Preterm Delivery and Maternal Cardiovascular Disease in Young and Middle-Aged Adult Women

STEMI, Revascularization, and Peak Troponin by Adverse Pregnancy Outcomes in Women With Myocardial Infarction

Background

Women with a history of adverse pregnancy outcomes have a higher risk of coronary heart disease. Emerging evidence suggests that women with a history of preeclampsia have a different pattern of overall coronary atherosclerosis and that they at the time of myocardial infarction (MI) more frequently present with ST-segment elevation MI (STEMI) compared to women with no such history.

Objectives

The purpose of this study was to determine whether among women with MI, those with a history of adverse pregnancy outcomes are more likely to present with STEMI or other clinical characteristics indicating a more severe myocardial injury.

Methods

The study sample consisted of 8,320 women aged ≤65 years with first MI in Sweden 2007 to 2022. Regression models were used to estimate the association between adverse pregnancy outcomes (hypertensive disorders of pregnancy [non-preeclamptic hypertension and preeclampsia], small for gestational age [SGA] infant, and preterm delivery) and STEMI, invasive revascularization, and high troponin, while considering known predictors of coronary heart disease.

Results

In total, 3,128 (38%) of women suffered STEMI. The adjusted OR of presenting with STEMI were higher in women with a history of preterm preeclampsia (OR: 1.40; 95% CI: 1.05-1.88), or an SGA infant (OR: 1.30; 95% CI: 1.13-1.50) compared to women with no such history, as well as for in-hospital revascularization. Stratified by infarct type, troponin levels did not differ by adverse pregnancy outcome history.

Conclusions

Among women with a first MI, a history of preterm preeclampsia or SGA infant were associated with STEMI and invasive revascularization.

Female-specific risk factors for cardiovascular disease: an update

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. While it was previously believed that men have greater susceptibility to CVD, recent research suggests that women face an increased risk of CVD after the onset of menopause, primarily due to the loss of the protective effects of estrogens. Premature ovarian insufficiency (POI), polycystic ovarian syndrome (PCOS), and gestational factors, such as gestational diabetes mellitus (GDM), recurrent pregnancy loss, preterm delivery, and preeclampsia, are specific reproductive disorders that may contribute to an elevated risk of CVD at earlier ages, i.e., before the onset of menopause. This suggests that women with these conditions should be closely monitored for CVD risk factors even before reaching menopause. Such early intervention may help reduce the incidence of CVD and improve overall cardiovascular health in this population. The precise pathophysiological mechanism underlying the development of CVD in women with menopause, premature POI, PCOS, and gestational factors remains elusive. This review article seeks to elucidate the latest research on the relationship between these conditions and CVD in women, aiming to explore the underlying pathogenic mechanisms contributing to this association.

History of multifetal gestation and long-term maternal mortality

BACKGROUND

Multifetal gestation could be associated with higher long-term maternal mortality because it increases the risk of pregnancy complications such as preeclampsia and preterm birth, which are in turn linked to postpartum cardiovascular risk.

OBJECTIVES

We examined whether spontaneously conceived multifetal versus singleton gestation was associated with long-term maternal mortality in a racially diverse U.S.

COHORT

METHODS

We ascertained vital status as of 2016 via linkage to the National Death Index and Social Security Death Master File of 44,174 mothers from the Collaborative Perinatal Project (CPP; 1959-1966). Cox proportional hazards models with maternal age as the time scale assessed associations between history of spontaneous multifetal gestation (in the last CPP observed pregnancy or prior pregnancy) and all-cause and cardiovascular mortality, adjusted for demographics, smoking status, and preexisting medical conditions. We calculated hazard ratios (HR) for all-cause and cause-specific mortality over the study period and until age 50, 60, and 70 years (premature mortality).

RESULTS

Of eligible participants, 1672 (3.8%) had a history of multifetal gestation. Participants with versus without a history of multifetal gestation were older, more likely to have a preexisting condition, and more likely to smoke. By 2016, 51% of participants with and 38% of participants without a history of multifetal gestation had died (unadjusted all-cause HR 1.14, 95% confidence interval [CI] 1.07, 1.23). After adjustment for smoking and preexisting conditions, a history of multifetal gestation was not associated with all-cause (adjusted HR 1.00, 95% CI 0.93, 1.08) or cardiovascular mortality (adjusted HR 0.99, 95% CI 0.87, 1.11) over the study period. However, history of multifetal gestation was associated with an 11% lower risk of premature all-cause mortality (adjusted HR 0.89, 95% CI 0.82, 0.96).

CONCLUSIONS

In a cohort with over 50 years of follow-up, history of multifetal gestation was not associated with all-cause mortality, but may be associated with a lower risk of premature mortality.

Update on sex specific risk factors in cardiovascular disease

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.

Study Design and Protocol of the Multisite Pregnancy 24/7 Cohort Study

Hypertensive disorders of pregnancy and other adverse pregnancy outcomes (APOs) are associated with an increased risk of future maternal cardiovascular disease. Physical activity during pregnancy reduces the risk of these APOs, yet few meet physical activity guidelines during pregnancy. Little is known about the role of sedentary behavior or sleep in APOs, a critical gap in knowledge given these behaviors comprise the majority of a 24-hour day. To address this knowledge gap, the Pregnancy 24/7 cohort study (2020-2025) uses 2 devices for 24-hour activity assessment in each trimester of pregnancy to examine associations of sedentary behavior, sleep, and the 24-hour activity cycle (composition of sedentary behavior, physical activity, and sleep) with hypertensive disorders and other APOs. Participants (n = 500) are recruited from the University of Iowa, University of Pittsburgh, and West Virginia University in early pregnancy and followed through delivery. The activPAL3 micro and Actiwatch Spectrum Plus are worn in each trimester for 7 days of 24-hour wear to assess the 24-hour activity cycle. APOs are abstracted from medical charts. This study will provide critical data to fuel future research examining how modifying the 24-hour activity cycle in pregnancy can improve maternal health.

Pregnancy-related maternal mortality in the state of Georgia: Timing and causes of death

BACKGROUND

The maternal mortality rate in the United States is high and disparities among non-Hispanic White and non-Hispanic Black women remain. In the State of Georgia, the pregnancy-related death rate is among the worst in the nation.

OBJECTIVE

To examine current pregnancy-related deaths in the State of Georgia using measures of timing and cause-specific mortality across maternal sociodemographic characteristics.

DESIGN

This cross-sectional study of pregnancy-related deaths in Georgia was based on 2016-2019 maternal mortality data obtained from the Georgia Department of Public Health.

METHODS

Our study analysis involved complete-case data of maternal deaths identified as pregnancy-related deaths (n = 129). Statistical analyses included two distinct population-level measures: (a) timing (i.e. during pregnancy, 0 to 60 days, 61 to 180 days, and 181 to 365 days postpartum) and (b) cause-specific deaths patterned by sociodemographic groups of women and by rural and urban county of residence. Categorical variables were compared using the Chi square or Fisher's exact test and presented as numbers and percentages. A post hoc power analysis was conducted to inform whether there was sufficient power to detect statistically significant effects given available sample sizes.

RESULTS

Among a total of 129 pregnancy-related deaths, 30 (23.3%) deaths occurred during pregnancy and 63 (48.8%) deaths occurred within the first 60 days postpartum. Pregnancy-related deaths were disproportionally common among non-Hispanic Black, 25 to 34 years old, and poorly educated women. Three leading underlying causes, cardiomyopathy (22.7%), hemorrhage (21.6%), and cardiovascular or coronary disease (20.4%), accounted for about 65% of all pregnancy-related deaths. Mental health conditions were common causes of death among non-Hispanic White women during pregnancy and in late postpartum.

CONCLUSION

Continued monitoring, collecting and analyzing reliable data will help identify root causes and find ways to eliminate the disproportionate burden of pregnancy-related deaths in the State of Georgia.

Risk factors for preterm birth: an umbrella review of meta-analyses of observational studies

BACKGROUND

Preterm birth defined as delivery before 37 gestational weeks is a leading cause of neonatal and infant morbidity and mortality. The aim of this study is to summarize the evidence from meta-analyses of observational studies on risk factors associated with PTB, evaluate whether there are indications of biases in this literature, and identify which of the previously reported associations are supported by robust evidence.

METHODS

We searched PubMed and Scopus until February 2021, in order to identify meta-analyses examining associations between risk factors and PTB. For each meta-analysis, we estimated the summary effect size, the 95% confidence interval, the 95% prediction interval, the between-study heterogeneity, evidence of small-study effects, and evidence of excess-significance bias. Evidence was graded as robust, highly suggestive, suggestive, and weak.

RESULTS

Eighty-five eligible meta-analyses were identified, which included 1480 primary studies providing data on 166 associations, covering a wide range of comorbid diseases, obstetric and medical history, drugs, exposure to environmental agents, infections, and vaccines. Ninety-nine (59.3%) associations were significant at P < 0.05, while 41 (24.7%) were significant at P < 10-6. Ninety-one (54.8%) associations had large or very large heterogeneity. Evidence for small-study effects and excess significance bias was found in 37 (22.3%) and 12 (7.2%) associations, respectively. We evaluated all associations according to prespecified criteria. Seven risk factors provided robust evidence: amphetamine exposure, isolated single umbilical artery, maternal personality disorder, sleep-disordered breathing (SDB), prior induced termination of pregnancy with vacuum aspiration (I-TOP with VA), low gestational weight gain (GWG), and interpregnancy interval (IPI) following miscarriage < 6 months.

CONCLUSIONS

The results from the synthesis of observational studies suggest that seven risk factors for PTB are supported by robust evidence. Routine screening for sleep quality and mental health is currently lacking from prenatal visits and should be introduced. This assessment can promote the development and training of prediction models using robust risk factors that could improve risk stratification and guide cost-effective preventive strategies.

TRIAL REGISTRATION

PROSPERO 2021 CRD42021227296.

Prepregnancy Healthy Lifestyle and Adverse Pregnancy Outcomes

OBJECTIVE

To investigate the association of healthy lifestyle factors before pregnancy (body mass index [BMI] 18.5-24.9, nonsmoking, 150 min/wk or more of moderate-to-vigorous physical activity, healthy eating [top 40% of Dietary Approaches to Stop Hypertension score], no or low-to-moderate alcohol intake [less than 15 g/d], and use of multivitamins) with risk of adverse pregnancy outcomes.

METHODS

We conducted a secondary analysis of prospectively collected data for women without chronic diseases who are participating in an ongoing cohort in the United States (the NHSII [Nurses' Health Study II]). Healthy lifestyle factors preceding pregnancy were prospectively assessed every 2-4 years from 1991 to 2009 with validated measures. Reproductive history was self-reported in 2001 and 2009. A composite outcome of adverse pregnancy outcomes that included miscarriage, ectopic pregnancy, gestational diabetes, gestational hypertension, preeclampsia, preterm birth, stillbirth, or low birth weight was assessed.

RESULTS

Overall, 15,509 women with 27,135 pregnancies were included. The mean maternal age was 35.1±4.2 years. Approximately one in three pregnancies (n=9,702, 35.8%) was complicated by one or more adverse pregnancy outcomes. The combination of six low-risk factors was inversely associated with risk of adverse pregnancy outcomes in a dose-dependent manner ( P for trend <.001). Compared with women who had zero or one healthy lifestyle factor, those with six had a 37% lower risk of adverse pregnancy outcomes (relative risk 0.63, 95% CI 0.55-0.72), driven primarily by lower risks of gestational diabetes, gestational hypertension, and low birth weight. All prepregnancy healthy lifestyle factors, except avoiding harmful alcohol consumption and regular physical activity, were independently associated with lower risk of adverse pregnancy outcomes after mutual adjustment for each other. Healthy BMI, high-quality diet, and multivitamin supplementation showed the strongest inverse associations with adverse pregnancy outcomes. If the observed relationships were causal, 19% of adverse pregnancy outcomes could have been prevented by the adoption of all six healthy lifestyle factors (population attributable risk 19%, 95% CI 13-26%).

CONCLUSION

Prepregnancy healthy lifestyle is associated with a substantially lower risk of adverse pregnancy outcomes and could be an effective intervention for the prevention of adverse pregnancy outcomes.

Cardiovascular diseases in women - Consensus document of the Sociedade Portuguesa de Cardiologia, Sociedade Portuguesa de Ginecologia, Sociedade Portuguesa de Obstetrícia e Medicina Materno-Fetal, Sociedade Portuguesa de Contraceção e Associação Portuguesa de Medicina Geral e Familiar

The main objective of this consensus statement from the Portuguese Society of Cardiology, the Portuguese Society of Gynecology, the Portuguese Society of Obstetrics and Maternal-Fetal Medicine, Portuguese Society of Contraception, Portuguese Association of General Practice and Family Medicine is to improve cardiovascular care for women. It includes a brief review of the state-of-the-art of cardiovascular diseases in women and of the links to other fields such as Gynaecology, Obstetrics and Endocrinology. It also provides final recommendations to help clinicians working in care of women's health.

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

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Per- and polyfluoroalkyl substances, gestational weight gain, postpartum weight retention and body composition in the UPSIDE cohort

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals found in drinking water and consumer products, resulting in ubiquitous human exposure. PFAS have been linked to endocrine disruption and altered weight gain across the lifespan. A limited and inconsistent body of research suggests PFAS may impact gestational weight gain (GWG) and postpartum body mass index (BMI), which are important predictors of overall infant and maternal health, respectively.

METHODS

In the Understanding Pregnancy Signals and Infant Development (UPSIDE/UPSIDE-MOMs) study (n = 243; Rochester, NY), we examined second trimester serum PFAS (PFOS: perfluorooctanesulfonic acid, PFOA: perfluorooctanoic acid, PFNA: perfluorononanoic acid, PFHxS: perfluorohexanesulfonic acid, PFDA: perfluorodecanoic acid) in relation to GWG (kg, and weekly rate of gain) and in the postpartum, weight retention (PPWR (kg) and total body fat percentage (measured by bioelectrical impedance)). We fit multivariable linear regression models examining these outcomes in relation to log-transformed PFAS in the whole cohort as well as stratified by maternal pre-pregnancy BMI (< 25 vs. =  > 25 kg/m2), adjusting for demographics and lifestyle factors. We used weighted quantile sum regression to find the combined influence of the 5 PFAS on GWG, PPWR, and body fat percentage.

RESULTS

PFOA and PFHxS were inversely associated with total GWG (PFOA: ß = -1.54 kg, 95%CI: -2.79, -0.30; rate ß = -0.05 kg/week, 95%CI: -0.09, -0.01; PFHxS: ß = -1.59 kg, 95%CI: -3.39, 0.21; rate ß = -0.05 kg/week, 95%CI: -0.11, 0.01) and PPWR at 6 and 12 months (PFOA 6 months: ß = -2.39 kg, 95%CI: -4.17, -0.61; 12 months: ß = -4.02 kg, 95%CI: -6.58, -1.46; PFHxS 6 months: ß = -2.94 kg, 95%CI: -5.52, -0.35; 12 months: ß = -5.13 kg, 95%CI: -8.34, -1.93). PFOA was additionally associated with lower body fat percentage at 6 and 12 months (ß = -1.75, 95%CI: -3.17, -0.32; ß = -1.64, 95%CI: -3.43, 0.16, respectively) with stronger associations observed in participants with higher pre-pregnancy BMI. The PFAS mixture was inversely associated with weight retention at 12 months (ß = -2.030, 95%CI: -3.486, -0.573) amongst all participants.

CONCLUSION

PFAS, in particular PFOA and PFHxS, in pregnancy are associated with altered patterns of GWG and postpartum adiposity with potential implications for fetal development and long-term maternal cardiometabolic health.

Endometriosis increases the risk of gestational diabetes: a meta-analysis stratified by mode of conception, disease localization and severity

To review the current evidence on the risk of gestational diabetes mellitus (GDM) in women with endometriosis, taking into account relevant confounders such as the higher frequency of Assisted Reproductive Technologies (ART) conceptions. Database searches on PubMed, Medline, Embase and Scopus through June 2022, using combinations of relevant keywords. A total of 18 studies, involving N = 4,600,885 women, were included. The overall risk of GDM in endometriosis patients was significantly higher than in controls (OR, 1.23; 95% CI 1.07-1.51). This significant association persisted in natural pregnancies (OR, 1.08; 95% CI 1.04-1.12) but not in pregnancies conceived through ART (OR, 0.93;95% CI 0.70-1.24). Based on the limited number of studies that examined this association in relation to endometriosis phenotype, an increased risk was found in more severe stages (OR, 3.20; 95% CI 1.20-8.54) but independently from localization of the lesions. Endometriosis increases the risk of GDM, with a possible progressive effect in more advanced stages of the disease. Although the effect magnitude may be limited in some subgroups, this finding has a clinically relevant impact due to both the strong biological plausibility and to the relatively high incidence of both endometriosis and GDM.

Prepregnancy Migraine, Migraine Phenotype, and Risk of Adverse Pregnancy Outcomes

BACKGROUND AND OBJECTIVE

Migraine is a highly prevalent neurovascular disorder among reproductive-aged women. Whether migraine history and migraine phenotype might serve as clinically useful markers of obstetric risk is not clear. The primary objective of this study was to examine associations of prepregnancy migraine and migraine phenotype with risks of adverse pregnancy outcomes.

METHODS

We estimated associations of self-reported physician-diagnosed migraine and migraine phenotype with adverse pregnancy outcomes in the prospective Nurses' Health Study II (1989-2009). Log-binomial and log-Poisson models with generalized estimating equations were used to estimate relative risks (RRs) and 95% CIs for gestational diabetes mellitus (GDM), preeclampsia, gestational hypertension, preterm delivery, and low birthweight.

RESULTS

The analysis included 30,555 incident pregnancies after cohort enrollment among 19,694 participants without a history of cardiovascular disease, diabetes, or cancer. After adjusting for age, adiposity, and other health and behavioral factors, prepregnancy migraine (11%) was associated with higher risks of preterm delivery (RR = 1.17; 95% CI = 1.05-1.30), gestational hypertension (RR = 1.28; 95% CI = 1.11-1.48), and preeclampsia (RR = 1.40; 95% CI = 1.19-1.65) compared with no migraine. Migraine was not associated with low birthweight (RR = 0.99; 95% CI = 0.85-1.16) or GDM (RR = 1.05; 95% CI = 0.91-1.22). Risk of preeclampsia was somewhat higher among participants with migraine with aura (RR vs no migraine = 1.51; 95% CI = 1.22-1.88) than migraine without aura (RR vs no migraine = 1.30; 95% CI = 1.04-1.61; p-heterogeneity = 0.32), whereas other outcomes were similar by migraine phenotype. Participants with migraine who reported regular prepregnancy aspirin use had lower risks of preterm delivery (<2×/week RR = 1.24; 95% CI = 1.11-1.38; ≥2×/week RR = 0.55; 95% CI = 0.35-0.86; p-interaction < 0.01) and preeclampsia (<2×/week RR = 1.48; 95% CI = 1.25-1.75; ≥2×/week RR = 1.10; 95% CI = 0.62-1.96; p-interaction = 0.39); however, power for these stratified analyses was limited.

DISCUSSION

Migraine history, and to a lesser extent migraine phenotype, appear to be important considerations in obstetric risk assessment and management. Future research should determine whether aspirin prophylaxis may be beneficial for preventing adverse pregnancy outcomes among pregnant individuals with a history of migraine.

Risk factors for preterm labor: An Umbrella Review of meta-analyses of observational studies

Preterm birth defined as delivery before 37 gestational weeks, is a leading cause of neonatal and infant morbidity and mortality. Understanding its multifactorial nature may improve prediction, prevention and the clinical management. We performed an umbrella review to summarize the evidence from meta-analyses of observational studies on risks factors associated with PTB, evaluate whether there are indications of biases in this literature and identify which of the previously reported associations are supported by robust evidence. We included 1511 primary studies providing data on 170 associations, covering a wide range of comorbid diseases, obstetric and medical history, drugs, exposure to environmental agents, infections and vaccines. Only seven risk factors provided robust evidence. The results from synthesis of observational studies suggests that sleep quality and mental health, risk factors with robust evidence should be routinely screened in clinical practice, should be tested in large randomized trial. Identification of risk factors with robust evidence will promote the development and training of prediction models that could improve public health, in a way that offers new perspectives in health professionals.

Adverse pregnancy outcomes and future risk of heart failure

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death in women. Women with history of adverse pregnancy outcomes (APOs) have approximately two-fold risk of future CVD, but until recently the association with future heart failure (HF) was unclear. Here, we summarize evidence for associations of APOs with HF, potential underlying mechanisms, and future directions for clinical translation.

RECENT FINDINGS

Women with history of hypertensive disorders of pregnancy (HDPs) have roughly two-fold risk of future HF compared with other parous women even after accounting for interval development of coronary artery disease. The HDPs portend heightened risk of HF with both reduced and preserved ejection fraction. Gestational diabetes mellitus (GDM) and other APOs such as preterm delivery, small-for-gestational-age delivery, and placental abruption may also confer additional risk for HF development. Possible underlying mechanisms linking APOs to HF include shared upstream risk factors and genetics, accelerated development of cardiometabolic risk factors postpartum, persistent endothelial and microvascular dysfunction, and impaired natriuretic peptide signaling.

SUMMARY

History of APOs, including HDPs and GDM, confer increased risk for development of HF years after delivery. Further research is needed to define strategies to optimize prepregnancy and postpartum cardiovascular health toward HF prevention.

Pregnancy-Related Complications and Incidence of Atrial Fibrillation: A Systematic Review

Pregnancy-related complications are associated with a higher risk of various incident cardiovascular diseases, but their specific potential relationship with incident atrial fibrillation (AF) is less clear. This systematic review summarises the available evidence from observational studies which have examined associations between pregnancy-related complications and the risk of AF. MEDLINE and EMBASE (Ovid) were searched for studies between 1990 to 10 February 2022. Pregnancy-related complications examined included hypertensive disorders of pregnancy (HDP), gestational diabetes, placental abruption, preterm birth, small-for-gestational-age and stillbirth. Study selection, data extraction and quality assessment were completed independently by two reviewers. Narrative synthesis was used to evaluate the results of the included studies. Nine observational studies were included, with eight eligible for narrative synthesis. Sample sizes ranged from 1839 to 2,359,386. Median follow-up ranged from 2 to 36 years. Six studies reported that pregnancy-related complications were associated with a significantly increased risk of incident AF. Hazard ratios (HRs) (95% confidence intervals) for the four studies that evaluated HDP ranged from 1.1 (0.8-1.6) to 1.9 (1.4-2.7). For the four studies that evaluated pre-eclampsia, HRs ranged from 1.2 (0.9-1.6) to 1.9 (1.7-2.2). Current evidence from observational studies suggests pregnancy-related complications are associated with a significantly higher risk of incident AF. However, only a small number of studies examining each pregnancy-related complication were identified, and considerable statistical heterogeneity was observed. Further large-scale prospective studies are required to confirm the association between pregnancy-related complications and incident AF.

Preterm birth and maternal heart disease: A machine learning analysis using the Korean national health insurance database

BACKGROUND

Maternal heart disease is suspected to affect preterm birth (PTB); however, validated studies on the association between maternal heart disease and PTB are still limited. This study aimed to build a prediction model for PTB using machine learning analysis and nationwide population data, and to investigate the association between various maternal heart diseases and PTB.

METHODS

A population-based, retrospective cohort study was conducted using data obtained from the Korea National Health Insurance claims database, that included 174,926 primiparous women aged 25-40 years who delivered in 2017. The random forest variable importance was used to identify the major determinants of PTB and test its associations with maternal heart diseases, i.e., arrhythmia, ischemic heart disease (IHD), cardiomyopathy, congestive heart failure, and congenital heart disease first diagnosed before or during pregnancy.

RESULTS

Among the study population, 12,701 women had PTB, and 12,234 women had at least one heart disease. The areas under the receiver-operating-characteristic curves of the random forest with oversampling data were within 88.53 to 95.31. The accuracy range was 89.59 to 95.22. The most critical variables for PTB were socioeconomic status and age. The random forest variable importance indicated the strong associations of PTB with arrhythmia and IHD among the maternal heart diseases. Within the arrhythmia group, atrial fibrillation/flutter was the most significant risk factor for PTB based on the Shapley additive explanation value.

CONCLUSIONS

Careful evaluation and management of maternal heart disease during pregnancy would help reduce PTB. Machine learning is an effective prediction model for PTB and the major predictors of PTB included maternal heart disease such as arrhythmia and IHD.

Long-term cardiovascular mortality in women with twin pregnancies by lifetime reproductive history

BACKGROUND

Women with one lifetime singleton pregnancy have increased risk of cardiovascular disease (CVD) mortality compared with women who continue reproduction particularly if the pregnancy had complications. Women with twins have higher risk of pregnancy complications, but CVD mortality risk in women with twin pregnancies has not been fully described.

OBJECTIVES

We estimated risk of long-term CVD mortality in women with naturally conceived twins compared to women with singleton pregnancies, accounting for lifetime number of pregnancies and pregnancy complications.

METHODS

Using linked data from the Medical Birth Registry of Norway and the Norwegian Cause of Death Registry, we identified 974,892 women with first pregnancy registered between 1967 and 2013, followed to 2020. Adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for maternal CVD mortality were estimated by Cox regression for various reproductive history (exposure categories): (1) Only one twin pregnancy, (2) Only one singleton pregnancy, (3) Only two singleton pregnancies, (4) A first twin pregnancy and continued reproduction, (5) A first singleton pregnancy and twins in later reproduction and (6) Three singleton pregnancies (the referent group). Exposure categories were also stratified by pregnancy complications (pre-eclampsia, preterm delivery or perinatal loss).

RESULTS

Women with one lifetime pregnancy, twin or singleton, had increased risk of CVD mortality (adjusted hazard [HR] 1.72, 95% confidence interval [CI] 1.21, 2.43 and aHR 1.92, 95% CI 1.78, 2.07, respectively), compared with the referent of three singleton pregnancies. The hazard ratios for CVD mortality among women with one lifetime pregnancy with any complication were 2.36 (95% CI 1.49, 3.71) and 3.56 (95% CI 3.12, 4.06) for twins and singletons, respectively.

CONCLUSIONS

Women with only one pregnancy, twin or singleton, had increased long-term CVD mortality, however highest in women with singletons. In addition, twin mothers who continued reproduction had similar CVD mortality compared to women with three singleton pregnancies.

Association of adverse pregnancy outcomes and multiple gestation with natural menopause: A population-based cohort study

OBJECTIVE

Adverse pregnancy outcomes (APOs) and early menopause are each associated with increased risk of cardiovascular disease (CVD); whether APOs are associated with age at menopause is unclear. We examined the association of gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), preterm birth, and multiple gestation with age at natural menopause.

STUDY DESIGN

Observational, prospective study within the Nurses' Health Study II cohort (1989-2019).

MAIN OUTCOMES MEASURES

Risk of early natural menopause, defined as occurring before the age of 45 years, and age at onset of natural menopause (hazard ratio (HR) >1 indicates younger age at menopause).

RESULTS

The mean [SD] baseline age of 69,880 parous participants was 34.5 [4.7] years. Compared with participants who had a term singleton first birth, those with a term multiple-gestation first birth had higher risk of early menopause (HR: 1.65, 95% CI: 1.05, 2.60) and younger age at natural menopause (HR: 1.46, 95% CI: 1.31, 1.63). Estimates for preterm multiple gestation were of similar magnitude. Menopause occurred at a younger age for those with a preterm birth with spontaneous labor (HR: 1.08, 95% CI: 1.03, 1.14) compared to those with a term birth with spontaneous labor. Conversely, estimates for GDM (HR: 0.95, 95% CI: 0.89, 1.02) and HDP (preeclampsia, HR: 0.93, 95% CI: 0.89, 0.97) suggested an association with older age at menopause.

CONCLUSIONS

In this large cohort study, several statistically significant associations between APOs and age at natural menopause were observed. A deeper understanding of the relationships among APOs, menopause, and CVD is needed to help identify people at higher risk for early menopause and later CVD.

Long-Term Outcome Following Coronary Artery Stenting by History of Preterm Delivery

Background

Women are at a greater risk of a major adverse cardiovascular event (MACE) after percutaneous coronary intervention than men. A history of preterm delivery is a female-specific risk factor for coronary artery disease, but its relevance in the treatment of coronary artery disease is unknown.

Objectives

The purpose of this study was to analyze the association between a history of preterm delivery and MACE after the first coronary artery stenting.

Methods

We included a nationwide sample of 5,766 Swedish women aged ≤65 years receiving their first coronary stent during 2006 to 2017. To adjust for periprocedural characteristics and estimate the association between a history of preterm delivery and MACE at >30 days from stenting, we used proportional hazards regression. We also investigated mortality by history of preterm delivery.

Results

During a median follow-up time of 3.7 years (IQR: 1.3-6.7 years), 1,200 (20.8%) women had a MACE. In total, 963 (16.7%) women had a history of preterm delivery. A history of preterm delivery was associated with a higher risk of MACE (adjusted HR: 1.19; 95% CI: 1.03-1.38) and mortality (adjusted HR ratio: 1.38; 95% CI: 1.02-1.85). Similar associations were observed when excluding women with a history of hypertensive disorders of pregnancy or diabetes. Subgroup analyses suggested that women with a history of early preterm delivery had lower risk of MACE than those who had late preterm delivery (P = 0.04).

Conclusions

History of preterm delivery is associated with worse prognosis following the first coronary artery stenting in women and warrants consideration as a risk factor also in the secondary prevention setting.

Chronic Exposure to Fine Particulate Matter Increases Mortality Through Pathways of Metabolic and Cardiovascular Disease: Insights From a Large Mediation Analysis

Background

Long‐term exposure to outdoor fine particulate matter (PM 2.5 ) is the leading environmental risk factor for premature mortality worldwide. Characterizing important pathways through which PM 2.5 increases individuals' mortality risk can clarify the PM 2.5 –mortality relationship and identify possible points of interventions. Recent evidence has linked PM 2.5 to the onset of diabetes and cardiovascular disease, but to what extent these associations contribute to the effect of PM 2.5 on mortality remains poorly understood.

Methods and Results

We conducted a population‐based cohort study to investigate how the effect of PM 2.5 on nonaccidental mortality is mediated by its impacts on incident diabetes, acute myocardial infarction, and stroke. Our study population comprised ≈200 000 individuals aged 20 to 90 years who participated in population‐based health surveys in Ontario, Canada, from 1996 to 2014. Follow‐up extended until December 2017. Using causal mediation analyses with Aalen additive hazards models, we decomposed the total effect of PM 2.5 on mortality into a direct effect and several path‐specific indirect effects mediated by diabetes, each cardiovascular event, or both combined. A series of sensitivity analyses were also conducted. After adjusting for various individual‐ and neighborhood‐level covariates, we estimated that for every 1000 adults, each 10 μg/m 3 increase in PM 2.5 was associated with ≈2 incident cases of diabetes, ≈1 major cardiovascular event (acute myocardial infarction and stroke combined), and ≈2 deaths annually. Among PM 2.5 ‐related deaths, 31.7% (95% CI, 17.2%–53.2%) were attributable to diabetes and major cardiovascular events in relation to PM 2.5 . Specifically, 4.5% were explained by PM 2.5 ‐induced diabetes, 22.8% by PM 2.5 ‐induced major cardiovascular events, and 4.5% through their interaction.

Conclusions

This study suggests that a significant portion of the estimated effect of long‐term exposure to PM 2.5 on deaths can be attributed to its effect on diabetes and cardiovascular diseases, highlighting the significance of PM 2.5 on deteriorating cardiovascular health. Our findings should raise awareness among professionals that improving metabolic and cardiovascular health may reduce mortality burden in areas with higher exposure to air pollution.

Changes in Vascular Function from Preconception to Postpartum Among Mongolian Women

Background: Pregnancy is associated with physiological changes to meet the metabolic demands of the growing fetus. To understand adverse pregnancy outcomes it is important to establish vascular changes throughout pregnancy. We examined longitudinal changes in vascular measurements from prepregnancy through postpartum. Materials and Methods: Seventy women planning to conceive in Ulaanbaatar, Mongolia enrolled in this prospective study. Within 6 months, 44 (63%) had conceived; of which 36 (82%) delivered. Ten (28%) developed complex pregnancies and were analyzed separately. Vascular measures included central systolic blood pressure (cSBP), central diastolic blood pressure (cDBP), augmentation index corrected for heart rate of 75 beats/minute (AIx-75), and pulse wave velocity (PWV). Measurements were performed at prepregnancy, second trimester (22-24 weeks), third trimester (34-36 weeks), and 2 months postpartum. Missing values (n = 0-6 per time period) were replaced by multiple imputation. A repeated measures analysis of variance analyzed changes within individual women over the four time points adjusted for age, parity, and body mass index. Results: We observed significant reductions from prepregnancy to second trimester for mean Alx-75 (17.1%-12.6%; p = 0.006) and cSBP (91.7-86.8 mmHg; p = 0.03) but not for cDBP or PWV. Both mean AIx-75 and cSBP increased in third trimester. In the postpartum, cSBP returned to prepregnancy levels, whereas AIx-75 exceeded prepregnancy levels, although this fell short of significance (p = 0.09). Similar vascular patterns were observed in women with complex pregnancies for AIx-75; however, PWV increased from the second trimester and remained higher through postpartum, although not significant. Conclusion: In Mongolian women, we observed a decrease in AIx-75 and cSBP from prepregnancy through second trimester, which resolved postpartum. These results provide an understanding of changes across pregnancies in an Asian country. Future studies should assess vascular changes across pregnancies to determine if it can predict conditions such as pre-eclampsia.

Assessment of Cardiovascular Disease Risk: A 2022 Update

Assessment of atherosclerotic cardiovascular disease (ASCVD) risk is the cornerstone of primary ASCVD prevention, enabling targeted use of the most aggressive therapies in those most likely to benefit, while guiding a conservative approach in those who are low risk. ASCVD risk assessment begins with the use of a traditional 10-year risk calculator, with further refinement through the consideration of risk-enhancing factors (particularly lipoprotein(a)) and subclinical atherosclerosis testing (particularly coronary artery calcium (CAC) testing). In this review, we summarize the current field of ASCVD risk assessment in primary prevention and highlight new guidelines from the Endocrine Society.

Sex Differences in Acute Coronary Syndromes: A Global Perspective

Despite increasing evidence and improvements in the care of acute coronary syndromes (ACS), sex disparities in presentation, comorbidities, access to care and invasive therapies remain, even in the most developed countries. Much of the currently available data are derived from more developed regions of the world, particularly Europe and the Americas. In contrast, in more resource-constrained settings, especially in Sub-Saharan Africa and some parts of Asia, more data are needed to identify the prevalence of sex disparities in ACS, as well as factors responsible for these disparities, particularly cultural, socioeconomic, educational and psychosocial. This review summarizes the available evidence of sex differences in ACS, including risk factors, pathophysiology and biases in care from a global perspective, with a focus on each of the six different World Health Organization (WHO) regions of the world. Regional trends and disparities, gaps in evidence and solutions to mitigate these disparities are also discussed.

Risk factors for incident cardiovascular events among adults in low- and middle-income countries: A systematic review and meta-analysis of prospective cohort studies

The relative contributions of risk factors for cardiovascular events at a population level has received little attention in low- and middle-income countries (LMICs). We estimated the population attributable fraction (PAF) of risk factors associated with incident cardiovascular events in LMICs. We searched six databases for relevant articles, supplemented with a manual search of reference lists. Articles included in the meta-analyses were those based on prospective community-based cohorts and incorporating adjusted hazard ratios (HR) or relative risks with 95% confidence intervals (95% CI) for associations between risk factors and a composite cardiovascular and/or stroke endpoint. Pooled HRs and 95% CI were calculated using the random effects model. We assessed heterogeneity using the I² test and study quality using the Newcastle-Ottawa Scale. We calculated the PAF of each associated risk factor. The protocol was registered in PROSPERO (CRD42019122741). We identified 18 cohorts from LMICs with 1,125,846 participants, 77,045 composite cardiovascular events and 42,216 strokes. Substantial proportions of incident cardiovascular events were attributable to hypertension (HR [95% CI], 2.23 [2.01-2.48], PAF = 28%); current smoking (1.44 [1.31-1.58], PAF = 10%); and diabetes mellitus (1.93 [1.67-2.23], PAF = 8%). Other risk factors identified included number of children, depression, bone mineral density, and air pollution. A substantial proportion of incident cardiovascular events were linked to traditional metabolic and behavioural modifiable risk factors. However, other novel risk factors also appear to contribute. Targeting of these established and novel risk factors has the potential to reduce the burden of CVD in LMICs.

Women with Adverse Pregnancy Outcomes Have Higher Odds of Midlife Stroke: The Population Assessment of Tobacco and Health Study

Background: A history of adverse pregnancy outcomes (APOs) is associated with increased risk of future cardiovascular disease, including stroke. Few large U.S. population-based surveys included data on APOs. Methods: The Population Assessment of Tobacco and Health study is a nationally representative survey of 45,971 U.S. respondents. Female respondents ≥50 years old who reported pregnancy history at the 2013-2014 baseline interview were included in this cross-sectional analysis (n = 3,175; weighted n = 35,783,619). The primary exposure was a history of ≥1 APO, including preterm delivery, low birth weight, preeclampsia, placental abruption, and stillbirth. The primary outcomes were (1) stroke before age 60 and (2) any stroke. We used weighted logistic regression models to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for the association between APO and stroke, adjusting for age, race/ethnicity, socioeconomic status, parity, and vascular risk factors. Results: Among stroke-free respondents, 15% reported ≥1 APO. Among women who reported a stroke before age 60, 39% reported ≥1 APO (p < 0.001); among women reporting stroke at any age, 25% reported ≥1 APO (p = 0.01). Controlling for covariates, women with APOs had increased odds of stroke before age 60 (adjusted OR 2.66, 95% CI 1.49, 4.75). The association of APOs with stroke at any age was not significant after controlling for covariates (adjusted OR 1.57, 95% CI 0.93, 2.64). Conclusion: In this analysis of U.S. nationally representative survey data, APOs were independently associated with midlife stroke. Women with APOs have higher odds of midlife stroke and warrant targeted prevention strategies.

First Trimester Prediction of Preterm Delivery in the Absence of Other Pregnancy-Related Complications Using Cardiovascular-Disease Associated MicroRNA Biomarkers

The aim of the study was to determine if aberrant expression profile of cardiovascular disease associated microRNAs would be able to predict within 10 to 13 weeks of gestation preterm delivery such as spontaneous preterm birth (PTB) or preterm prelabor rupture of membranes (PPROM) in the absence of other pregnancy-related complications (gestational hypertension, preeclampsia, fetal growth restriction, or small for gestational age). In addition, we assessed if aberrant expression profile of cardiovascular disease associated microRNAs would be able to predict preterm delivery before and after 34 weeks of gestation. The retrospective study was performed within the period November 2012 to March 2020. Whole peripheral blood samples were collected from 6440 Caucasian individuals involving 41 PTB and 65 PPROM singleton pregnancies. A control group, 80 singleton term pregnancies, was selected on the base of equal sample storage time. Gene expression of 29 selected cardiovascular disease associated microRNAs was studied using real-time RT-PCR. Downregulation of miR-16-5p, miR-20b-5p, miR-21-5p, miR-24-3p, miR-26a-5p, miR-92a-3p, miR-126-3p, miR-133a-3p, miR-145-5p, miR-146a-5p, miR-155-5p, miR-210-3p, miR-221-3p and miR-342-3p was observed in pregnancies with preterm delivery before 37 (≤36 + 6/7) weeks of gestation. Majority of downregulated microRNAs (miR-16-5p, miR-24-3p, miR-26a-5p, miR-92a-3p, miR-133a-3p, miR-145-5p, miR-146a-5p, miR-155-5p, miR-210-3p, and miR-342-3p) was associated with preterm delivery occurring before 37 (≤36 + 6/7) weeks of gestation. The only miR-210-3p was downregulated in pregnancies with preterm delivery before 34 (≤33 + 6/7) weeks of gestation. The type of preterm delivery also had impact on microRNA gene expression profile. Downregulation of miR-24-3p, miR-92a-3p, miR-155-5p, and miR-210-3p was a common feature of PTB and PPROM pregnancies. Downregulation of miR-16-5p, miR-20b-5p, miR-26a-5p, miR-126-3p, miR-133a-3p, miR-146a-5p, miR-221-3p, and miR-342-3p appeared just in PTB pregnancies. No microRNA was uniquely dysregulated in PPROM pregnancies. The combination of 12 microRNAs (miR-16-5p, miR-20b-5p, miR-21-5p, miR-24-3p, miR-26a-5p, miR-92a-3p, miR-133a-3p, miR-145-5p, miR-146a-5p, miR-155-5p, miR-210-3p, and miR-342-3p, AUC 0.818, p < 0.001, 74.53% sensitivity, 75.00% specificity, cut off > 0.634) equally as the combination of 6 microRNAs (miR-16-5p, miR-21-5p, miR-24-3p, miR-133a-3p, miR-155-5p, and miR-210-3p, AUC 0.812, p < 0.001, 70.75% sensitivity, 78.75% specificity, cut off > 0.652) can predict preterm delivery before 37 weeks of gestation in early stages of gestation in 52.83% pregnancies at 10.0% FPR. Cardiovascular disease associated microRNAs represent promising biomarkers with very good diagnostical potential to be implemented into the current routine first trimester screening programme to predict preterm delivery.

Prior pregnancy complications and maternal cardiovascular disease in young Korean women within 10 years after pregnancy

BACKGROUND

This study aimed to compare obstetric outcomes in Korean women with and without future cardiovascular disease (CVD) within 10 years after pregnancy, and assessed whether pregnancy complications are independent risk factors, and whether the combination of pregnancy complications has an additive function for risk factors for CVD.

METHODS

This was a nationwide population-based study combining the database of the Korea National Health Insurance claims and National Health Screening Programs to assess preeclampsia, low birth weight (LBW), and preterm delivery as risk factors for CVD. Cox proportional hazards models was used to evaluate the risk of total CVD, ischemic heart disease (IHD), and stroke after the pregnancy complications, with adjustment for potential confounding variables.

RESULTS

Women with CVD were likely to have a higher prevalence of pregnancy complications than women without CVD. The risk of total CVD was associated with preeclampsia (adjusted hazard ratio (HR), 1.60 [95% confidence interval (CI) 1.50-1.72]), LBW (1.20 [1.12-1.28]), and preterm delivery (1.32 [1.22-1.42]), after adjustment for confounders, including cardiovascular risk factors before pregnancy. The risk estimates of pregnancy complications for IHD were higher than those for stroke. In this study, the risk of total CVD was higher in the combined presence of preeclampsia and preterm delivery (2.23 [1.57-3.17] or all three complications (2.06 [1.76-2.40]), relative to no complications. The highest HR was noted in the risk of all pregnancy complications for IHD (2.39 [1.98-2.89]).

CONCLUSION

Preeclampsia, preterm delivery, and LBW were independently associated with CVD in young Korean women. In addition, the combination of pregnancy complications had less-than-additive effects on CVD incidence.

Preterm birth buccal cell epigenetic biomarkers to facilitate preventative medicine

Preterm birth is the major cause of newborn and infant mortality affecting nearly one in every ten live births. The current study was designed to develop an epigenetic biomarker for susceptibility of preterm birth using buccal cells from the mother, father, and child (triads). An epigenome-wide association study (EWAS) was used to identify differential DNA methylation regions (DMRs) using a comparison of control term birth versus preterm birth triads. Epigenetic DMR associations with preterm birth were identified for both the mother and father that were distinct and suggest potential epigenetic contributions from both parents. The mother (165 DMRs) and female child (136 DMRs) at p < 1e-04 had the highest number of DMRs and were highly similar suggesting potential epigenetic inheritance of the epimutations. The male child had negligible DMR associations. The DMR associated genes for each group involve previously identified preterm birth associated genes. Observations identify a potential paternal germline contribution for preterm birth and identify the potential epigenetic inheritance of preterm birth susceptibility for the female child later in life. Although expanded clinical trials and preconception trials are required to optimize the potential epigenetic biomarkers, such epigenetic biomarkers may allow preventative medicine strategies to reduce the incidence of preterm birth.

Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women

Beyond conventional risk factors for cardiovascular disease, women face an additional burden of sex-specific risk factors. Key stages of a woman's reproductive history may influence or reveal short- and long-term cardiometabolic and cardiovascular trajectories. Early and late menarche, polycystic ovary syndrome, infertility, adverse pregnancy outcomes (eg, hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction), and absence of breastfeeding are all associated with increased future cardiovascular disease risk. The menopause transition additionally represents a period of accelerated cardiovascular disease risk, with timing (eg, premature menopause), mechanism, and symptoms of menopause, as well as treatment of menopause symptoms, each contributing to this risk. Differences in conventional cardiovascular disease risk factors appear to explain some, but not all, of the observed associations between reproductive history and later-life cardiovascular disease; further research is needed to elucidate hormonal effects and unique sex-specific disease mechanisms. A history of reproductive risk factors represents an opportunity for comprehensive risk factor screening, refinement of cardiovascular disease risk assessment, and implementation of primordial and primary prevention to optimize long-term cardiometabolic health in women.

Ten-Year Cardiovascular Disease Risk Trajectories by Obstetric History: A Longitudinal Study in the Norwegian HUNT Study

Background

Women with a history of obstetric complications are at increased risk of cardiovascular disease, but whether they should be specifically targeted for cardiovascular disease (CVD) risk screening is unknown.

Methods and Results

We used linked data from the Norwegian HUNT (Trøndelag Health) Study and the Medical Birth Registry of Norway to create a population‐based, prospective cohort of parous women. Using an established CVD risk prediction model (A Norwegian risk model for cardiovascular disease), we predicted 10‐year risk of CVD (nonfatal myocardial infarction, fatal coronary heart disease, and nonfatal or fatal stroke) based on established risk factors (age, systolic blood pressure, total and high‐density lipoprotein cholesterol, smoking, antihypertensive use, and family history of myocardial infarction). Predicted 10‐year CVD risk scores in women aged between 40 and 60 years were consistently higher in those with a history of obstetric complications. For example, when aged 40 years, women with a history of preeclampsia had a 0.06 percentage point higher mean risk score than women with all normotensive deliveries, and when aged 60 years this difference was 0.86. However, the differences in the proportion of women crossing established clinical thresholds for counseling and treatment in women with and without a complication were modest.

Conclusions

Findings do not support targeting parous women with a history of pregnancy complications for CVD screening. However, pregnancy complications identify women who would benefit from primordial and primary prevention efforts such as encouraging and supporting behavioral changes to reduce CVD risk in later life.

Maternal Cardiovascular and Cerebrovascular Health After Placental Abruption: A Systematic Review and Meta-Analysis (CHAP-SR)

Placental abruption and cardiovascular disease (CVD) have common etiological underpinnings, and there is accumulating evidence that abruption may be associated with future CVD. We estimated associations between abruption and coronary heart disease (CHD) and stroke. The meta-analysis was based on the random-effects risk ratio (RR) and 95% confidence interval (CI) as the effect measure. We conducted a bias analysis to account for abruption misclassification, selection bias, and unmeasured confounding. We included 11 cohort studies comprising 6,325,152 pregnancies, 69,759 abruptions, and 49,265 CHD and stroke cases (1967-2016). Risks of combined CVD morbidity-mortality among abruption and nonabruption groups were 16.7 and 9.3 per 1,000 births, respectively (RR = 1.76, 95% CI: 1.24, 2.50; I2 = 94%; τ2 = 0.22). Women who suffered abruption were at 2.65-fold (95% CI: 1.55, 4.54; I2 = 85%; τ2 = 0.36) higher risk of death related to CHD/stroke than nonfatal CHD/stroke complications (RR = 1.32, 95% CI: 0.91, 1.92; I2 = 93%; τ2 = 0.15). Abruption was associated with higher mortality from CHD (RR = 2.64, 95% CI: 1.57, 4.44; I2 = 76%; τ2 = 0.31) than stroke (RR = 1.70, 95% CI: 1.19, 2.42; I2 = 40%; τ2 = 0.05). Corrections for the aforementioned biases increased these estimates. Women with pregnancies complicated by placental abruption may benefit from postpartum screening or therapeutic interventions to help mitigate CVD risks.

The role of cardiovascular risk factors in maternal cardiovascular disease according to offspring birth characteristics in the HUNT study

A history of preterm or small (SGA) or large (LGA) for gestational age offspring is associated with smoking and unfavorable levels of BMI, blood pressure, glucose and lipids. Whether and to what extent the excess cardiovascular risk observed in women with these pregnancy complications is explained by conventional cardiovascular risk factors (CVRFs) is not known. We examined the association between a history of SGA, LGA or preterm birth and cardiovascular disease among 23,284 parous women and quantified the contribution of individual CVRFs to the excess cardiovascular risk using an inverse odds weighting approach. The hazard ratios (HR) between SGA and LGA offspring and CVD were 1.30 (95% confidence interval (CI) 1.15, 1.48) and 0.89 (95% CI 0.76, 1.03), respectively. Smoking explained 49% and blood pressure may have explained ≈12% of the excess cardiovascular risk in women with SGA offspring. Women with preterm birth had a 24% increased risk of CVD (HR 1.24, 95% CI 1.06, 1.45), but we found no evidence for CVRFs explaining any of this excess cardiovascular risk. While smoking explains a substantial proportion of excess cardiovascular risk in women with SGA offspring and blood pressure may explain a small proportion in these women, we found no evidence that conventional CVRFs explain any of the excess cardiovascular risk in women with preterm birth.

A Machine Learning-Based Prediction Model for Cardiovascular Risk in Women With Preeclampsia

Objective: Preeclampsia affects 2–8% of women and doubles the risk of cardiovascular disease in women after preeclampsia. This study aimed to develop a model based on machine learning to predict postpartum cardiovascular risk in preeclamptic women.

Methods: Collecting demographic characteristics and clinical serum markers associated with preeclampsia during pregnancy of 907 preeclamptic women retrospectively, we predicted the cardiovascular risk (ischemic heart disease, ischemic cerebrovascular disease, peripheral vascular disease, chronic kidney disease, metabolic system disease or arterial hypertension). The study samples were divided into training sets and test sets randomly in the ratio of 8:2. The prediction model was developed by 5 different machine learning algorithms, including Random Forest. 10-fold cross-validation was performed on the training set, and the performance of the model was evaluated on the test set.

Results: Cardiovascular disease risk occurred in 186 (20.5%) of these women. By weighing area under the curve (AUC), the Random Forest algorithm presented the best performance (AUC = 0.711[95%CI: 0.697–0.726]) and was adopted in the feature selection and the establishment of the prediction model. The most important variables in Random Forest algorithm included the systolic blood pressure, Urea nitrogen, neutrophil count, glucose, and D-Dimer. Random Forest algorithm was well calibrated (Brier score = 0.133) in the test group, and obtained the highest net benefit in the decision curve analysis.

Conclusion: Based on the general situation of patients and clinical variables, a new machine learning algorithm was developed and verified for the individualized prediction of cardiovascular risk in post-preeclamptic women.

Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy Outcomes: A Review

Importance

A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs.

Observations

A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians.

Conclusions and Relevance

These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.

Low-Intensity Exercise and Pregnancy Outcomes: An Examination in the Nurses' Health Study II

Background: The benefit of low-intensity exercise (LIE) during pregnancy is poorly understood at a time when few women participate in moderate or vigorous exercise. Using data from the Nurses' Health Study II (NHSII), we tested the hypothesis that women who engaged in more LIE before and during pregnancy experience fewer pregnancy complications.

Methods: Among 116,429 U.S. female registered nurses (25–42 years of age) who were enrolled in NHSII in 1989, we included participants (36–50 years of age) who reported in 2001 or 2005 that they were pregnant and completed questionnaires about pregnancy “low-intensity exercise (yoga, stretching, toning),” and who in 2009, provided a full pregnancy outcome history. Multivariable-adjusted relative risk (RR) and 95% confidence intervals (CIs) were calculated between LIE and adverse pregnancy outcomes using log-binomial regression models.

Results: Among 225 eligible pregnant participants, 71 (31.6%) reported engaging in any LIE. LIE was associated with lower preterm birth, but not significantly associated with pregnancy loss or other adverse pregnancy outcomes. The RR for any LIE for preterm birth was 0.31 (95% CI: 0.09–1.07), with a significant dose–response association [RR = 0.65 (95% CI: 0.48–0.89) per every 30-minute session]. Some suggestive inverse associations were also observed for other adverse pregnancy outcomes: the RR for any LIE for low birthweight was 0.35 (95% CI: 0.08–1.48); for preeclampsia/gestational hypertension was 0.51 (95% CI: 0.13–1.96); and for gestational diabetes was 0.64 (95% CI: 0.25–1.64).

Conclusion: Pregnant women can include yoga, stretching, and toning exercise for promoting wellbeing.

Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association

The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.

Trends in Prepregnancy Obesity and Association With Adverse Pregnancy Outcomes in the United States, 2013 to 2018

Background

The prevalence of obesity in the population has increased in parallel with increasing rates of adverse pregnancy outcomes (APOs). Quantifying contemporary trends in prepregnancy obesity and associations with interrelated APOs (preterm birth, low birth weight, and pregnancy‐associated hypertension) together and individually can inform prevention strategies to optimize cardiometabolic health in women and offspring.

Methods and Results

We performed a serial, cross‐sectional study using National Center for Health Statistics birth certificate data including women aged 15 to 44 years with live singleton births between 2013 and 2018, stratified by race/ethnicity (non‐Hispanic White, non‐Hispanic Black, Hispanic, and non‐Hispanic Asian). We quantified the annual prevalence of prepregnancy obesity (body mass index ≥30.0 kg/m²; body mass index ≥27.5 kg/m² if non‐Hispanic Asian). We then estimated adjusted associations using multivariable logistic regression (odds ratios and population attributable fractions) for obesity‐related APOs compared with normal body mass index (18.5–24.9 kg/m²; 18.5–22.9 kg/m² if non‐Hispanic Asian). Among 20 139 891 women, the prevalence of prepregnancy obesity increased between 2013 and 2018: non‐Hispanic White (21.6%–24.8%), non‐Hispanic Black (32.5%–36.2%), Hispanic (26.0%–30.5%), and non‐Hispanic Asian (15.3%–18.6%) women (P‐trend < 0.001 for all). Adjusted odds ratios (95% CI) for APOs associated with obesity increased between 2013 and 2018, and by 2018, ranged from 1.27 (1.25–1.29) in non‐Hispanic Black to 1.94 (1.92–1.96) in non‐Hispanic White women. Obesity was most strongly associated with pregnancy‐associated hypertension and inconsistently associated with preterm birth and low birth weight. Population attributable fractions of obesity‐related APOs increased over the study period: non‐Hispanic White (10.6%–14.7%), non‐Hispanic Black (3.7%–6.9%), Hispanic (7.0%–10.4%), and non‐Hispanic Asian (7.4%–9.7%) women (P‐trend < 0.01 for all).

Conclusions

The prevalence of prepregnancy obesity and burden of obesity‐related APOs have increased, driven primarily by pregnancy‐associated hypertension, and vary across racial/ethnic subgroups.

DNA methylation changes in African American women with a history of preterm birth from the InterGEN study

Background

Preterm birth (< 37 weeks’ gestation) is a common outcome of pregnancy that has been associated with increased risk of cardiovascular disease for women later in life. Little is known about the physiologic mechanisms underlying this risk. To date, no studies have evaluated if differences in DNA methylation (DNAm) among women who experience preterm birth are short-term or if they persist and are associated with subsequent cardiovascular sequelae or other health disorders. The purpose of this study was to examine long-term epigenetic effects of preterm birth in African American mothers (n = 182) from the InterGEN Study (2014–2019). In this study, we determine if differences in DNAm exist between women who reported a preterm birth in the last 3–5 years compared to those who had full-term births by using two different approaches: epigenome-wide association study (EWAS) and genome-wide co-methylation analyses.

Results

Though no significant CpG sites were identified using the EWAS approach, we did identify significant modules of co-methylation associated with preterm birth. Co-methylation analyses showed correlations with preterm birth in gene ontology and KEGG pathways. Functional annotation analysis revealed enrichment for pathways related to central nervous system and sensory perception. No association was observed between DNAm age and preterm birth, though larger samples are needed to confirm this further.

Conclusions

We identified differentially methylated gene networks associated with preterm birth in African American women 3–5 years after birth, including pathways related to neurogenesis and sensory processing. More research is needed to understand better these associations and replicate them in an independent cohort. Further study should be done in this area to elucidate mechanisms linking preterm birth and later epigenomic changes that may contribute to the development of health disorders and maternal mood and well-being.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12863-021-00988-x.

Association of second trimester uterine artery Doppler parameters with maternal hypertension 2–7 years after delivery

Background

Reduced uterine artery compliance is associated with adverse pregnancy outcomes (APOs) and may indicate underlying maternal cardiovascular pathology. We investigated associations between second trimester uterine artery Doppler (UAD) parameters and incident maternal hypertension 2–7 years after delivery.

Methods

A cohort of 10,038 nulliparous US participants was recruited early in pregnancy. A subgroup of 3739, without baseline hypertension and with complete follow-up visits 2–7 years after delivery, were included in this analysis. We investigated UAD indicators of compliance including: 1) early diastolic notch; 2) resistance index (RI); and 3) pulsatility index (PI). We defined hypertension as systolic blood pressure ≥130 mmHg, diastolic ≥80 mmHg, or antihypertensive medication use. We calculated odds ratios (OR) and 95 % confidence intervals (95%CI) for associations between UAD parameters and hypertension, adjusting for age, obesity, race/ethnicity, insurance, smoking, and APOs.

Results

A total of 187 (5 %) participants developed hypertension after the index pregnancy. Presence of early diastolic notch on UAD was not associated with incident hypertension. Increased RI and PI correlated with higher odds of hypertension (RI: adjusted OR 1.15 [95 % CI 1.03–1.30]; PI: adjusted OR 1.03 [95%CI 1.01–1.05] for each 0.1 unit increase). Maximum RI above 0.84 or maximum PI above 2.3 more than doubled the odds of incident hypertension (RI: adjusted OR 2.49, 95%CI 1.45–4.26; PI: adjusted OR 2.36, 95%CI 1.45–3.86).

Conclusion

Higher resistance and pulsatility indices measured on second trimester UAD were associated with increased odds of incident hypertension 2–7 years later, and may be biomarkers of higher maternal cardiovascular risk.

Contributions of Preterm Delivery to Cardiovascular Disease Risk Prediction in Women

Background: Preterm delivery is associated with a 1.4- to 2-fold increased risk of cardiovascular disease (CVD), but inclusion of preterm delivery in CVD risk prediction algorithms has not been tested. We evaluated whether including preterm delivery and parity in CVD risk scores improved identification of women at high risk versus scores based on traditional risk factors. Methods: We predicted 10-year CVD risk using 119,587 observations contributed by 76,512 women ≥40 years of age and 20-year CVD risk with 72,533 women ≥40 years of age and 72,872 women ≥30 years of age from the Nurses' Health Study II. Cox proportional hazards models were fit with established CVD risk factors (Model 1) and established risk factors plus preterm delivery and parity (Model 2). We evaluated model fit, calibration, discrimination, and risk reclassification. Results: Very preterm delivery (<32 weeks) was associated with CVD in all 10- and 20-year models that included the established CVD risk factors (e.g., hazard ratio: 1.61, 95% confidence interval: 1.19 to 2.20 in 10-year risk model). Model 2 had improved fit relative to Model 1, but discrimination was not improved in Model 2 based on the C-difference or net reclassification index. Similar models for 20-year CVD risk prediction at age ≥30 years indicated improved discrimination when including preterm delivery and parity. Conclusions: Incorporating preterm delivery and parity into CVD risk scores appears most useful when women are young, before they develop established CVD risk factors. Observed improvements in risk prediction were small and warrant further investigation to confirm our findings and assess utility in a clinical setting.

Patterns of Cardiovascular Risk Factors in the Years Before Pregnancy in Nulliparous Women With and Without Preterm Birth and Small-for-Gestational-Age Delivery

Background Women with either preterm or small-for-gestational-age (SGA) delivery have an elevated lifetime risk of cardiovascular disease that has been attributed to the accrual of vascular risk factors over time. We sought to determine whether an adverse cardiovascular risk factor profile develops in the years before pregnancies complicated by preterm delivery or SGA. Methods and Results Using administrative databases, we identified all 156 278 nulliparous women in Ontario, Canada, who had singleton pregnancies between January 2011 and December 2018 and ≥2 measurements of the following analytes between January 2008 and the start of pregnancy: glycosylated hemoglobin, glucose, lipids, and alanine aminotransferase. There were 11 078 women with preterm delivery and 19 367 with SGA. The 2 most recent pregravid tests were performed at median 0.6 (interquartile range, 0.3-1.4) and 1.9 (interquartile range, 1.1-3.3) years before pregnancy, respectively. Women with preterm delivery had higher pregravid glycosylated hemoglobin, glucose, low-density lipoprotein cholesterol, triglycerides, and alanine aminotransferase, and lower high-density lipoprotein cholesterol, than those without preterm delivery. In contrast, women with SGA had lower pregravid fasting glucose, random glucose, and triglycerides than those without SGA. In the years before pregnancy, women with preterm delivery had higher annual increases than their peers in glycosylated hemoglobin (0.7-times higher), triglycerides (7.9-times higher), and alanine aminotransferase (2.2-times higher). During this time, fasting glucose increased in women who developed preterm delivery but decreased in their peers. Conclusions An adverse cardiovascular risk factor profile evolves over time in the years before pregnancy complicated by preterm delivery, but does not necessarily precede SGA.

Gestational Weight Gain and Long-term Maternal Obesity Risk: A Multiple-Bias Analysis

BACKGROUND

Lifecourse research provides an important framework for chronic disease epidemiology. However, data collection to observe health characteristics over long periods is vulnerable to systematic error and statistical bias. We present a multiple-bias analysis using real-world data to estimate associations between excessive gestational weight gain and mid-life obesity, accounting for confounding, selection, and misclassification biases.

METHODS

Participants were from the multiethnic Study of Women's Health Across the Nation. Obesity was defined by waist circumference measured in 1996-1997 when women were age 42-53. Gestational weight gain was measured retrospectively by self-recall and was missing for over 40% of participants. We estimated relative risk (RR) and 95% confidence intervals (CI) of obesity at mid-life for presence versus absence of excessive gestational weight gain in any pregnancy. We imputed missing data via multiple imputation and used weighted regression to account for misclassification.

RESULTS

Among the 2,339 women in this analysis, 937 (40%) experienced obesity in mid-life. In complete case analysis, women with excessive gestational weight gain had an estimated 39% greater risk of obesity (RR = 1.4, CI = 1.1, 1.7), covariate-adjusted. Imputing data, then weighting estimates at the guidepost values of sensitivity = 80% and specificity = 75%, increased the RR (95% CI) for obesity to 2.3 (2.0, 2.6). Only models assuming a 20-point difference in specificity between those with and without obesity decreased the RR.

CONCLUSIONS

The inference of a positive association between excessive gestational weight gain and mid-life obesity is robust to methods accounting for selection and misclassification bias.

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman’s risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

Preterm birth and cardiac function in adulthood

Preterm birth affects 1 in 10 pregnancies worldwide, with increasing survival rates over the last 30 years. However, as this new generation of long-term survivors approaches middle age, recent studies have revealed increased cardiovascular risk factors and higher rates of ischaemic heart disease and heart failure. Cardiovascular imaging has identified smaller cardiac chamber size, changes in myocardial mass and impaired ventricular function, particularly under physiological stress. Accordingly, this population should be recognised as having a higher risk of heart failure as they age. In this review, we present current evidence for increased rates of heart failure and evidence of alterations in cardiac structure and function in those born preterm. We discuss potential mechanisms to explain this risk including greater frequency of co-morbidities known to be associated with heart failure. We also explore potential mechanistic links specific to the preterm-born population, including the impact of premature birth on myocardial and vascular development and the effects of perinatal haemodynamic changes and chronic lung disease on the developing heart. We highlight gaps in our knowledge and consider implications for patient management relevant to the adult physician.