Adverse pregnancy outcomes independently tied to later atherosclerotic cardiovascular disease

In a large multi-ethnic cohort study of postmenopausal women, researchers found that hypertensive disorders in pregnancy, as well as low birth weight, were independently associated with atherosclerotic cardiovascular disease (ASCVD) in this patient cohort, after adjusting for standard risk factors and other adverse pregnancy outcomes.

Results of the study, by Nisha I. Parikh, MD, MPH, UCSF School of Medicine, University of California, San Francisco, and colleagues, were published in JAMA Cardiology.

Since cardiovascular disease is the leading cause of death among women in the United States, and pregnancy is an exposure unique to women, it makes sense to examine the role adverse pregnancy outcomes potentially play in cardiovascular disease.

In fact, in a commentary accompanying the study, Odayme Quesada, MD, Chrisandra Shufelt, MD, MS, and C. Noel Bairey Merz, MD, all of the Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute in Los Angeles, referred to pregnancy as a risk factor “literally under our collective noses.”

According to Parikh and colleagues, evidence shows there are associations between adverse pregnancy outcomes (APOs) and ASCVD, but gaps remain.

“For example, most prior studies of these APOs have not adjusted for all established ASCVD risk factors, many were not prospective or lacked long-term follow-up, and few have been conducted in multiethnic cohorts,” Parikh and colleagues wrote. “Furthermore, most studies have only examined the association of a single APO with ASCVD risk, even though several APOs may occur in the same woman.”

In this study, Parikh and colleagues assessed the APO risk in participants of the Women’s Health Initiative (WHI), a longitudinal cohort study consisting of randomized trials of hormone therapy, dietary changes, and calcium/vitamin D supplementation, as well as an observational study. Postmenopausal and ethnically diverse women between the ages of 50 and 79 were enrolled WHI between the years 1994 and 1998 and were followed prospectively.

The APO history of participants in the WHI was assessed using a 2017 questionnaire that included 6 questions on APOs during any pregnancy and was sent out to surviving enrollees who still participated in the study.

Of the 48,113 participants who responded to the survey, 28.8% reported 1 or more APOs. Among those women ASCVD was more frequent (7.6%) than in women who reported no APOs (5.8%).

When analyzed separately, each APO (gestational diabetes, hypertensive disorders of pregnancy, low birth weight, high birth weight, and preterm delivery) was significantly associated with ASCVD and, except for high birth weight, each remained statistically significantly associated with ASCVD after adjusting for traditional ASCVD risk factors.

When all of the APOs were analyzed jointly for their association with ASCVD (in a model adjusted for traditional ASCVD risk factors), only hypertensive disorders of pregnancy with an adjusted OR of 1.34, and low birth rate with an adjusted OR of 1.18, were independently associated with ASCVD.

These results did not change when adjusting for race/ethnicity, income, education, BMI, breastfeeding, or parity.

“Our study supports guideline recommendations that clinicians should consider a history of pregnancy-associated disorders when assessing ASCVD risk in older women,” wrote Parikh and colleagues. “Indeed, our results suggest that hypertensive disorders of pregnancy and low birth weight are the most important APOs to consider as potential risk enhancers.” They suggested that further research is needed to understand those mechanisms that might link those two APOs with late atherosclerotic cardiovascular disease.

Quesada and colleagues wrote that the study’s results “convincingly show that hypertensive disorders of pregnancy and low birth weight are independently associated with future CVD in women after adjustment for established risk factors and other APOs.”

They further suggested that policy actions are needed ensure that pregnancy or APO history should he required EHR fields in medical and surgical history, APOs are identified and entered into the EHR at the time of delivery, and that clinicians and continuity of care systems have increased access to APO EHR history.

“Finally, these new data support generation of new hypotheses regarding links between APOs and CVD to be tested for sex-specific, mechanistic understanding and novel treatments,” Quesada and colleagues concluded.

  1. Adverse pregnancy outcomes are associated with the risk of atherosclerotic cardiovascular disease in post-menopausal women.

  2. Specifically, hypertensive disorders of pregnancy, as well as low birth weight, are independently associated with ASCVD after adjusting for standard risk factors and other adverse pregnancy outcomes.

Michael Bassett, Contributing Writer, BreakingMED™

Quesada, Shufelt, and Merz report that article was was supported by the National Heart, Lung and Blood Institutes (contracts N01-HV-68161, N01-HV-68162, N01-HV-68163, and N01-HV-68164), the National Institute on Aging (grants U01 64829, U01 HL649141, U01 HL649241, T32 HL69751, K23HL105787, K23HL127262, K23HL125941, and 1R03 AG032631), the National Center for Research Resources (General Clinical Research Centers grant MO1-RR00425), the National Center for Advancing Translational Sciences (grants UL1TR000124 and UL1TR000064), and the Edythe L. Broad Women’s Heart Research Fellowship and the Constance Austin Women’s Heart Health Fellowship (both at Cedars-Sinai Medical Center), the Barbra Streisand Women’s Cardiovascular Research and Education Program at Cedars-Sinai Medical Center, the Linda Joy Pollin Women’s Heart Health Program, and the Erika Glazer Women’s Heart Health Project.

Cat ID: 102

Topic ID: 74,102,730,102,308,6,914,41,192,916,925