Parity and cardiovascular disease risk among older women: how do pregnancy complications mediate the association?

Cardiometabolic risk factors in women: what's sauce for the goose is not sauce for the gander

PURPOSE OF REVIEW

The aim of this review was to discuss cardiometabolic risk factors that affect women.

RECENT FINDINGS

Recent calls to action to address cardiometabolic risk factors specific to women relate to increasing evidence of sex-specific differences in patient-related, drug-related, and socio-demographic factors leading to sub-optimal care of women.

SUMMARY

Certain aspects of common modifiable cardiovascular risk factors (e.g. smoking, hypertension, dyslipidaemia and diabetes) affect female individuals more adversely. Additionally, there are risk factors or enhancers that particularly affect cardiometabolic health in women [e.g. premature menopause, polycystic ovarian syndrome (PCOS), familial partial lipodystrophy, socio-cultural factors]. Understanding these risk factors may provide insight on how to improve cardiometabolic outcomes in women.

Reproductive Factors Linked With Myocardial Fibrosis: MESA (Multi-Ethnic Study of Atherosclerosis)

Background

Recent evidence has shown that reproductive factors are associated with an increased risk of heart failure with preserved ejection fraction in women. However, the pathogenic pathways underlying this relationship are unclear. Subclinical myocardial fibrosis has been found to be a common pathway in a large proportion of patients with heart failure with preserved ejection fraction.

Objectives

This study examined the relationship between vital reproductive factors (parity, pregnancy, age at menopause, and use of hormone replacement therapy [HRT]) with interstitial myocardial fibrosis (IMF) and myocardial scar measured by cardiac magnetic resonance imaging (CMR) T1 mapping and late gadolinium enhancement, respectively.

Methods

There were 596 female participants (mean age 67 ± 8 years) enrolled in MESA (Multi-Ethnic Study of Atherosclerosis) who had complete parity data and underwent CMR. Parity was categorized as 0 live births, 1 to 2, 3 to 4, and ≥5 live births. Multivariable regression models were constructed to assess the associations of parity status, history of null gravidity, age at menopause and HRT with CMR obtained measures of IMF (extracellular volume [ECV], native-T1 time) and myocardial scar.

Results

Women with a history of nulliparity had greater ECV% (β = 0.95 ± 0.28, P = 0.001) and native-T1 ms (β = 10.6 ± 4.9, P = 0.03) than those who had 1 to 2 live births. These associations were independent of age, traditional cardiovascular risk factors, and interim cardiovascular events. Similar associations were found for women with a history of null gravidity compared to those with a history of pregnancy (ECV% [β = 0.7 ± 0.3, P = 0.02] and native-T1 ms [β = 10.6 ± 5.2, P = 0.04]). There was no association between age at menopause and HRT with markers of IMF. There were no associations between parity status, null gravidity, and age of menopause with the presence of myocardial scar; however, those who used HRT were independently associated with a lesser risk of myocardial scar (OR: 0.20; 95% CI: 0.05-0.82).

Conclusions

In a multiethnic cohort, women with a history of nulliparity or null gravidity had greater IMF defined by CMR, while those who used HRT were less likely to have myocardial scar.

Association between the number of pregnancies and cardiac target organ damages: a cross-sectional analysis of data from the Korean women's chest pain registry (KoROSE)

BACKGROUND

Pregnancy increases long-term cardiovascular risk after childbirth, but the mechanisms are unclear. This study was performed to investigate the association between the number of pregnancies and several cardiac target organ damage (TOD) in middle-aged and elderly women.

METHODS

Using the database of the nation-wide registry, a total of 1,137 women (mean age 63.0 ± 10.9 years) with stable chest pain undergoing invasive coronary angiography (CAG) were analyzed. Information on the number of pregnancies was obtained through a questionnaire. Obstructive coronary artery disease (CAD), left ventricular (LV) mass index (LVMI) and LV septal annular (e') velocity were assessed as indicators of cardiac TOD.

RESULTS

Women with higher number of pregnancies (≥ 3) were older (66.3 ± 9.6 vs. 57.4 ± 10.7 years; P < 0.001), had more cardiovascular risk factors, and took more cardiovascular medications than those with lower number of pregnancies (< 3). In multivariable analyses, higher number of pregnancies (≥ 3) was associated with obstructive CAD (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.21-2.17; P = 0.001), a higher LVMI (> 95 g/m²) (OR, 1.46; 95% CI, 1.08-1.98; P = 0.013) and a lower septal e' velocity (< 7 cm/s) (OR, 1.55; 95% CI, 1.12-2.14; P = 0.007) even after controlling for potential confounders. As the number of pregnancies increased, the prevalence of CAD and LVMI increased, and the septal e' velocity gradually decreased (P < 0.001 for each).

CONCLUSIONS

In women with chest pain undergoing invasive CAG, higher number of pregnancies was associated with multiple cardiac TOD. Parity information should be checked when assessing a woman's cardiovascular risk.

Walking for Cognitive Health: Previous Parity Moderates the Relationship Between Self-Reported Walking and Cognition

BACKGROUND

Older females show greater cognitive gains from physical activity (PA) than males, which may be related to long-term consequences of female-specific reproductive events (eg, pregnancy) on cognitive health.

METHODS

To determine whether previous parity could moderate the relationship between PA and cognitive decline in older women, we conducted secondary analyses of data from the Health, Aging, and Body Composition Study. We tested whether the association between average PA over 10 years and cognition (Modified Mini-Mental State Examination [3MS]) and executive functioning (digit symbol substitution test [DSST]) over 10 years varied by previous parity (nulliparity, low parity, medium parity, and grand multiparity). An analysis of covariance was performed with cognition (average and change over 10 years) as the dependent variables, parity as a categorical predictor, average PA as a continuous predictor, and a set of relevant covariates.

RESULTS

Significant interactions were found between PA and parity group for all 4 comparisons: average 3MS (p = .014), average DSST (p = .032), change in 3MS (p = .016), and change in DSST (p = .017). Simple slope analyses indicated the positive relationship between PA and average 3MS and DSST was only significant in the nulliparity and grand multiparity groups, and the positive relationship between PA and change in 3MS and DSST was only significant in the grand multiparity group.

CONCLUSION

The findings suggest the relationship between self-reported walking and cognitive performance was strongest in the groups at risk for cognitive decline and dementia, the nulliparous and grand multiparous groups.

Gender Differences and Cardiometabolic Risk: The Importance of the Risk Factors

Metabolic syndrome (Mets) is a clinical condition characterized by a cluster of major risk factors for cardiovascular disease (CVD) and type 2 diabetes: proatherogenic dyslipidemia, elevated blood pressure, dysglycemia, and abdominal obesity. Each risk factor has an independent effect, but, when aggregated, they become synergistic, doubling the risk of developing cardiovascular diseases and causing a 1.5-fold increase in all-cause mortality. We will highlight gender differences in the epidemiology, etiology, pathophysiology, and clinical expression of the aforementioned Mets components. Moreover, we will discuss gender differences in new biochemical markers of metabolic syndrome and cardiovascular risk.

Parity History and Later Life Sex Hormone Levels in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Multiparity is a risk factor for cardiovascular disease (CVD). A more androgenic sex hormone profile, with a higher testosterone (T)/estradiol (E2) ratio, is associated with worse CVD outcomes in women and might be one mechanism linking multiparity to increased CVD risk. We investigated the relationship between parity and sex hormones at mid-to-older age.

METHODS

We performed a cross-sectional analysis of 2979 women with data on parity and endogenous sex hormone levels from the Multi-Ethnic Study of Atherosclerosis (MESA), a community-based cohort. Parity and gravidity (our exposures) were categorized as 0 (reference), 1-2, 3-4, or ≥ 5. Our outcome measures were T, E2, sex hormone binding globulin, dehydroepiandrosterone, and T/E2 ratio. Progressively adjusted linear regression was used to evaluate the association of parity/gravidity with sex hormones.

RESULTS

In multivariable adjusted models, there were no significant associations of parity with E2, dehydroepiandrosterone, and sex hormone binding globulin. Compared with nulliparity, after adjustment for CVD risk factors, women with 1-2 and 3-4 live births had higher T, but this was not significant for grand multiparity (≥ 5 live births). However, grand multigravidity (≥ 5 pregnancies) was associated with 10% (95% confidence interval [CI], 1%-20%) higher T and 14% (95% CI, 1%-29%) higher T/E2, compared with null gravidity. Grand multiparity was associated with an 18% (95% CI, 4%-34%) higher T/E2 ratio compared with nulliparity, after adjustment for CVD risk factors.

CONCLUSIONS

In this multiethnic cohort, women with grand multigravidity and grand multiparity had higher T/E2 levels, reflecting a more androgenic sex hormone profile. Longitudinal studies on sex hormones' influence on the relationship between multiparity and CVD are warranted.

Association of Number of Live Births With Electrocardiographic and Cardiac Structural Changes

Background Pregnancy is a major life event unique to women and leads to significant hemodynamic, hormonal, and metabolic changes. The purpose of this study was to use the DHS (Dallas Heart Study), a multiethnic population-based cohort study of Dallas county adults, to evaluate the association between number of live births and cardiac magnetic resonance imaging and ECG parameters later in life. Methods and Results Women were included if they had data on self-reported live births and ECG or cardiac magnetic resonance imaging measurements. The 3014 women were stratified by number of live births: 0, 1, 2, 3, 4, and ≥5. Higher number of live births was associated with larger left ventricular (LV) end-diastolic volume (β, 1.31±0.41; P<0.01), LV end-systolic volume (β, 0.83±0.24; P<0.01), and LV mass (β, 1.13±0.49; P=0.02) and lower LV ejection fraction (β, -0.004±0.0014; P<0.01). Increasing parity was associated with longer PR intervals (β, 1.07±0.38; P<0.01). Subgroup analysis by race demonstrated that the association between number of live births and magnetic resonance imaging parameters (LV end-diastolic volume, LV end-systolic volume, and LV ejection fraction) only remained significant in Black women (P value for interaction <0.05). Conclusions Increasing number of live births was associated with electrocardiographic and cardiac structural changes in a multiethnic population. When stratified by race and ethnicity, magnetic resonance imaging structural changes only remained significant in Black participants. Whether these changes are pathologic and increase the risk of heart failure or arrhythmias in multiparous women warrants further investigation.

Association between parity and markers of inflammation: The multi-ethnic study of atherosclerosis

Introduction

Multiparity has been associated with increased risk of cardiovascular disease (CVD). Inflammation may be a mechanism linking parity to CVD. We investigated the association between parity and later-life markers of inflammation.

Methods

We studied 3,454 female MESA participants aged 45-84, free of CVD, who had data on parity and inflammatory markers. Parity was categorized as 0 (reference), 1-2, 3-4, or ≥5. Linear regression was used to evaluate the association between parity and natural log-transformed levels of fibrinogen, D-dimer, GlycA, high sensitivity C-reactive protein (hsCRP), and interleukin-6 (IL-6).

Results

Mean age was 62 ± 10 years. The proportion of women with nulliparity, 1-2, 3-4, and ≥5 live births were 18, 39, 29, and 14%, respectively. There was no association between parity and fibrinogen. Women with grand multiparity (≥5 live births) had 28, 10, and 18% higher levels of hsCRP, IL-6 and D-dimer, respectively, compared to nulliparous women, after adjustment for demographic factors. After additional adjustment for CVD risk factors, women with 1-2 and 3-4 live births had higher hsCRP and women with 1-2 live births had higher GlycA.

Conclusion

In this diverse cohort of middle-to-older aged women, we found that higher parity was associated with some inflammatory markers; however, these associations were largely attenuated after adjustment for CVD risk factors. There was no clear dose-response relationship between parity and these inflammatory markers. Future studies are needed to evaluate how inflammation may influence the link between parity and CVD and whether healthy lifestyle/pharmacotherapies targeting inflammation can reduce CVD risk among multiparous women.

Clinical trial registration

The MESA cohort design is registered at clinicaltrials.gov as follows: https://clinicaltrials.gov/ct2/show/NCT00005487.

Fertility Histories and Heart Disease in Later Life in China

Purpose

Based on life course theories, health among older people is driven by a continuous and cumulative process that develops over the life course. To better understand the aging process, it is important to assess associations between parity and heart disease in older people of China.

Method

The associations between heart disease prevalence and number of births, number of boys or girls ever born were evaluated among 5,990 samples (mean age 64.1 years) using the Probit regression model based on the data from China Health and Retirement Longitudinal Study (CHARLS) conducted in 2013 and 2018. The model was adjusted only for rural or urban residents, and multivariate regression models were run separately by gender.

Results

Our results showed that more than three children or more than two boys ever born were associated with a higher risk of heart disease. However, the number of girls ever born had no significant effect on heart disease in the elderly. We further analyzed the group difference between urban and rural residents using the regression model. More than three children or more than two boys ever born were associated with a high risk of heart disease in rural areas. Compared to urban residents, rural residents were more likely to be suffering from heart disease due to high parity. When considering the digender difference the paper found that more than three children ever born were associated with a high risk of heart disease in the female group. Late age at the time of giving birth for the first time was associated with a poorer risk level of heart disease in the rural residents, because the phenomenon of early childbearing was serious in the rural residents. But after considering the impact on the physical health of using chronic diseases, the first birth and the last birth both increased the risk of heart disease.

Conclusions

Some policy implications were being put forward. Firstly, parents who were ready to give birth should be aware of the possible health loss of high parity. Postpartum nutrition supplements and chronic disease prevention were suggested to prevent heart disease in later life. Secondly, the elderly in rural areas should pay more attention to heart diseases. Participating in more daily exercise and physical examinations was a good choice to reduce the risk of heart disease. Thirdly, women who give birth prematurely have a higher risk of CVD. Based on our results, age at entry to parenthood was closely related to the risk of heart disease in later life.

Parity and Risk of Cardiovascular Disease in Women over 45 Years in the United States: National Health and Nutrition Examination Survey 2007-2018

Objective: Current research results on the association between parity and cardiovascular disease (CVD) risk are inconclusive. The purpose of this study was to examine the relationship between parity and risk of CVD in women over 45 years of age. Materials and Methods: Data were from the National Health and Nutrition Examination Survey for 2007-2018. A total of 8,882 women ≥45 years of age were included. The exposure of parity referred to the number of live births, and the outcome variable was the occurrence of CVD events, including stroke, heart attack, coronary heart disease (CHD), heart failure, and angina. We performed logistic regression to calculate the unadjusted and adjusted odds ratios (ORs; 95% confidence intervals [CIs]) controlling for confounding factors. Results: Among 8,882 women, the mean age was 62.4 ± 10.8 years, with a range of 45 to 80 years. The weighted prevalence of CVD, stroke, heart attack, CHD, heart failure, and angina in parous women were significantly higher than those of nulliparous women (p < 0.05). After adjusting for demographic factors, CVD risk factors, reproductive factors, the ORs of CVD with parity 1-2, 3-4, and 5+ were 1.85 (95% CI: 1.29-2.64), 1.70 (95% CI: 1.15-2.50), and 1.92 (95% CI: 1.28-2.88), respectively. The odds of stroke and heart attack were also significantly positively related to increasing parity compared with nulliparity. However, compared with nulliparity, parity of 3 was associated with a slightly lower risk of CVD. Conclusions: Our findings indicated that parity was significantly positively associated with CVD, giving birth to three children associated with a slightly lower risk compared with nulliparity. Further cohort studies are warranted to confirm the findings.

Prolongation of QTc interval due to increased parity and great grand multiparity

Women are more prone to cardiac arrhythmias. Increased exposure to sex hormones may alter the ventricular repolarisation of the heart as the parity number increases. In this study, we aim to investigate the effect of parity number to electrocardiographic parameters. A total of 205 adult women were included for the study. Nulliparous (NP), primiparous (PP), multiparous (MP), grand multiparous (GMP) and great grand multiparous (GGMP) women constituted the study population. Increased parity has positive correlation with QTc interval (p=.000, r = 0.303). GGMP has significantly higher QTc compared to NP, PP, MP and GMP (p=.001, p=.000, p=.004 and p=.007, respectively). GGMP and parity have explanatory power on QTc (p=.019 and p=.020, respectively). Parity and GGMP affect cardiac repolarisation and prolong the QTc interval most probably due to repeated exposure to sex hormones. This study showed that GGMP and parity are independent risk factors for QTc interval prolongation.Impact StatementWhat is already known on this subject? Increased exposure to sex hormones may alter the ventricular repolarisation of the heart as the parity number increases. Previous studies showed that increased parity (up to 7) deteriorates ventricular diastolic functions, prolongs QTc interval and these conditions cause cardiovascular diseases.What do the results of this study add? In this study, we added great grand multiparity (10 or more parity) (GGMP) group that have never been studied before. We found that GGMP has much more impact on QTc prolongation than fewer parity groups and this result shows us that GGMP deteriorates ventricular functions more.What are the implications of these findings for clinical practice and/or further research? These results show us that women should be discouraged from having more delivery. Also, women with a pregnancy history of five and more (grand multiparity) should be evaluated with an electrocardiography and a cardiology consultation should be performed before re-conception. In the future, larger prospective studies are needed on this subject. In addition, other electrocardiographic parameters (QRS-T angle and Tpe/QTc in electrocardiography, etc.) that related with diastolic functions should be evaluated for comparison of GGMP and non-GGMP populations in future studies.

Traditional medicine utilisation and maternal complications during antenatal care among women in Bulilima, Plumtree, Zimbabwe

BACKGROUND

As part of the expectation enshrined in the Sustainable Development Goals, countries are expected to ensure maternal health outcomes are improved. It follows that under ideal circumstances, pregnant women should deliver safely without complications, neonatal, and maternal mortality. This paper analyses the relationship between traditional medicine utilisation and maternal complications during antenatal care among women in Bulilima, Plumtree, Zimbabwe.

METHODS

A quantitative cross-sectional survey was conducted on 185 randomly selected women who responded to a pre-tested semi-structured questionnaire. The Fisher's Exact Test and the Test of Proportions were used to probe the relationship between traditional medicine utilisation and the prevalence of maternal complications using STATA SE Version 13.

RESULTS

Complications were reported by (51) 29% of the women who were under study. The proportion of women who developed complications was higher in those that did not use traditional medicine as compared to those that used traditional medicine (30 and 26% respectively). In a generalised assessment, women who did not use traditional medicine contributed a significantly higher proportion of complications as compared to those that utilised traditional medicine.

CONCLUSION

This study found a significant relationship between the utilisation of traditional medicines and lesser chances of experiencing maternal complications. Significantly higher prevalence of maternal complications was observed in women who did not use traditional medicine compared to those that did. There is, therefore, a need to investigate further the constituents or active ingredients in this traditional medicine. This study provides a window of opportunity for fully recognising and integrating traditional medicine into Modern Health Systems. It can be argued that traditional medicine utilisation could be a viable alternative to modern medicine, particularly in resource-poor settings where access to modern medicine is seriously constrained.

Go Red for Women Strategically Focused Research Network: Summary of Findings and Network Outcomes

The Go Red for Women movement was initiated by the American Heart Association (AHA) in the early 2000s to raise awareness concerning cardiovascular disease (CVD) risk in women. In 2016, the AHA funded 5 research centers across the United States to advance our knowledge of the risks and presentation of CVD that are specific to women. This report highlights the findings of the centers, showing how insufficient sleep, sedentariness, and pregnancy-related complications may increase CVD risk in women, as well as presentation and factors associated with myocardial infarction with nonobstructive coronary arteries and heart failure with preserved ejection fraction in women. These projects were augmented by collaborative ancillary studies assessing the relationships between various lifestyle behaviors, including nightly fasting duration, mindfulness, and behavioral and anthropometric risk factors and CVD risk, as well as metabolomic profiling of heart failure with preserved ejection fraction in women. The Go Red for Women Strategically Focused Research Network enhanced the evidence base related to heart disease in women, promoting awareness of the female-specific factors that influence CVD.

Estimated Number of Lifetime Ovulatory Years and Its Determinants in Relation to Levels of Circulating Inflammatory Biomarkers

Reproductive events, such as ovulation, trigger an inflammatory cascade. Few studies have examined their long-term influence on inflammatory profiles. We included 3,393 premenopausal and 3,915 postmenopausal women with intact ovaries/uterus from the Nurses' Health studies (Nurses' Health Study (1989-1990) and Nurses' Health Study II (1996-1999)) in an analysis of the association between lifetime ovulatory years (LOY) and levels of inflammatory biomarkers. We estimated LOY as age at menopause (age at blood collection for premenopausal women) minus age at menarche, subtracting years of oral contraceptive (OC) use and 1 year per pregnancy. After adjustment for other inflammation-related factors (e.g., body mass index, exercise, diet), every 5-year increase in LOY was associated with lower C-reactive protein (CRP) levels in both premenopausal (difference = -11.5%, 95% confidence interval: -15.0, -8.0; P < 0.0001) and postmenopausal (difference = -7.2%, 95% confidence interval: -10.0, -4.3; P < 0.0001) women. Older age at menopause (P = 0.007), earlier menarche (P = 0.007), and shorter duration of OC use (P = 0.002) were associated with lower CRP levels in postmenopausal women, whereas duration of OC use was positively associated with CRP levels in premenopausal women (P < 0.0001). LOY was modestly inversely associated with interleukin 6 in postmenopausal women (P = 0.03). Notably, the associations of CRP with LOY were similar in magnitude to associations with exercise and a healthy diet, though weaker than the association with body mass index. Although many reproductive events induce acute inflammation, increased LOY was associated with lower chronic systemic inflammation even after menopause.

The effect of parity on exercise physiology in women with heart failure with preserved ejection fraction

Aims

Women are overrepresented amongst patients with heart failure with preserved ejection fraction (HFpEF); however, the underpinning mechanism for this asymmetric distribution is unclear. Pregnancy represents a potential gender‐specific risk factor for HFpEF. It leads to significant physiological adaption, and increasing parity has been associated with some cardiovascular risk. We sought to examine the relationship between prior parity with the rest and exercise haemodynamic and echocardiographic profile of women with HFpEF.

Methods and results

Patients referred for assessment of exertional dyspnoea and confirmed to have a haemodynamic and clinical profile consistent with HFpEF were included. Detailed evaluation consisted of rest and exercise right heart catheterization and echocardiography. A socio‐economic and obstetric history was also documented. Fifty‐eight women were assessed and categorized as having either 0–2 births or ≥3 births, dividing the cohort equally. Women with ≥3 births achieved a lower symptom‐limited workload than those with 0–2 births [38 (24–51) vs. 46 (31–68) W, P = 0.04]. Women with ≥3 births had a greater rise in pulmonary capillary wedge pressure indexed to workload with exercise [0.5 (0.3–0.8) vs. 0.3 (0.2–0.5) mmHg/W, P = 0.03], paralleled by a greater rise in right atrial pressure [10 (8–12) vs. 7 (3–11), P = 0.01]. Pulmonary vascular resistance was also higher in women with ≥3 births [1.9 (1.6–2.4) vs. 1.6 (1.4–1.9) mmHg/L/min rest, P = 0.046, and 1.9 (2.4–2.4) vs. 1.4 (1–1.8) mmHg/L/min exercise, P = 0.024]. Left ventricular ejection fraction was lower at rest [60 (57–61) vs. 63 (60–66), P = 0.008] and during exercise [65 (62–67) vs. 68 (66–70), P = 0.038] in women with higher parity.

Conclusions

Higher parity is associated with greater impairments in multiple physiologic parameters of HFpEF severity in women, including diastolic reserve, pulmonary vascular resistance, and systolic dysfunction.

Multiparity is associated with poorer cardiovascular health among women from the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Multiparity is associated with a greater risk of incident cardiovascular disease. However, the relationship of parity with cardiovascular health, as measured by the American Heart Association Life's Simple 7 metrics, is uncertain.

OBJECTIVE

We aimed to examine the association between parity and ideal cardiovascular health among 3430 women, aged 45-84 years, free of clinical cardiovascular disease enrolled in the Multi-Ethnic Study of Atherosclerosis.

STUDY DESIGN

The Multi-Ethnic Study of Atherosclerosis is a prospective cohort study that recruited middle-aged to older women and men from 6 centers in the United States between 2000 and 2002. The study population comprised 38% White, 28% Black, 23% Hispanic, and 11% Chinese American subjects. Parity (total number of live births) was self-reported and categorized as 0, 1-2, 3-4 and ≥5. The Life's Simple 7 metrics, defined according to American Heart Association criteria, include health behaviors (smoking, physical activity, body mass index, diet) and health factors (blood pressure, total cholesterol, and blood glucose). We categorized each metric into ideal (2 points), intermediate (1 point), and poor (0 points). A total cardiovascular health score of 0-8 was considered inadequate; 9-10, average; and 11-14, optimal. We used multinomial logistic regression to examine the cross-sectional association between parity and the cardiovascular health score, adjusted for sociodemographics, field site, hormone therapy, and menopause.

RESULTS

The mean (standard deviation) age was 62 (10) years. The mean (standard deviation) cardiovascular health score was lower with higher parity (8.9 [2.3], 8.7 [2.3], 8.5 [2.2], and 7.8 [2.0] for 0, 1-2, 3-4, and ≥5 live births, respectively). In comparison to inadequate cardiovascular health scores, the adjusted odds of average cardiovascular health scores were significantly lower for all parity categories relative to nulliparity (prevalence odds ratios [OR] for parity of 1-2, 0.64 [95% confidence interval 0.49-0.83]; 3-4, 0.65 [0.49-0.86]; ≥5, 0.64 [0.45-0.91]). Women with ≥5 live births had a lower prevalence of optimal cardiovascular health scores (OR 0.50 [0.30-0.83]). In the fully adjusted models, the association between parity and each Life's Simple 7 metric was only statistically significant for body mass index. Women with ≥5 live births had lower prevalence of ideal body mass index (OR 0.52 [0.35-0.80]). In addition, the test for interaction showed that the association between parity and cardiovascular health was not modified by race/ethnicity (P = .81 for average cardiovascular health scores and P = .20 for optimal cardiovascular health scores).

CONCLUSION

Multiparity was associated with poorer cardiovascular health, especially for women with ≥5 live births. More research is required to explore the mechanisms by which parity may worsen cardiovascular health.

Relationships Between Reproductive History and Mortality From Cardiovascular Diseases Among Japanese Women: The Japan Collaborative Cohort Study for Evaluation of Cancer Risk (JACC) Study

Background

Reproductive history has been addressed as a risk factor for cardiovascular disease (CVD). We examined the relationship between reproductive history and CVD mortality in Japanese women.

Methods

We followed 53,836 women without previous CVD or cancer history from 1988–1990 to 2009 in a prospective cohort study. Hazard ratios (HRs) and 95% confidence intervals (CIs) of CVD mortality were estimated according to the number of deliveries and maternal age at first delivery.

Results

During the follow-up, 2,982 CVD-related deaths were identified. There was U-shaped association between the number of deliveries and risk of CVD mortality with reference to three deliveries, although the excess risk of CVD mortality associated with ≥5 deliveries was of borderline statistical significance. The corresponding multivariable HRs were 1.33 (95% CI, 1.12–1.58) and 1.11 (95% CI, 0.99–1.24). In addition, higher CVD mortality was associated with maternal age ≥28 years at first delivery than maternal age of 24–27 years at first delivery. The multivariable HRs were 1.22 (95% CI, 1.10–1.36) for 28–31 years at first delivery and 1.26 (95% CI, 1.04–1.52) for ≥32 years at first delivery. Moreover, among women with ≥3 deliveries, maternal age ≥28 years at first delivery was associated with 1.2- to 1.5-fold increased CVD mortality.

Conclusion

The number of deliveries showed a U-shaped association with risk of CVD mortality. Higher maternal age at first delivery was associated with an increased risk of CVD mortality, and excessive risk in women aged ≥28 years at first delivery was noted in those with ≥3 deliveries.

Women's Reproductive History and Pre-Clinical Peripheral Arterial Disease in Late Life: The San Diego Population Study

Objective: Reproductive events have been linked with increased cardiovascular risk in women, but whether they are associated with pre-clinical peripheral arterial disease (PAD) has been understudied. We evaluated associations between reproductive factors and later-life ankle-brachial index (ABI), femoral artery intima-media thickness (fIMT), and femoral plaques. Methods: Cross-sectional analysis of 707 multiethnic women who participated in a follow-up exam of the San Diego Population Study in 2007-2011. To assess associations between reproductive factors (age at menarche, parity, age at menopause, surgical menopause, hormone therapy) with ABI, and Doppler ultrasound measurements of common and superficial fIMT, linear regression was used; for femoral plaque presence, logistic regression was used. Models were adjusted for age, race/ethnicity, and cardiometabolic factors. We tested interactions of reproductive factors with menopause type (natural vs. surgical). Results: Women were on average 71 years old, and 56% were non-Hispanic White. Reproductive factors were not associated with fIMT, femoral plaque presence, or ABI. There were significant interactions between menopause type (surgical vs. natural) and oral contraceptive use (-β: 0.04, p = 0.03) for ABI, as well as between menopause type and parity (β: 0.11, p = 0.05) and age at menopause (β: 0.001, p = 0.05) for fIMT. Among women with natural menopause, oral contraceptive use was associated with higher ABI (β: 0.03, p = 0.007) and older age at natural menopause was related to greater fIMT (β: 0.009, p = 0.06). Among women with surgical menopause, nulliparity was marginally associated with greater fIMT (β: 0.33, p = 0.07). Conclusions: Reproductive history may not be independently associated with later-life lower extremity atherosclerosis in women. Studies are necessary to confirm findings and examine pregnancy-related exposures in relation to pre-clinical PAD.

Second-trimester maternal lipid profiles predict pregnancy complications in an age-dependent manner

PURPOSE

Our objective was to investigate the combinatorial effect of maternal age and second-trimester maternal lipid profiles for pregnancy complications.

METHODS

With 1:4 matching, this retrospective study selected 499 advanced maternal age women and 1996 younger controls. Logistic regression analysis was used to estimate the correlation between second-trimester lipid profiles [total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C)] and pregnancy complications [gestational diabetes mellitus (GDM), pregnancy-induced hypertension syndrome (PIH), preterm labor (PTL), and macrosomia]. Optimal cutoff points were determined by ROC curve analysis.

RESULTS

In women aged 20-34 years, TG are a risk factor for PIH (OR 1.54, 95% CI 1.16-2.04) and PTL (OR 1.34, 95% CI 1.04-1.72). LDL-C was positively associated with macrosomia (OR 1.25, 95% CI 1.04-1.50), while HDL-C was negatively associated with PIH (OR 0.45, 95% CI 0.21-0.93). The optimal cutoff points for TG predicting PIH and PTL were separately ≥ 2.135 and 2.305 mmol/L. The optimal cutoff point for HDL-C identifying PIH was ≤ 1.995 mmol/L and for LDL-C identifying macrosomia was ≥ 3.425 mmol/L. As for advanced maternal age, only TG was an independent risk factor for PIH (OR 1.60, 95% CI 1.01-2.54), and its optimal cutoff point was ≥ 2.375 mmol/L.

CONCLUSIONS

Second-trimester lipid profiles might predict pregnancy complications varied by maternal age. This suggested that individualized prenatal care strategies should be established for women with advanced and normal maternal age to prevent pregnancy complications.

Effects of multiparity on left ventricular diastolic dysfunction in women: cross-sectional study of the KoRean wOmen'S chest pain rEgistry (KoROSE)

OBJECTIVES

To investigate the association between left ventricular (LV) diastolic dysfunction and multiparity in patients with suspected coronary artery disease (CAD).

DESIGN

Cross-sectional study.

SETTING

Linked secondary and tertiary care records from 29 cardiac centres which participated in KoRean wOmen'S chest pain rEgistry.

PARTICIPANTS

960 women with suspected CAD who underwent invasive coronary angiography from February 2011 to May 2017. The patients were classified by parity number, as follows: low-parity, 0 to <3; multiparity, ≥3 pregnancies.

MAIN OUTCOME MEASURE

Prevalence of LV diastolic dysfunction.

RESULTS

There were 302 and 658 low-parity and multiparity patients, respectively. The prevalence of LV diastolic dysfunction was significantly higher in the multiparity than in the low-parity group. The multiparity group had significantly lower E and e´ septal velocities and E/A ratio, and had a significantly higher E/e´ ratio and right ventricular systolic pressure, which are parameters of LV diastolic dysfunction, than the low-parity group. The prevalence of CAD was significantly higher in the multiparity than in the low-parity group. Receiver operating characteristic curve analysis identified a parity of 2.5 as the cut-off for predicting LV diastolic dysfunction (area under the curve, 0.66; sensitivity, 74.1%; specificity, 52.0%; 95% CI 0.607 to 0.706; p<0.001). After adjustment for confounding factors, multivariate regression analysis showed that multiparity had a 1.80-fold increased risk for LV diastolic dysfunction (OR 1.80, 95% CI 1.053 to 3.081, p=0.032).

CONCLUSIONS

The prevalence of LV diastolic dysfunction was higher in multiparity than in low-parity women with suspected CAD. Multiparity was an independent risk factor for LV diastolic dysfunction. LV diastolic dysfunction should be evaluated in multiparous women for the risk of subsequent cardiovascular disease and facilitate the initiation of appropriate treatment.

Association between number of children and carotid intima-media thickness in Bangladesh

Previous studies on the association between number of children and carotid intima-media thickness (cIMT) were limited to Western populations. Pregnancy in women is associated with physiologic changes that may influence the risk of cardiovascular disease. Comparing the association between number of children and cIMT in men and women can provide insights on whether the association may be due to pregnancy. We investigated the association between number of children and cIMT among 718 female (mean age 37.5 years) and 417 male participants (mean age 41.3 years), randomly selected from the Health Effect of Arsenic Longitudinal Study (HEALS), a population-based cohort study in Bangladesh. Multivariate linear regression was used to assess the association and to control for education attainment, history of diabetes, age, smoking, betel use, BMI, systolic blood pressure, and diastolic blood pressure. The average number of children was 4.43 for women and 3.74 for men. There were no nulliparous women. We observed a positive association between number of children and cIMT in women. Mean cIMT increased by 4.5 μm (95% CI, 0.8–8.1) per increment of one birth (P = 0.02). Compared to women with two children, cIMT in women with 4 children and ≥5 children was 23.6μm (95%CI, 2.6–44.7; P = 0.03) and 25.1 μm (95%CI, 3.5–46.6; P = 0.02) greater, respectively. The association was not modified by BMI, SBP, betel use or age. Data in men showed no evidence of association (P = 0.4). The finding suggests a role of high parity in atherosclerosis in women of a low-income, high parity population.

Parity As a Protective Biomarker Against Silent Brain Infarction in Community-Dwelling Older Adults: The Sefuri Study

BACKGROUND

Although several studies have reported an association between parity and increased risk of stroke, this relationship remains controversial.

AIMS

The present study aimed to determine whether parity is associated with silent brain infarction (SBI), independent of other confounders.

METHODS

We analyzed the brain magnetic resonance imaging findings in 576 of community-dwelling older adults with a mean age of 72.1 years. All female participants were asked to provide information regarding the total number of live births, their age at the last parity, and their age at menopause.

RESULTS

The prevalence of SBI and the number of infarcts per participant were higher in men than in women. Although all women who had given birth (0, 1-2, 3-4, or 5+ times) exhibited lower age-adjusted odds ratios (ORs) for SBI than men, a significant difference was observed between women with ≧5 births and men after adjustment for common vascular risk factors (OR: .348, 95% confidence interval [95% CI]: .123-.986). Among women who had given birth, the relationship between fertility and SBI was attenuated, but was enhanced after adjustment for age at the last parity (OR: .300, 95% CI: .102-.886).

CONCLUSIONS

Our findings indicate that fertile women may be protected against SBI or cerebral small vessel disease via the biological effects associated with reproductive activity, and that high fertility may be a marker of protection against SBI. However, late childbearing may blunt protective effects of fertility against SBI.

A risk score assessment tool for peripheral arterial disease in women: From the National Health and Nutrition Examination Survey

BACKGROUND

Peripheral arterial disease (PAD) carries a significant morbidity and mortality. Women are more commonly affected with this condition and are mostly asymptomatic, and undertreated. The objective of the study was to develop and validate a simple risk score to identify women with PAD.

HYPOTHESIS

Identifying those at early stage of the disease could help reduce the risk of complications.

METHODS

Using data from the National Health and Nutrition Examination Survey 1999-2004, we identified women who had data on ankle brachial index. The cohort was divided into development (70%) and validation (30%) groups. Using variables that are self-reported or measured without laboratory data, we developed a multivariable logistic regression to predict PAD, which was evaluated in the validation cohort.

RESULTS

A total of 150.6 million women were included. A diagnosis of PAD was reported in 13.7%. Age, body mass index, hypertension, diabetes mellitus, smoking, non-oral contraceptive pill usage, and parity were all independently associated with PAD. The C-statistics was 0.74, with good calibration. The model showed good stability in the validation cohort (C-statistics 0.73).

CONCLUSION

This parsimonious risk model is a valid tool for risk prediction of PAD in women, and could be easily applied in routine clinical practice.

Effect of Normal Pregnancy Followed by Lactation on Long-Term Maternal Health in a Mouse Model

Although it has been widely accepted that pregnancies with complications are associated with increased maternal cardiovascular risk later in life, there is no consensus if noncomplicated pregnancy followed by lactation plays a protective role or is a risk factor. The objective of this study was to investigate the effects of normal pregnancy and lactation on long-term maternal health in a mouse model. CD-1 mice were allocated to breeding (primigravid [PG]) and nonbreeding (nulligravid [NG]) groups. The PG group proceeded through normal pregnancy and delivery. Using a telemetry system, blood pressure (BP) was analyzed in the PG group at 6 months postpartum and in age-matched NG mice. Serum analytes, gene expressions, and protein levels were determined using appropriate analysis methods. Primigravid mice had significantly lower systolic and diastolic BP and fasting glucose levels. Circulating oxytocin (OXT) levels were significantly higher in PG mice. Oxt gene expression was significantly higher in the heart and aorta and lower in visceral adipose tissue (VAT) from PG mice. The oxytocin receptor ( Oxtr) gene expression was significantly higher in the heart, aorta, and VAT from PG animals. The level of Oxtr DNA hypermethylation and the expression of mmu-miR-29a were significantly lower in the hearts of PG mice. In PG VAT, glucose transporter-4 expression was significantly higher. Our study demonstrates that a history of normal pregnancy followed by lactation was associated with lower maternal cardiovascular risk factors later in life in female mouse.

Preventing cardiovascular disease after hypertensive disorders of pregnancy: Searching for the how and when

Background

Women with a history of a hypertensive disorder during pregnancy (HDP) have an increased risk of cardiovascular events. Guidelines recommend assessment of cardiovascular risk factors in these women later in life, but provide limited advice on how this follow-up should be organized.

Design

Systematic review and meta-regression analysis.

Methods

The aim of our study was to provide an overview of existing knowledge on the changes over time in three major modifiable components of cardiovascular risk assessment after HDP: blood pressure, glucose homeostasis and lipid levels. Data from 44 studies and up to 6904 women with a history of a HDP were compared with risk factor levels reported for women of corresponding age in the National Health And Nutrition Examination Survey, Estudio Epidemiólogico de la Insuficiencia Renal en España and Hong Kong cohorts (N = 27,803).

Results

Compared with the reference cohort, women with a HDP presented with higher mean blood pressure. Hypertension was present in a higher rate among women with a previous HDP from 15 years postpartum onwards. At 15 years postpartum (±age 45), one in five women with a history of a HDP suffer from hypertension. No differences in glucose homeostasis parameters or lipid levels were observed.

Conclusions

Based on our analysis, it is not possible to point out a time point to commence screening for cardiovascular risk factors in women after a HDP. We recommend redirection of future research towards the development of a stepwise approach identifying the women with the highest cardiovascular risk.

Central fat accretion and insulin sensitivity: differential relationships in parous and nulliparous women

BACKGROUND/OBJECTIVES

Childbearing is associated with a disproportionate accumulation of visceral fat and an increased risk of metabolic disease. However, it is unknown whether the visceral fat accretion associated with pregnancy modifies a woman's risk for metabolic disease. The purpose of this study was to test whether the association between abdominal fat and insulin sensitivity differs by parity status in healthy overweight women.

SUBJECTS/METHODS

Intra-abdominal adipose tissue (IAAT) via CT, body composition by DXA, insulin sensitivity via intravenous glucose tolerance test and minimal model (SI), HOMA-IR, and cardiorespiratory fitness (VO2max) were assessed in 212 non-diabetic, premenopausal, overweight non-Hispanic white and African-American women.

RESULTS

Nulliparous women (n=98) were younger, had less IAAT and higher VO2max, but similar SI, HOMA-IR and leg fat, compared to parous (n=114). In nulliparous women, IAAT was negatively associated with SI, controlling for age, race and body fat mass (r=-0.40, P<0.001), but this relationship was attenuated in parous women (r=-0.15, P=0.16). In multiple linear regression analysis, leg fat and IAAT were significant predictors of SI in nulliparous, but not parous women.

CONCLUSIONS

Results suggest that greater IAAT in parous women does not lead to greater insulin resistance; rather, transient insulin resistance during pregnancy may encourage intra-abdominal fat accumulation that is metabolically benign. This underscores the need to consider parity when assessing cardiometabolic risk.

Advanced Maternal Age Worsens Postpartum Vascular Function

The age at which women experience their first pregnancy has increased throughout the decades. Pregnancy has an important influence on maternal short- and long-term cardiovascular outcomes. Pregnancy at an advanced maternal age increases maternal risk of gestational diabetes, preeclampsia, placenta previa and caesarian delivery; complications which predict worsened cardiovascular health in later years. Aging also independently increases the risk of cardiovascular disease; therefore, combined risk in women of advanced maternal age may lead to detrimental cardiovascular outcomes later in life. We hypothesized that pregnancy at an advanced maternal age would lead to postpartum vascular dysfunction. We used a reproductively aged rat model to investigate vascular function in never pregnant (virgin), previously pregnant (postpartum) and previously mated but never delivered (nulliparous) rats at approximately 13.5 months of age (3 months postpartum or equivalent). Nulliparous rats, in which pregnancy was spontaneously lost, demonstrated significantly reduced aortic relaxation responses (methylcholine [MCh] Emax: 54.2 ± 12.6%) vs. virgin and postpartum rats (MCh Emax: 84.8 ± 3.5% and 84.7 ± 3.2% respectively); suggesting pregnancy loss causes a worsened vascular pathology. Oxidized LDL reduced relaxation to MCh in aorta from virgin and postpartum, but not nulliparous rats, with an increased contribution of the LOX-1 receptor in the postpartum group. Further, in mesenteric arteries from postpartum rats, endothelium-derived hyperpolarization (EDH)-mediated vasodilation was reduced and a constrictive prostaglandin effect was apparent. In conclusion, aged postpartum rats exhibited vascular dysfunction, while rats which had pregnancy loss demonstrated a distinct vascular pathology. These data demonstrate mechanisms which may lead to worsened outcomes at an advanced maternal age; including early pregnancy loss and later life cardiovascular dysfunction.

Higher number of live births is associated with left ventricular diastolic dysfunction and adverse cardiac remodelling among US Hispanic/Latina women: results from the Echocardiographic Study of Latinos

Introduction

Female sex is a risk factor for heart failure with preserved ejection fraction (HFpEF). Previous literature suggests that some diastolic dysfunction (DD) develops during pregnancy and may persist postdelivery. Our objective was to examine the relationship between parity and cardiac structure and function in a population-based cohort.

Methods

Participants included 1172 Hispanic/Latina women, aged ≥45 years, enrolled in the Echocardiographic Study of Latinos from four US communities (Bronx, Miami, San Diego and Chicago). Standard echocardiographic techniques were used to measure cardiac volumes, left ventricular mass, systolic and diastolic function. Using sampling weights and survey statistics, multivariable linear and logistic regression models were constructed adjusting for age, body mass index, diabetes or prediabetes, systolic blood pressure, use of antihypertensive medications, smoking, total cholesterol and high-density lipoprotein cholesterol.

Results

In the target population, 5.0% were nulliparous (no live births) and 10.5% were grand multiparous (≥5 live births). Among the nulliparous women, 46% had DD as compared with 51%–58% of women with 1–4 live births and 81% of women with ≥5 live births (p<0.01). In full multivariate models, higher parity was significantly associated with greater left ventricular end-systolic volumes, end-diastolic volumes, left atrial volume indices and presence of DD (all p<0.01) but was not associated with ejection fraction. The log odds for having any grade of DD in grand-multiparous women was over three times that seen in nulliparous women (OR=3.4, 95% CI 1.5 to 7.9, p<0.01) in models further adjusted for income and education.

Conclusions

Higher parity is associated with increased cardiac mass, volumes and the presence of DD. Further studies are needed to elucidate this apparent deleterious relation and whether parity can help explain the increased risk of HFpEF in women.

Parenthood and the risk of cardiovascular diseases among 0.5 million men and women: findings from the China Kadoorie Biobank

Background

Women's parity has been associated with risk of cardiovascular disease (CVD). It is unclear, however, whether it reflects biological effects of childbearing or uncontrolled socio-economic and lifestyle factors associated with childrearing. We assessed the association between number of children and incident CVD outcomes separately in women and men.

Methods

In 2004-08, the nationwide China Kadoorie Biobank recruited 0.5 million individuals aged 30-79 years from 10 diverse regions. During 7 years of follow-up, 24 432 incident cases of coronary heart disease (CHD) and 35 736 of stroke were recorded among 489 762 individuals without prior CVD. Multivariable Cox regression models were used to estimate sex-specific hazard ratios (HRs) and 95% confidence intervals (CIs) for CHD and stroke associated with number of children.

Results

Overall, 98% of all participants had children and the mean number of children declined progressively from four in older participants to one or two in younger participants. Compared with childless women, women with children had an increased risk of CHD, but not of stroke [HR (95% CI): 1.14 (1.00; 1.30) and 1.03 (0.92; 1.16)]. Corresponding results for men were 1.20 (1.06; 1.35) and 1.13 (1.03; 1.24), respectively. In individuals with children, there was a log-linear association between number of children and CVD outcomes; in women, each additional child was associated with adjusted HRs of 1.02 (1.01; 1.04) for CHD and 1.02 (1.01; 1.03) for stroke, similar in magnitude to that in men [1.03 (1.01; 1.04) for CHD and 1.02 (1.01; 1.03) for stroke].

Conclusion

In Chinese adults, the association between the number of children and risk of CHD and stroke was similar between men and women, suggesting that factors associated with parenthood and childrearing are more likely to affect the risk of CVD outcomes than factors associated with childbearing.

[Effect of advanced maternal age on birth defects and postnatal complications of neonates]

OBJECTIVE

To investigate the effect of advanced maternal age on birth defects and postnatal complications of neonates.

METHODS

Among the 1 109 neonates who were born at The First People's Hospital of Yunnan Province between January 2014 and December 2015, 536 neonates whose mothers were aged ≥35 years were enrolled as advanced age group and 573 neonates whose mothers were aged <35 years were enrolled as appropriate-age group. The incidences of the comorbidities in pregnancy, fetal intrauterine distress, neonatal birth defects, and postnatal complications were compared between the two groups. A univariate logistic regression analysis was performed to analyze the effect of advanced maternal age on neonatal comorbidities during perinatal period.

RESULTS

Compared with the appropriate-age group, the advanced age group had significantly higher rate of caesarean section and incidence rates of multiple birth, gestational diabetes, pregnancy-induced hypertension, in vitro fertilization, and fetal intrauterine distress (P<0.01). The neonates in the advanced age group had a significantly higher incidence rate of cleft lip and palate and a significantly lower rate of skeletal dysplasia than in the appropriate-age group (P<0.05). Advanced maternal age was the risk factor for fetal intrauterine distress (OR=2.27, 95%CI: 1.33-3.88, P=0.003), neonatal resuscitation (OR=1.66, 95%CI: 1.19-2.31, P=0.003), and intracranial hemorrhage (OR=2.70, 95%CI: 1.21-6.04, P=0.02).

CONCLUSIONS

The women of maternal advanced age have higher incidence rates of pregnancy comorbidities than those of appropriate age, and the neonates born to the mothers of advanced maternal age have a higher incidence rate of cleft lip and palate. Advanced maternal age may increase the risks of fetal intrauterine distress, neonatal resuscitation, and intracranial hemorrhage.

Parity, coronary heart disease and mortality in the old order Amish

BACKGROUND AND AIMS

Prior data on the association between parity and mortality are limited by the presence of sociodemographic confounders including cultural norms of parity. Our objective was to determine the association between parity and mortality in the Amish, a socioeconomically homogenous group with large numbers of children per family.

METHODS

We conducted a population-based cohort study among 518 Old Order Amish women enrolled in a cardiovascular awareness program. The mean length of follow-up for mortality was 13.52 years. We determined the adjusted associations between parity and obesity, prevalent coronary heart disease and mortality.

RESULTS

The mean number of total births per woman was 6.7 ± 3.6 with a mode of 8. No significant association was observed between parity and all-cause mortality when adjusted for age (HR 1.00 per additional birth; 95% CI 0.96-1.05; p = 0.85) or in multivariate analysis (HR 1.00, 95% CI 0.95-1.05; p = 0.95). There was also no association of parity in age- or multivariable adjusted models with prevalent diabetes, hypertension or coronary heart disease. Despite the lack of effect of parity on mortality, a significant association of ten or more births was observed with higher body mass index (BMI) compared to the referent group of 8-9 total births.

CONCLUSIONS

In a highly homogeneous population with high rates of parity, no association between overall mortality and parity was observed. Ten or more births were significantly associated with a higher BMI but not with overall mortality.

Associations Between Parity, Obesity, and Cardiovascular Risk Factors Among Middle-Aged Women

BACKGROUND

Several studies have demonstrated an association between parity and the risk of developing cardiovascular disease (CVD) in middle-aged women; however, some inconsistencies still remain in the literature after accounting for obesity. The purpose of this study was to examine the association between parity and the risk factors of CVD while accounting for current obesity status in middle-aged women.

METHOD

Data for this study came from the National Health and Nutrition Examination Survey 2007-2012. The final analytic sample included 2024 middle-aged women (40-60 years old). General linear models predicting CVD risk factors based on parity (nulliparous, 1, 2, 3, and ≥4) were established after controlling for study covariates. Least square adjusted means of CVD risk factors and associated 95% confidence intervals were estimated across parity and body mass index (BMI) levels.

RESULTS

Women with ≥4 parity (8.34%; standard error [SE] = 0.84) showed significantly distinct demographic characteristics and health conditions, including obesity (49.08%; SE = 3.55). There were no significant associations between parity and CVD risk factors after controlling for covariates. Follow-up analyses showed consistent results across parity; however, CVD risk factors were significantly increased with higher BMI levels, regardless of parity status.

CONCLUSIONS

Our results suggest that parity is not a significant predictor of CVD risk factors in middle-aged women, whereas current overweight or obesity status is more important when explaining the risk of the development of CVD.

Parity and Cardiovascular Disease Mortality: a Dose-Response Meta-Analysis of Cohort Studies

Parity has been shown to inversely associate with cardiovascular disease (CVD) mortality, but the evidence of epidemiological studies is still controversial. Therefore, we quantitatively assessed the relationship between parity and CVD mortality by summarizing the evidence from prospective studies. We searched MEDLINE (PubMed), EMBASE and ISI Web of Science databases for relevant prospective studies of parity and CVD mortality through the end of March 2015. Fixed- or random-effects models were used to estimate summary relative risks (RRs) and 95% confidence intervals (CIs). Heterogeneity among studies was assessed using the I² statistics. All statistical tests were two-sided. Ten prospective studies were included with a total of 994,810 participants and 16,601 CVD events. A borderline significant inverse association was observed while comparing parity with nulliparous, with summarized RR = 0.79 (95% CI: 0.60–1.06; I² = 90.9%, P < 0.001). In dose-response analysis, we observed a significant nonlinear association between parity number and CVD mortality. The greatest risk reduction appeared when the parity number reached four. The findings of this meta-analysis suggests that ever parity is inversely related to CVD mortality. Furthermore, there is a statistically significant nonlinear inverse association between parity number and CVD mortality.

Adverse Pregnancy Conditions, Infertility, and Future Cardiovascular Risk: Implications for Mother and Child

Adverse pregnancy conditions in women are common and have been associated with adverse cardiovascular and metabolic outcomes such as myocardial infarction and stroke. As risk stratification in women is often suboptimal, recognition of non-traditional risk factors such as hypertensive disorders of pregnancy and premature delivery has become increasingly important. Additionally, such conditions may also increase the risk of cardiovascular disease in the children of afflicted women. In this review, we aim to highlight these conditions, along with infertility, and the association between such conditions and various cardiovascular outcomes and related maternal risk along with potential translation of risk to offspring. We will also discuss proposed mechanisms driving these associations as well as potential opportunities for screening and risk modification.

Association between number of live births and markers of subclinical atherosclerosis: The Dallas Heart Study

AIMS

Higher parity has been associated with increased maternal risk of cardiovascular disease, but the mechanism is not well delineated. Whether the number of live births is associated with coronary and aortic subclinical atherosclerosis has not been fully evaluated.

METHODS AND RESULTS

Women from the Dallas Heart Study, a multiethnic population-based cohort of subjects aged 30-65 years, were included if they had data on self-reported live births and coronary artery calcium (CAC) measured by computed tomography or aortic wall thickness (AWT) by MRI. Coronary artery calcium was positive if >10 Agatston units, and aortic wall thickness if greater than the 75(th) percentile reference point for age and gender. Among the 1644 women included in the study, the mean age was 45 years and 55% were Black. Sequential multivariable models were done adjusting for age, race, traditional cardiovascular risk factors, body mass index, income, education, hormone replacement therapy, oral contraceptives, and physical activity. Using women with 2-3 live births as the reference, those with four or more live births had an increased prevalence of elevated coronary artery calcium (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.28-3.65) and aortic wall thickness (OR 1.6, 95% CI 1.04-2.41). Women with 0-1 live births also had increased coronary artery calcium (OR 1.9, 95% CI 1.16-3.03) and aortic wall thickness (OR 1.5, 95% CI 1.05-2.09) after multivariable adjustment.

CONCLUSION

The number of live births is associated with subclinical coronary and aortic atherosclerosis, with an apparent U-shaped relationship. Further studies are needed to confirm this association and explore the biological underpinnings of these findings.

Sex differences in cardiovascular risk factors and disease prevention

Cardiovascular disease (CVD) has been seen as a men's disease for decades, however it is more common in women than in men. It is generally assumed in medicine that the effects of the major risk factors (RF) on CVD outcomes are the same in women as in men. Recent evidence has emerged that recognizes new, potentially independent, CVD RF exclusive to women. In particular, common disorders of pregnancy, such as gestational hypertension and diabetes, as well as frequently occurring endocrine disorders in women of reproductive age (e.g. polycystic ovary syndrome (PCOS) and early menopause) are associated with accelerated development of CVD and impaired CVD-free survival. With the recent availability of prospective studies comprising men and women, the equivalency of major RF prevalence and effects on CVD between men and women can be examined. Furthermore, female-specific RFs might be identified enabling early detection of apparently healthy women with a high lifetime risk of CVD. Therefore, we examined the available literature regarding the prevalence and effects of the traditional major RFs for CVD in men and women. This included large prospective cohort studies, cross-sectional studies and registries, as randomised trials are lacking. Furthermore, a literature search was performed to examine the impact of female-specific RFs on the traditional RFs and the occurrence of CVD. We found that the effects of elevated blood pressure, overweight and obesity, and elevated cholesterol on CVD outcomes are largely similar between women and men, however prolonged smoking is significantly more hazardous for women than for men. With respect to female-specific RF only associations (and no absolute risk data) could be found between preeclampsia, gestational diabetes and menopause onset with the occurrence of CVD. This review shows that CVD is the main cause of death in men and women, however the prevalence is higher in women. Determination of the CV risk profile should take into account that there are differences in impact of major CV RF leading to a worse outcome in women. Lifestyle interventions and awareness in women needs more consideration. Furthermore, there is accumulating evidence that female-specific RF are of influence on the impact of major RF and on the onset of CVD. Attention for female specific RF may enable early detection and intervention in apparently healthy women. Studies are needed on how to implement the added RF's in current risk assessment and management strategies to maximize benefit and cost-effectiveness specific in women.

Association of parity with carotid diameter and distensibility: multi-ethnic study of atherosclerosis

Pregnancy and childbirth are associated with hemodynamic changes and vascular remodeling. It is not known whether parity is associated with later adverse vascular properties such as larger arterial diameter, wall thickness, and lower distensibility. We used baseline data from 3283 women free of cardiovascular disease aged 45 to 84 years enrolled in the population-based Multi-Ethnic Study of Atherosclerosis. Participants self-reported parity status. Ultrasound-derived carotid artery lumen diameters and brachial artery blood pressures were measured at peak-systole and end-diastole. Common carotid intima-media thickness was also measured. Regression models to determine the association of carotid distensibility coefficient, lumen diameter, and carotid intima-media thickness with parity were adjusted for age, race, height, weight, diabetes mellitus, current smoking, blood pressure medication use, and total and high-density lipoprotein cholesterol levels. The prevalence of nulliparity was 18%. In adjusted models, carotid distensibility coefficient was 0.09×10−5 Pa−1 lower (P=0.009) in parous versus nulliparous women. Among parous women, there was a nonlinear association with the greatest carotid distensibility coefficient seen in women with 2 live births and significantly lower distensibility seen in primiparas (P=0.04) or with higher parity >2 (P=0.005). No such pattern of association with parity was found for lumen diameter or carotid intima-media thickness. Parity is associated with lower carotid artery distensibility, suggesting arterial remodeling that lasts beyond childbirth. These long-term effects on the vasculature may explain the association of parity with cardiovascular events later in life.

The mother--the long-term implications on metabolic and cardiovascular complications

There is cumulating evidence linking the occurrence of pregnancy complications, including miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm birth, and fetal growth restriction, with increased future risk of type 2 diabetes mellitus, and hospitalization and death due to cardiovascular and cerebrovascular diseases. Such association is largely related to genetic predisposition and shared pathophysiological mechanisms and changes, which may precede the index pregnancy. Awareness of this association would allow identification of the at-risk women for implementation of preventive measures to reduce the recurrence risk of these complications and mitigate the future development of metabolic and cardiovascular diseases worldwide.

Early maternal age at first birth is associated with chronic diseases and poor physical performance in older age: cross-sectional analysis from the International Mobility in Aging Study

BACKGROUND

Early maternal age at first birth and elevated parity may have long-term consequences for the health of women as they age. Both are known risk factors for obstetrical complications with lifelong associated morbidities. They may also be related to diabetes and cardiovascular disease development.

METHODS

We examine the relationship between early maternal age at first birth, defined as ≤18 years of age, multiparity (>2 births), and poor physical performance (Short Physical Performance Battery≤8) in community samples of women between 65 and 74 years of age from Canada, Albania, Colombia, and Brazil (N=1040). Data were collected in 2012 to provide a baseline assessment for a longitudinal cohort called the International Mobility in Aging Study. We used logistic regression and general linear models to analyse the data.

RESULTS

Early maternal age at first birth is significantly associated with diabetes, chronic lung disease, high blood pressure, and poor physical performance in women at older ages. Parity was not independently associated with chronic conditions and physical performance in older age. After adjustment for study site, age, education, childhood economic adversity and lifetime births, women who gave birth at a young age had 1.75 (95% CI: 1.17-2.64) the odds of poor SPPB compared to women who gave birth>18 years of age. Adjustment for chronic diseases attenuated the association between early first birth and physical performance. Results were weaker in Colombia and Brazil, than Canada and Albania.

CONCLUSIONS

This study provides evidence that adolescent childbirth may increase the risk of developing chronic diseases and physical limitations in older age. Results likely reflect both the biological and social consequences of early childbearing and if the observed relationship is causal, it reinforces the importance of providing contraception and sex education to young women, as the consequences of early pregnancy may be life-long.

Is interpregnancy interval associated with cardiovascular risk factors in later life? A cohort study

OBJECTIVES

Pregnancy represents a metabolic challenge to women; in a normal pregnancy, transient metabolic changes occur that support the needs of the growing fetus. It is possible that repeating this challenge within a relatively short amount of time may result in lasting damage to the woman's cardiovascular health. Conversely, it is also possible that a long interpregnancy interval (IPI) may reflect subfertility, which has been found to be associated with cardiovascular disease (CVD). We examine the associations of short and long IPI with measures of cardiovascular health.

DESIGN

Prospective cohort.

SETTING

Mothers of the Avon Longitudinal Study of Parents and Children (ALSPAC).

PARTICIPANTS

Women with two live births in order to control for confounding by parity.

OUTCOME MEASURES

Arterial distensibility, common carotid intima, adiposity, blood pressure, lipids, glucose, insulin, proinsulin, triglycerides, C reactive protein.

RESULTS

25% (n=3451) of ALSPAC mothers had provided sufficient data to determine full reproductive history-of these, 1477 had two live births, with 54% mothers having non-missing data on all variables required for our analyses. A total of 1268 mothers with IPI (interbirth interval minus 9 months' gestation) had CVD risk factors measured/imputed at mean age 48 years. After adjusting for confounding, we found no association of either short (≤15 months) or long (>27 months) IPI and increased levels of cardiovascular risk factors. There was some suggestion that women with long and short IPIs had a more favourable lipid profile compared with women whose IPI was 16-27 months; however, the differences were small in magnitude and imprecisely estimated.

CONCLUSIONS

This study does not support the hypothesis that either long or short IPI is a risk factor for later cardiovascular health.

Cardiovascular mortality after pre-eclampsia in one child mothers: prospective, population based cohort study

OBJECTIVE

To assess the association of pre-eclampsia with later cardiovascular death in mothers according to their lifetime number of pregnancies, and particularly after only one child.

DESIGN

Prospective, population based cohort study.

SETTING

Medical Birth Registry of Norway.

PARTICIPANTS

We followed 836,147 Norwegian women with a first singleton birth between 1967 and 2002 for cardiovascular mortality through linkage to the national Cause of Death Registry. About 23,000 women died by 2009, of whom 3891 died from cardiovascular causes. Associations between pre-eclampsia and cardiovascular death were assessed by hazard ratios, estimated by Cox regression analyses. Hazard ratios were adjusted for maternal education (three categories), maternal age at first birth, and year of first birth

RESULTS

The rate of cardiovascular mortality among women with preterm pre-eclampsia was 9.2% after having only one child, falling to 1.1% for those with two or more children. With term pre-eclampsia, the rates were 2.8% and 1.1%, respectively. Women with pre-eclampsia in their first pregnancy had higher rates of cardiovascular death than those who did not have the condition at first birth (adjusted hazard ratio 1.6 (95% confidence interval 1.4 to 2.0) after term pre-eclampsia; 3.7 (2.7 to 4.8) after preterm pre-eclampsia). Among women with only one lifetime pregnancy, the increase in risk of cardiovascular death was higher than for those with two or more children (3.4 (2.6 to 4.6) after term pre-eclampsia; 9.4 (6.5 to 13.7) after preterm pre-eclampsia). The risk of cardiovascular death was only moderately elevated among women with pre-eclamptic first pregnancies who went on to have additional children (1.5 (1.2 to 2.0) after term pre-eclampsia; 2.4 (1.5 to 3.9) after preterm pre-eclampsia). There was little evidence of additional risk after recurrent pre-eclampsia. All cause mortality for women with two or more lifetime births, who had pre-eclampsia in first pregnancy, was not elevated, even with preterm pre-eclampsia in first pregnancy (1.1 (0.87 to 1.14)).

CONCLUSIONS

Cardiovascular death in women with pre-eclampsia in their first pregnancy is concentrated mainly in women with no additional births. This association might be due to health problems that discourage or prevent further pregnancies rather than to pre-eclampsia itself. As a screening criterion for cardiovascular disease risk, pre-eclampsia is a strong predictor primarily among women with only one child-particularly with preterm pre-eclampsia.

Triglyceride metabolism in pregnancy

During pregnancy, complex changes occur in lipid profiles. From the 12th week of gestation, phospholipids, cholesterol (total, LDL, HDL), and triglycerides (TG) increase in response to estrogen stimulation and insulin resistance. Transition to a catabolic state favors maternal tissue lipid use as energy sources, thus sparing glucose and amino acids for the fetus. In addition, maternal lipids, that is, cholesterol, are available for fetal use in building cell membranes and as precursor of bile acids and steroid hormones. It is also required for cell proliferation and development of the growing body. Free-fatty acids (FFA), oxidized in the maternal liver as ketone-bodies, represent an alternative fuel for the fetus. Maternal hypertriglyceridemia (vs. other lipids) has many positive effects such as contributing to fetal growth and development and serving as an energy depot for maternal dietary fatty acids. However, increased TG during pregnancy appears to increase risk of preeclampsia and preterm birth. Some have suggested that maternal hypertriglyceridemia has a role in increasing cardiovascular risk later in life. This chapter reviews lipid metabolism during pregnancy to elucidate its effect on fetal growth and its potential role in pregnancy-associated complications and future cardiovascular risk.

The association of reproductive history with all-cause and cardiovascular mortality in older women: the Rancho Bernardo Study

OBJECTIVE

To examine associations of gravidity and parity with all-cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in postmenopausal women.

DESIGN

Prospective cohort study.

SETTING

Rancho Bernardo, a southern California community.

PATIENT(S)

One thousand two hundred ninety-four postmenopausal women ages 50-96 who attended a 1984-87 research clinic visit at which reproductive and medical histories were obtained and who were followed through 2007.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

All-cause, CVD, CHD, and non-CHD CVD mortality, determined by nosologist-coded death certificates.

RESULT(S)

Average baseline age was 70.6 ± 9.2. Numbers of pregnancies ranged from 0 to 13 (median = 2); births ranged from 0 to 11 (median = 2). During a median of 19.3 years of follow-up, 707 women (54.6%) died, with 46.5% attributed to CVD, 20.5% to CHD, and 26.0% to non-CHD CVD. Trend analyses showed inverse associations of gravidity with CVD mortality and non-CHD CVD mortality. Women with four or more pregnancies were less likely than nulligravidas to have fatal CVD (hazard ratio [HR] = 0.63, 95% confidence interval [CI] = 0.40-0.99) and non-CHD CVD (HR = 0.48, 95% CI = 0.26-0.91) independent of age, years postmenopause, obesity, and HDL. Associations increased after the first decade of follow-up. Parity and gravidity were not associated with overall or CHD mortality.

CONCLUSION(S)

High gravidity was associated with reduced CVD and non-CHD CVD mortality in postmenopausal women. Protective associations could reflect biological mechanisms that occur with repeated pregnancy or greater social support related to family size among multiparous women.