and Diabetes Mellitus According to Offspring's Birthweight in Women With Normal Body Mass Index: A Nationwide Population-Based Study. J Korean Med Sci 2024; 39:e50. [PMID: 38317450 PMCID: PMC10843973 DOI: 10.3346/jkms.2024.39.e50] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/27/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Maladaptation to vascular, metabolic, and physiological changes during pregnancy can lead to fetal growth disorders. Moreover, adverse outcomes during pregnancy can further increase the risk of cardiovascular and metabolic diseases in mothers. Delivering a large-for-gestational-age (LGA) baby may indicate a pre-existing metabolic dysfunction, whereas delivering a small-for-gestational-age (SGA) baby may indicate a pre-existing vascular dysfunction. This study aims to assess the risk of hypertension (HTN) and diabetes mellitus (DM) in women with normal body mass index (BMI) scores who did not experience gestational DM or hypertensive disorders during pregnancy based on the offspring's birthweight. METHODS This retrospective nationwide study included women with normal BMI scores who delivered a singleton baby after 37 weeks. Women with a history of DM or HTN before pregnancy and those with gestational DM or hypertensive disorders, were excluded from the study. We compared the risk of future maternal outcomes (HTN and DM) according to the offspring's birthweight. Multivariate analyses were performed to estimate the hazard ratio (HR) for the future risk of HTN or DM. RESULTS A total of 64,037 women were included in the analysis. Of these, women who delivered very LGA babies (birthweight > 97th percentile) were at a higher risk of developing DM than those who delivered appropriate-for-gestational-age (AGA) babies (adjusted HR = 1.358 [1.068-1.727]), and women who delivered very SGA babies (birthweight < 3rd percentile) were at a higher risk of developing HTN than those who delivered AGA babies (adjusted HR = 1.431 [1.181-1.734]), even after adjusting for age, parity, gestational age at delivery, fetal sex, maternal BMI score, and a history of smoking. CONCLUSION These findings provide a novel support for the use of the offspring's birthweight as a predictor of future maternal diseases such as HTN and DM.
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Affiliation(s)
- Young Mi Jung
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Wonyoung Wi
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Kyu-Dong Cho
- Big Data Department, National Health Insurance Service, Wonju, Korea
| | - Su Jung Hong
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Ho Yeon Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Ki Hoon Ahn
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Soon-Cheol Hong
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Hai-Joong Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Min-Jeong Oh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea.
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Chen W, Chen M, Tang H, Wei W, Shao P, Dou S, Wu J, Lu B, Shi R, Chen J. Advances in diagnosis and treatment of perimenopausal syndrome. Open Life Sci 2023; 18:20220754. [PMID: 38152579 PMCID: PMC10751995 DOI: 10.1515/biol-2022-0754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 12/29/2023] Open
Abstract
With the development and progress of society, people's average life expectancy has increased, and relevant literature reports that the number of postmenopausal women in China continues to increase. With lifespans extended, the transition period and post-menopause period have become the longest essential period in every woman's life. The life quality of women troubled by perimenopausal syndrome has been significantly reduced, which also places a burden on families and society. It is well known that hormone replacement therapy plays a vital role in improving women's menopause-related symptoms and is the most effective medical measure. With research ongoing into the treatment of menopausal symptoms in different patients, dose size, treatment duration, and medication regimens for hormones are still hot topics of discussion. This article reviews the definition, clinical diagnosis, staging, clinical manifestations, and treatment of menopause and explores the current diagnosis and treatment scenarios of perimenopausal syndrome.
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Affiliation(s)
- Wanying Chen
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Mengjuan Chen
- Zhoukou Maternal and Child Health Hospital, Zhoukou, Henan, 466000, PR China
| | - Huimin Tang
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Weiwei Wei
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Panqiu Shao
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Shulan Dou
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Jia Wu
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Bingying Lu
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Ruxia Shi
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
| | - Jiming Chen
- Department of Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, PR China
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Bae JH, Jung YM, Lee J, Shivakumar M, Park CW, Park JS, Jun JK, Kim D, Kim SK, Lee SM. Future risk of metabolic syndrome after recurrent pregnancy loss: a cohort study using UK Biobank. Fertil Steril 2023; 120:1227-1233. [PMID: 38008468 DOI: 10.1016/j.fertnstert.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE To evaluate the risk of metabolic syndrome (MS) after recurrent pregnancy loss (RPL) using UK Biobank data. A history of pregnancy loss is associated with the development of cardiovascular diseases in the future. However, the association between RPL and subsequent MS is poorly understood. Therefore, we aimed to check the risk of MS after RPL. DESIGN The study population was divided into 2 groups according to reproductive history: women with a history of RPL and women without a history of RPL. Recurrent pregnancy loss was defined as 2 or more spontaneous miscarriages, and MS was defined as at least 3 of the following: abdominal obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol levels, high-blood pressure, and hyperglycemia. SETTING UK Biobank resource. PATIENTS The UK Biobank is a prospective cohort study that enrolled individuals aged between 40 and 69 years whose medical and reproductive histories were retrieved at enrollment. In this cohort, only women with a history of at least one pregnancy were selected. INTERVENTIONS Recurrent pregnancy loss. MAIN OUTCOME MEASURES The primary outcome was the prevalence of MS. The secondary outcomes were 5 diagnostic components of MS. RESULTS We analyzed 228,674 women, including 15,702 with a history of RPL and 212,972 without a history of RPL. Women with a history of RPL have a higher prevalence of MS between the ages of 40 and 60 years (33.0% vs. 31.5%). After adjusting for covariates (age, race, number of live births, early menopause, smoking, alcohol consumption, and physical activity), the increased risk of MS after RPL remained significant (adjusted odds ratio, 1.10; 95% confidence interval, 1.06-1.15). Furthermore, in the analysis of the 5 diagnostic components of MS, a history of RPL significantly increased the risk of abdominal obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol levels, and hyperglycemia. CONCLUSION Middle-aged women with a history of RPL have an increased risk of MS.
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Affiliation(s)
- Ji Hye Bae
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Young Mi Jung
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea; Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Jeesun Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Manu Shivakumar
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chan-Wook Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea; Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea; Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea; Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Dokyoon Kim
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea; Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea; Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea; Innovative Medical Technology Research Institute, Seoul National University Hospital, Seoul, Korea; Institute of Reproductive Medicine and Population, Medical Research Center, Seoul National University, Seoul, Korea.
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Farland LV, Wang Y, Gaskins AJ, Rich‐Edwards JW, Wang S, Magnus MC, Chavarro JE, Rexrode KM, Missmer SA. Infertility and Risk of Cardiovascular Disease: A Prospective Cohort Study. J Am Heart Assoc 2023; 12:e027755. [PMID: 36847044 PMCID: PMC10111453 DOI: 10.1161/jaha.122.027755] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/17/2023] [Indexed: 03/01/2023]
Abstract
Background Certain symptoms associated with infertility are associated with cardiovascular disease, including menstrual cycle irregularity, early menopause, and obesity; however, few studies have investigated the association between infertility and cardiovascular disease risk. Methods and Results Participants in the NHSII (Nurses' Health Study II) who reported infertility (12 months of trying to conceive without success, including women who subsequently conceived) or who were gravid, with no infertility were followed from 1989 until 2017 for development of incident, physician-diagnosed coronary heart disease (CHD) (myocardial infarction, coronary artery bypass grafting, angioplasty, stent) and stroke. Time-varying Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% CIs and were adjusted a priori for potential confounding variables. Among 103 729 participants, 27.6% reported having ever experienced infertility. Compared with gravid women who had not reported infertility, women with a history of infertility had greater risk of CHD (HR, 1.13 [95% CI, 1.01-1.26]) but not stroke (HR, 0.91 [95% CI, 0.77-1.07]). The association between history of infertility and CHD was strongest among women who reported infertility at an earlier age (HR for infertility first reported at ≤25 years, 1.26 [95% CI, 1.09-1.46]; HR at 26-30 years, 1.08 [95% CI, 0.93-1.25]; HR at >30 years, 0.91 [95% CI, 0.70-1.19]). When we investigated specific infertility diagnoses, elevated risk of CHD was observed among women whose infertility was attributed to an ovulatory disorder (HR, 1.28 [95% CI, 1.05-1.55]) or endometriosis (HR, 1.42 [95% CI, 1.09-1.85]). Conclusions Women with infertility may be at an increased risk of CHD. Risk differed by age at first infertility diagnosis and was restricted to ovulatory- and endometriosis-related infertility.
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Affiliation(s)
- Leslie V. Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public HealthUniversity of ArizonaTucsonAZ
- Department of Obstetrics and Gynecology, College of Medicine‐TucsonUniversity of ArizonaTucsonAZ
| | - Yi‐Xin Wang
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMA
| | - Audrey J. Gaskins
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Janet W. Rich‐Edwards
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMA
- Division of Women’s Health, Department of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Siwen Wang
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMA
| | | | - Jorge E. Chavarro
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMA
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Kathryn M. Rexrode
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMA
- Division of Women’s Health, Department of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Stacey A. Missmer
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMA
- Department of Obstetrics and Gynecology and Reproductive Biology, College of Human MedicineMichigan State UniversityGrand RapidsMI
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The Link Between Reproductive History, Cardiovascular Disease, and Peripheral Arterial Disease in Women: Implications for Practice. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1209] [Impact Index Per Article: 1209.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Wright CE, Enquobahrie DA, Prager S, Painter I, Kooperberg C, Wild RA, Park K, Sealy-Jefferson S, Kernic MA. Pregnancy loss and risk of incident CVD within 5 years: Findings from the Women's Health Initiative. Front Cardiovasc Med 2023; 10:1108286. [PMID: 36895838 PMCID: PMC9989010 DOI: 10.3389/fcvm.2023.1108286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/20/2023] [Indexed: 02/25/2023] Open
Abstract
Background Previous studies have demonstrated an increased risk of cardiovascular disease (CVD) in women with a history of pregnancy loss. Less is known about whether pregnancy loss is associated with age at the onset of CVD, but this is a question of interest, as a demonstrated association of pregnancy loss with early-onset CVD may provide clues to the biological basis of the association, as well as having implications for clinical care. We conducted an age-stratified analysis of pregnancy loss history and incident CVD in a large cohort of postmenopausal women aged 50-79 years old. Methods Associations between a history of pregnancy loss and incident CVD were examined among participants in the Women's Health Initiative Observational Study. Exposures were any history of pregnancy loss (miscarriage and/or stillbirth), recurrent (2+) loss, and a history of stillbirth. Logistic regression analyses were used to examine associations between pregnancy loss and incident CVD within 5 years of study entry in three age strata (50-59, 69-69, and 70-79). Outcomes of interest were total CVD, coronary heart disease (CHD), congestive heart failure, and stroke. To assess the risk of early onset CVD, Cox proportional hazard regression was used to examine incident CVD before the age of 60 in a subset of subjects aged 50-59 at study entry. Results After adjustment for cardiovascular risk factors, a history of stillbirth was associated with an elevated risk of all cardiovascular outcomes in the study cohort within 5 years of study entry. Interactions between age and pregnancy loss exposures were not significant for any cardiovascular outcome; however, age-stratified analyses demonstrated an association between a history of stillbirth and risk of incident CVD within 5 years in all age groups, with the highest point estimate seen in women aged 50-59 (OR 1.99; 95% CI, 1.16-3.43). Additionally, stillbirth was associated with incident CHD among women aged 50-59 (OR 3.12; 95% CI, 1.33-7.29) and 60-69 (OR 2.06; 95% CI, 1.24-3.43) and with incident heart failure and stroke among women aged 70-79. Among women aged 50-59 with a history of stillbirth, a non-significantly elevated hazard ratio was observed for heart failure before the age of 60 (HR 2.93, 95% CI, 0.96-6.64). Conclusions History of stillbirth was strongly associated with a risk of cardiovascular outcomes within 5 years of baseline in a cohort of postmenopausal women aged 50-79. History of pregnancy loss, and of stillbirth in particular, might be a clinically useful marker of cardiovascular disease risk in women.
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Affiliation(s)
- Catherine E Wright
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Daniel A Enquobahrie
- Department of Epidemiology, University of Washington, Seattle, WA, United States.,Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States
| | - Sarah Prager
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States
| | - Ian Painter
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States.,Washington State Department of Health, Olympia, WA, United States
| | - Charles Kooperberg
- Department of Biostatistics, University of Washington, Seattle, WA, United States.,Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Robert A Wild
- Department of Obstetrics and Gynecology, Oklahoma University Health Sciences Center, Oklahoma City, OK, United States.,Department of Epidemiology and Biostatistics, Oklahoma University Health Sciences Center, Oklahoma City, OK, United States
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, United States
| | - Shawnita Sealy-Jefferson
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, OH, United States
| | - Mary A Kernic
- Department of Epidemiology, University of Washington, Seattle, WA, United States
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11
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Cortés YI, Zhang S, Hussey JM. Pregnancy loss is related to body mass index and prediabetes in early adulthood: Findings from Add Health. PLoS One 2022; 17:e0277320. [PMID: 36454867 PMCID: PMC9714908 DOI: 10.1371/journal.pone.0277320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/24/2022] [Indexed: 12/03/2022] Open
Abstract
Pregnancy loss, including miscarriage and stillbirth, affects 15-20% of pregnancies in the United States (US) annually. Accumulating evidence suggests that pregnancy loss is associated with a greater cardiovascular disease (CVD) burden later in life. However, few studies have evaluated the impact of pregnancy loss on CVD risk factors in early adulthood (age <35 years). The aim of this study was to examine associations between pregnancy loss and CVD risk factors (body mass index, blood pressure, hyperlipidemia, diabetes status) in early adulthood. We conducted a cross-sectional analysis using the public-use dataset for Wave IV (2007-2009) of the National Longitudinal Study of Adolescent to Adult Health (Add Health). Our sample consisted of women, ages 24-32 years, with a previous pregnancy who completed biological data collection (n = 2,968). Pregnancy loss was assessed as any history of miscarriage or stillbirth; and quantified as none, one, or recurrent (≥2) pregnancy loss. Associations between pregnancy loss and each CVD risk factor were tested using linear and logistic regression adjusting for sociodemographic factors, parity, health behaviors during pregnancy, and depression. We tested for interactions with race/ethnicity. A total of 670 women reported a pregnancy loss, of which 28% reported recurrent pregnancy loss. A prior pregnancy loss was related to a 3.79 (kg/mm2) higher BMI in non-Hispanic Black women, but not white women. Women with recurrent pregnancy loss were more likely to have prediabetes (AOR, 1.93; 95% CI, 1.10-3.37, p<0.05) than women with all live births. Findings suggest that pregnancy loss may be associated with a more adverse CVD risk profile in early adulthood, particularly for women who experience recurrent pregnancy loss. This highlights the need for CVD risk assessment in young women with a prior pregnancy loss. Further research is necessary to identify underlying risk factors of pregnancy loss that may predispose women to CVD.
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Affiliation(s)
- Yamnia I. Cortés
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Shuo Zhang
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jon M. Hussey
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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12
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Petersen MMBS, Hartwig TS, Nielsen HS. Pregnancy Loss and Cardiovascular Diseases in Women: Recent Findings and Potential Mechanisms. Curr Atheroscler Rep 2022; 24:889-899. [PMID: 36383292 DOI: 10.1007/s11883-022-01065-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE OF REVIEW Pregnancy loss (PL) has been acknowledged by the American Heart Association as a risk factor for cardiovascular diseases (CVD) later in life. This review aims to sum up recent findings (< ~ 5 years), concerning the link between PL and CVD. RECENT FINDINGS The association between PL and risk of CVD increased with increasing number of PLs and is inversely correlated to maternal age, indicating that the association concerns euploid PLs. Likely mechanisms leading to PL and an increased risk of CVD include endothelial dysfunction, a pro-inflammatory state, antiphospholipid syndrome, autoimmunity, and genetic predisposition. PL as an independent risk factor for CVD constitutes an obvious gateway for a more targeted approach to future research, prevention, and treatment. Future research should clarify the following questions to which the answers are still unknown: whether PL is (a) directly causing the increased risk of CVD or (b) sharing pathophysiological mechanisms also leading to CVD.
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Affiliation(s)
- Mette Marie Babiel Schmidt Petersen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark. .,Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
| | - Tanja Schlaikjær Hartwig
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
| | - Henriette Svarre Nielsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark.,Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
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13
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Wilkie G, Skaritanov E, Tobin M, Essa A, Gubala A, Ferraro L, Kovell LC. Hypertension in Women: Impact of Contraception, Fertility, and Hormone Treatment. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Rahmati M, Saei Ghare Naz M, Azizi F, Ramezani Tehrani F. Pregnancy loss and subsequent risk of prediabetes, diabetes and metabolic syndrome in couples: Tehran lipid and glucose study. Lab Invest 2022; 20:372. [PMID: 35982490 PMCID: PMC9389652 DOI: 10.1186/s12967-022-03578-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/07/2022] [Indexed: 12/15/2022]
Abstract
Background There is limited evidence regarding the impact of pregnancy loss on the subsequent risk of metabolic disorders. We aimed to investigate whether history of pregnancy loss is associated with the subsequent risk of prediabetes (pre-DM), diabetes (DM), and metabolic syndrome (METs) among couples. Method In this population-based cohort study, 2765 couples with and without history of pregnancy loss and free of DM, pre-DM, and METs at baseline were included and followed for incidents of DM, pre-DM, and METs by 3-year intervals visits from 1999 to 2018. Detailed data of variables was collected using standard questionnaires, interviews, clinical and laboratory assessments. A modified Poisson regression for binary outcome data with a log link function and robust error variance was used to estimate relative risks (RRs) in couples with and without history of pregnancy loss. Both unadjusted and adjusted models were fitted, and effect measures were calculated. Result During a median follow-up of 15 years, females with history of pregnancy loss were experienced more pre-DM (50% vs. 45.5%), DM (28.9% vs. 21.3%), and METs (70% vs. 60.1%) than females without such history. Moreover, history of pregnancy loss increased the risk of METs by 8% among females. The incidence of DM in males with history of pregnancy loss in their spouses was higher than in males without it (28.8% vs. 23.5%). Among males, having a spouse with history of pregnancy loss was positively associated with the risk of pre-DM (RR = 1.12; 95%CI: 1.02, 1.23, p = 0.02); furthermore, they were more prone to the risk of METs than females with a history of pregnancy loss (RR = 1.13; 95%CI: 1.07, 1.20, p < 0.001). Conclusion Although pregnancy loss is a female-specific factor, may foreshadow the subsequent METs, our study identified a higher risk of subsequent pre-DM and METs in males with history of pregnancy loss in their spouses. Pregnancy loss could be considered a possible future risk factor for metabolic disorders in couples.
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Affiliation(s)
- Maryam Rahmati
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid, Beheshti University of Medical Sciences, Tehran, Iran
| | - Marzieh Saei Ghare Naz
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid, Beheshti University of Medical Sciences, Tehran, Iran.
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fahimeh Ramezani Tehrani
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid, Beheshti University of Medical Sciences, Tehran, Iran
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15
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Liang C, Chung HF, Dobson AJ, Hayashi K, van der Schouw YT, Kuh D, Hardy R, Derby CA, El Khoudary SR, Janssen I, Sandin S, Weiderpass E, Mishra GD. Infertility, recurrent pregnancy loss, and risk of stroke: pooled analysis of individual patient data of 618 851 women. BMJ 2022; 377:e070603. [PMID: 35732311 PMCID: PMC9214882 DOI: 10.1136/bmj-2022-070603] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To examine the associations of infertility, recurrent miscarriage, and stillbirth with the risk of first non-fatal and fatal stroke, further stratified by stroke subtypes. DESIGN Individual participant pooled analysis of eight prospective cohort studies. SETTING Cohort studies across seven countries (Australia, China, Japan, Netherlands, Sweden, the United Kingdom, and the United States) participating in the InterLACE (International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events) consortium, which was established in June 2012. PARTICIPANTS 618 851 women aged 32.0-73.0 years at baseline with data on infertility, miscarriage, or stillbirth, at least one outcome event (non-fatal or fatal stroke), and information on covariates were included; 93 119 women were excluded. Of the participants, 275 863 had data on non-fatal and fatal stroke, 54 716 only had data on non-fatal stroke, and 288 272 only had data on fatal stroke. MAIN OUTCOME AND MEASURES Non-fatal strokes were identified through self-reported questionnaires, linked hospital data, or national patient registers. Fatal strokes were identified through death registry data. RESULTS The median follow-up for non-fatal stroke and fatal stroke was 13.0 years (interquartile range 12.0-14.0) and 9.4 years (7.6-13.0), respectively. A first non-fatal stroke was experienced by 9265 (2.8%) women and 4003 (0.7%) experienced a fatal stroke. Hazard ratios for non-fatal or fatal stroke were stratified by hypertension and adjusted for race or ethnicity, body mass index, smoking status, education level, and study. Infertility was associated with an increased risk of non-fatal stroke (hazard ratio 1.14, 95% confidence interval 1.08 to 1.20). Recurrent miscarriage (at least three) was associated with higher risk of non-fatal and fatal stroke (1.35, 1.27 to 1.44, and 1.82, 1.58 to 2.10, respectively). Women with stillbirth were at 31% higher risk of non-fatal stroke (1.31, 1.10 to 1.57) and women with recurrent stillbirth were at 26% higher risk of fatal stroke (1.26, 1.15 to 1.39). The increased risk of stroke (non-fatal or fatal) associated with infertility or recurrent stillbirths was mainly driven by a single stroke subtype (non-fatal ischaemic stroke and fatal haemorrhagic stroke), while the increased risk of stroke (non-fatal or fatal) associated with recurrent miscarriages was driven by both subtypes. CONCLUSION A history of recurrent miscarriages and death or loss of a baby before or during birth could be considered a female specific risk factor for stroke, with differences in risk according to stroke subtypes. These findings could contribute to improved monitoring and stroke prevention for women with such a history.
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Affiliation(s)
- Chen Liang
- University of Queensland, School of Public Health, Queensland, Australia
| | - Hsin-Fang Chung
- University of Queensland, School of Public Health, Queensland, Australia
| | - Annette J Dobson
- University of Queensland, School of Public Health, Queensland, Australia
| | | | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, Netherlands
| | - Diana Kuh
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | - Carol A Derby
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Samar R El Khoudary
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA, USA
| | - Imke Janssen
- Department of Preventive Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Sven Sandin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Elisabete Weiderpass
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Gita D Mishra
- University of Queensland, School of Public Health, Queensland, Australia
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16
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Lucà F, Colivicchi F, Rossini R, Riccio C, Gelsomino S, Gulizia MM. Reply to Kielb et al. Untapped Potential for Female Patients? Comment on "Lucà et al. Update on Management of Cardiovascular Diseases in Women. J. Clin. Med. 2022, 11, 1176". J Clin Med 2022; 11:jcm11113086. [PMID: 35683475 PMCID: PMC9181007 DOI: 10.3390/jcm11113086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/24/2022] [Accepted: 05/28/2022] [Indexed: 11/16/2022] Open
Abstract
We would like to thank the authors of this letter for their comments [...].
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Big Metropolitano Hospital, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
- Correspondence:
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00100 Roma, Italy;
| | - Roberta Rossini
- Cardiology Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Michele Massimo Gulizia
- Cardiology Department, Garibaldi Nesima Hospital, 95122 Catania, Italy;
- Fondazione per ilTuocuore-Heart Care Foundation, 50121 Firenze, Italy
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17
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Murugappan G, Leonard SA, Farland LV, Lau ES, Shadyab AH, Wild RA, Schnatz P, Carmichael SL, Stefanick ML, Parikh NI. Association of infertility with atherosclerotic cardiovascular disease among postmenopausal participants in the Women's Health Initiative. Fertil Steril 2022; 117:1038-1046. [PMID: 35305814 PMCID: PMC9081220 DOI: 10.1016/j.fertnstert.2022.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the association of infertility with atherosclerotic cardiovascular disease (ASCVD) among postmenopausal participants in the Women's Health Initiative (WHI). We hypothesized that nulliparity and pregnancy loss may reveal more extreme phenotypes of infertility, enabling further understanding of the association of infertility with ASCVD. DESIGN Prospective cohort study. SETTING Forty clinical centers in the United States. PATIENT(S) A total of 158,787 postmenopausal participants in the Women's Health Initiative cohort. INTERVENTION(S) Infertility, parity, and pregnancy loss. MAIN OUTCOME MEASURE(S) The primary outcome was risk of ASCVD among women with and without a history of infertility, stratified by history of live birth and pregnancy loss. Cox proportional-hazards models were adjusted for demographics and risk factors for ASCVD. RESULT(S) Among 158,787 women, 25,933 (16.3%) reported a history of infertility; 20,427 (80%) had at least 1 live birth; and 9,062 (35%) had at least 1 pregnancy loss. There was a moderate overall association between infertility and ASCVD (adjusted hazard ratio, 1.02; 95% confidence interval [CI], 0.99-1.06) over 19 years of follow-up. Among nulliparous women, infertility was associated with a 13% higher risk of ASCVD (95% CI, 1.04-1.23). Among nulliparous women who had a pregnancy loss, infertility was associated with a 36% higher risk of ASCVD (95% CI, 1.09-1.71). CONCLUSION(S) Women with a history of infertility overall had a moderately higher risk of ASCVD compared with women without a history of infertility. Atherosclerotic cardiovascular disease risk was much higher among nulliparous infertile women and among nulliparous infertile women who also had a pregnancy loss, suggesting that in these more extreme phenotypes, infertility may be associated with ASCVD risk.
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Affiliation(s)
- Gayathree Murugappan
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California.
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Obstetrics and Gynecology, College of Medicine-Tucson, University of Arizona, Tucson, Arizona
| | - Emily S Lau
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Robert A Wild
- Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Peter Schnatz
- Department of Obstetrics and Gynecology and Internal Medicine, Reading Hospital, Reading, Pennsylvania
| | - Suzan L Carmichael
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California; Department of Pediatrics, Stanford University Medical Center, Stanford, California
| | - Marcia L Stefanick
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California; Department of Medicine, Stanford Prevention Research Center, Stanford, California
| | - Nisha I Parikh
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
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18
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Infertility: A Fertile Ground for Heart Failure? J Am Coll Cardiol 2022; 79:1604-1605. [PMID: 35450578 DOI: 10.1016/j.jacc.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 11/24/2022]
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19
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Grandi SM, Hinkle SN, Mumford SL, Sjaarda LA, Grantz KL, Mendola P, Mills JL, Pollack AZ, Yeung E, Zhang C, Schisterman EF. Long-Term Mortality in Women With Pregnancy Loss and Modification by Race/Ethnicity. Am J Epidemiol 2022; 191:787-799. [PMID: 35136903 DOI: 10.1093/aje/kwac023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/31/2022] Open
Abstract
Pregnancy loss is a common reproductive complication, but its association with long-term mortality and whether this varies by maternal race/ethnicity is not well understood. Data from a racially diverse cohort of pregnant women enrolled in the Collaborative Perinatal Project (CPP) from 1959 to 1966 were used for this study. CPP records were linked to the National Death Index and the Social Security Death Master File to identify deaths and underlying cause (until 2016). Pregnancy loss comprised self-reported losses, including abortions, stillbirths, and ectopic pregnancies. Among 48,188 women (46.0% White, 45.8% Black, 8.2% other race/ethnicity), 25.6% reported at least 1 pregnancy loss and 39% died. Pregnancy loss was associated with a higher absolute risk of all-cause mortality (risk difference, 4.0 per 100 women, 95% confidence interval: 1.4, 6.5) and cardiovascular mortality (risk difference, 2.2 per 100 women, 95% confidence interval: 0.8, 3.5). Stratified by race/ethnicity, a higher risk of mortality persisted in White, but not Black, women. Women with recurrent losses are at increased risk of death, both overall and across all race/ethnicity groups. Pregnancy loss is associated with death; however, it does not confer an excess risk above the observed baseline risk in Black women. These findings support the need to assess reproductive history as part of routine screening in women.
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2439] [Impact Index Per Article: 1219.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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21
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Liang C, Chung HF, Dobson AJ, Mishra GD. Infertility, Miscarriage, Stillbirth, and the Risk of Stroke Among Women: A Systematic Review and Meta-Analysis. Stroke 2022; 53:328-337. [PMID: 34983235 DOI: 10.1161/strokeaha.121.036271] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is one of the leading causes of mortality, and women are impacted more from stroke than men in terms of their absolute number and in having worse outcomes. A growing number of studies have explored the association between pregnancy complications, pregnancy outcomes, and stroke. Limited studies, however, have investigated links involving infertility, miscarriage, and stillbirth, which could plausibly be associated via a background of endocrine conditions, endothelial dysfunction, and chronic systematic inflammation. This review aims to summarize current evidence and provide up-to-date information on the associations of infertility, miscarriage, and stillbirth, with stroke incidence. METHODS A comprehensive literature search was conducted for cohort and case-control studies on associations between infertility, miscarriage, stillbirth, and stroke up to September 26, 2020. Seven databases were searched: PubMed, Embase, Cochrane, CINIHL, PsyclNFO, Wanfang, and CNKI. Random-effects models were used to estimate the pooled hazard ratios (HRs) and 95% CIs. RESULTS Sixteen cohort studies and 2 case-control studies enrolling 7 808 521 women were included in this meta-analysis. Women who had experienced miscarriage or stillbirth were at higher risk of stroke (miscarriage: HR, 1.07 [95% CI, 1.00-1.14]; stillbirth: HR, 1.38 [95% CI, 1.11-1.71]) than other women. The HRs of stroke for each additional miscarriage and stillbirth were 1.13 (95% CI, 0.96-1.33) and 1.25 (95% CI, 1.06-1.49), respectively. In subgroup analysis, increased risk of stroke was associated with repeated miscarriages and stillbirths (miscarriage ≥3: HR, 1.42 [95% CI, 1.05-1.90]; stillbirth ≥2: HR, 1.14 [95% CI, 1.04-1.26]). Associations between infertility and stroke were inconsistent and inconclusive (HR, 1.07 [95% CI, 0.87-1.32]). CONCLUSIONS Miscarriage and stillbirth are associated with increased risk of stroke among women, which could be used as a contributing risk factor to help identify women at higher risk of stroke.
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Affiliation(s)
- Chen Liang
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Hsin-Fang Chung
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Annette J Dobson
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Gita D Mishra
- The University of Queensland, School of Public Health, Brisbane, Australia
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22
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Shah LM, Wand A, Ying W, Hays AG, Blumenthal RS, Barouch LA, Zakaria S, Sharma G. Prevention Starts in the Womb: Opportunities for Addressing Cardiovascular Risk Factors During Pregnancy and Beyond. Methodist Debakey Cardiovasc J 2021; 17:48-59. [PMID: 34824681 PMCID: PMC8588699 DOI: 10.14797/mdcvj.696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/31/2022] Open
Abstract
Early identification and mitigation of sex-specific cardiovascular disease risk factors is a potential trajectory-changing strategy to improve lifelong cardiovascular health in women. These sex-specific risk factors include adverse pregnancy outcomes, polycystic ovarian syndrome, and premature menopause. We start by discussing the impact and management of risk factors for adverse pregnancy outcomes as an upstream intervention for cardiovascular disease risk reduction and then address the long-term effect and mitigation of sex-specific risk factors for cardiovascular disease.
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Affiliation(s)
- Lochan M Shah
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Alison Wand
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Wendy Ying
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Allison G Hays
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | | | - Lili A Barouch
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Sammy Zakaria
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Garima Sharma
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
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23
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Su Z, McDonnell D, Abbas J, Shi L, Cai Y, Yang L. Secondhand Smoke Exposure of Expectant Mothers in China: Factoring in the Role of Culture in Data Collection. JMIR Cancer 2021; 7:e24984. [PMID: 34617907 PMCID: PMC8532012 DOI: 10.2196/24984] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/26/2020] [Accepted: 12/24/2020] [Indexed: 01/22/2023] Open
Abstract
Cancer is the leading cause of death worldwide. Tobacco smoking, including secondhand smoking, causes cancer and is responsible for over 22% of global cancer deaths. The adverse impacts of secondhand smoke are more pronounced for expectant mothers, and can deteriorate both mothers’ and infants’ health and well-being. Research suggests that secondhand smoke significantly increases expectant mothers’ risk of miscarriage, cancer, and other chronic disease conditions, and exposes their unborn babies to an increased likelihood of having life-long poor health. In China, a pregnant woman’s family members, such as her husband, parents, or in-laws, are the most likely people to be smoking around her. Due to traditional Chinese cultural practices, even though some expectant mothers understand the harm of secondhand smoke, they may be reluctant to report their family members’ smoking behaviors. Resulting in severe underreporting, this compromises health experts’ ability to understand the severity of the issue. This paper proposes a novel approach to measure secondhand smoke exposure of pregnant women in the Chinese context. The proposed system could act as a stepping stone that inspires creative methods to help researchers more accurately measure secondhand smoking rates of expectant mothers in China. This, in turn, could help health experts better establish cancer control measures for expectant mothers and decrease their cancer risk.
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Affiliation(s)
- Zhaohui Su
- Center on Smart and Connected Health Technologies, Mays Cancer Center, School of Nursing, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Dean McDonnell
- Department of Humanities, Institute of Technology Carlow, Carlow, Ireland
| | - Jaffar Abbas
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lili Shi
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuyang Cai
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,China Institute for Urban Governance, Shanghai Jiao Tong University, Shanghai, China
| | - Ling Yang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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24
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Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, Gunderson EP, Stuart JJ, Vaidya D. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e902-e916. [PMID: 33779213 DOI: 10.1161/cir.0000000000000961] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman's risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD. Adopting a heart-healthy diet and increasing physical activity among women with APOs, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk. Lactation and breastfeeding may lower a woman's later cardiometabolic risk. Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs and CVD in non-White women are needed to better understand and address these health disparities. Future studies of aspirin, statins, and metformin may better inform our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.
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25
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 3058] [Impact Index Per Article: 1019.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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26
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Freaney PM, Khan SS, Lloyd-Jones DM, Stone NJ. The Role of Sex-Specific Risk Factors in the Risk Assessment of Atherosclerotic Cardiovascular Disease for Primary Prevention in Women. Curr Atheroscler Rep 2020; 22:46. [PMID: 32671475 PMCID: PMC7889439 DOI: 10.1007/s11883-020-00864-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Robust evidence is emerging regarding the contribution of sex-specific risk factors to a woman's unique risk of atherosclerotic cardiovascular disease (ASCVD). This review summarizes the available literature regarding the association of sex-specific risk factors and ASCVD in women. RECENT FINDINGS The American College of Cardiology and American Heart Association Guidelines recommend estimation of 10-year risk of a first ASCVD event using the 2013 Pooled Cohort Equations. This can be further personalized by identifying sex-specific risk factors present in a woman's history. There are multiple vulnerable periods across a woman's life course that are associated with increased risk of ASCVD. Risk factors across the reproductive life course that have been shown to correlate with higher risk for future ASCVD include early menarche, adverse pregnancy outcomes (such as pre-eclampsia or preterm birth), and early natural or surgical menopause. In addition, certain conditions that are more common among women, including autoimmune diseases, history of chest irradiation, and certain chemotherapies, also need to be considered. Finally, risk assessment can be refined with subclinical disease imaging (coronary calcium score) if there remains uncertainty about clinical management with lipid-lowering therapies for primary prevention after inclusion of these risk enhancers. Risk assessment for ASCVD in women requires a personalized approach that incorporates sex-specific risk factors to guide primary prevention measures, such as lipid-lowering therapies. Coronary calcium score imaging may also help further refine risk assessment, but no clinical trials conducted to date have addressed this question.
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Affiliation(s)
- Priya M Freaney
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA.
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Sadiya S Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Donald M Lloyd-Jones
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil J Stone
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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