Risk of cardiovascular disease among postmenopausal women with prior pregnancy loss: the women's health initiative

Socioeconomic variations in the proportions of stroke attributable to reproductive profiles among postmenopausal women in China

BACKGROUND

This prospective study aimed to examine the individual and combined population attributable fractions (PAFs) of stroke and its subtypes associated with reproductive factors among Chinese postmenopausal women, highlighting variations across socioeconomic status (SES) stratas.

METHODS

Data were from 138,873 Chinese postmenopausal women enrolled in the China Kadoorie Biobank. Reproductive factors evaluated in this study included early age at menarche, early age at menopause, advanced age at first live birth, high parity, history of stillbirth, history of miscarriage or termination, and non-lactation. PAFs were calculated using hazard ratios, estimated using Cox proportional hazard regression, and prevalence of the seven reproductive factors. PAF for each reproductive risk factor and combined PAFs for all factors were estimated in total population and across SES classes.

RESULTS

Of the 138,873 included participants, 17,042 developed strokes during a median follow-up period of 8.9 years. Across SES classes, the greatest attributable fractions of total stroke cases were observed for high parity among low-SES women (PAF 17.2%, 95% confidence interval [CI] 13.7%, 20.6%), history of miscarriage or termination among medium-SES women (PAF 11.4%, 95% CI 8.2%, 14.5%), and no history of lactation among high-SES women (PAF 3.1%, 95% CI 1.7%, 4.9%). A multiplicatively estimated 20.5% (95% CI 20.4%, 20.5%) and 3.1% (95% CI 1.7%, 4.9%) of stroke cases were attributable to the seven reproductive risk factors in low-SES and high-SES women, respectively.

CONCLUSIONS

A large fraction of stroke cases among Chinese postmenopausal women were associated with reproductive factors. Targeted cardiovascular prevention strategies are warranted among women with different SES to mitigate risks associated with different reproductive profiles.

Spontaneous Abortion and Myocardial Infarction: A Mendelian Randomization Investigation and Transcriptomic Analysis

Background

A link has been found between spontaneous abortion (SA) and myocardial infarction (MI). However, there is still a lack of comprehensive knowledge regarding the genetic links and biological mechanisms between SA and MI. An investigation of the causal association between SA and MI, along with the associated signaling networks, was conducted using univariate Mendelian randomization (MR) and transcriptome analysis.

Methods

Data from genome-wide association studies (GWAS) for SA and MI were analyzed using the FinnGen consortium database. To assess the causality between SA and MI, various methods were employed including inverse-variance-weighted (IVW), weighted median, simple mode, and weighted mode analyses. Sensitivity analysis was conducted using heterogeneity, pleiotropy, and the Leave-One-Out (LOO) approach. Transcriptomic analysis of the GSE60993 dataset was performed to identify differentially expressed genes (DEGs) associated with single nucleotide polymorphisms (SNPs). Following this, two bioinformatics analyses were carried out.

Results

Based on IVW results, SA was found to be causally associated with MI (OR = 1.095, 95%CI 1.012-1.186). Sensitivity analysis was subsequently conducted to validate the robustness of our findings. Through differential analysis, three key genes - GNAQ, ELP3, and TES - were identified as closely linked to processes related to ribosome biogenesis, DNA replication, and congenital immune deficiency. Furthermore, strong correlations were observed with various immunologic gene sets, including the Major Histocompatibility Complex (MHC), immunoactivators, and immunosuppressors.

Conclusion

This study reveals a robust causal relationship between SA and MI, highlighting genetic and immunological pathways that could inform future research and therapeutic approaches.

Risk factors for coronary atherosclerotic heart disease in postmenopausal women: a meta-analysis

Background

Coronary atherosclerotic heart disease (coronary heart disease; CHD) is the leading cause of death in women worldwide, and the number of patients and deaths is increasing each year. Approximately 3.8 million women die from CHD every year globally. After menopause, estrogen levels decrease, and the risk of cardiovascular disease increases substantially; however, research on risk factors for CHD in postmenopausal women has been inconclusive.

Objective

To systematically evaluate the risk factors for CHD in postmenopausal women.

Methods

The PubMed, Embase, Web of Science, CINAHL, CBM, CNKI, and VIP databases were searched up to February 9, 2024, for studies on risk factors for CHD in postmenopausal women. Two researchers independently screened the literature, extracted data, and evaluated the quality of the included literature. STATA17.0 software was used for meta-analysis.

Results

Nine studies involving 29,4103 patients were included. The results of the meta-analysis showed that history of six or more pregnancies (hazard ratio = 1.538, 95% confidence interval: 1.241%-1.906%) was significantly associated with risk of CHD (P < 0.05).

Conclusion

Multiple pregnancies are associated with CHD incidence and related mortality in postmenopausal women. In the future, more and higher quality studies are needed to further verify this conclusion.

Miscarriage, stillbirth, and mortality risk from stroke in women: findings from the PLCO study

OBJECTIVES

Existing evidence suggests that miscarriage and stillbirth are associated with an increased risk of stroke in women. However, the impact of these events on stroke mortality remains unclear. This study aimed to elucidate the potential association between miscarriage and stillbirth and stroke mortality in women.

METHODS

We employed a competing risk model using data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial to assess the relationship between miscarriage/stillbirth and stroke death. Death from other causes was considered as a competing risk, and we conducted a subgroup analysis to explore the potential impact.

RESULTS

Our study included 68,629 women for miscarriage and 65,343 women for stillbirth. No significant association was observed between miscarriage and stroke mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.84 to 1.10; p=0.58). While a single stillbirth did not show a significant association (HR, 0.81; 95% CI, 0.57 to 1.15; p=0.23), recurrent stillbirth (≥2) was associated with a significantly increased risk of stroke mortality compared to women with no stillbirths (HR, 2.24; 95% CI, 1.45 to 3.46; p<0.001).

CONCLUSIONS

Our findings suggest that recurrent stillbirth, but not single events, is associated with an elevated risk of stroke mortality in women. Further research is warranted to clarify the underlying mechanisms and potential long-term health implications of recurrent pregnancy loss.

Pregnancy loss and risk of cardiometabolic multimorbidity in Chinese women: the China Kadoorie Biobank study

BACKGROUND

While the association between pregnancy loss and individual cardiometabolic diseases (CMDs) is well-established, its impact on the risk of coexisting CMDs remains unclear. Therefore, the aim of this study is to investigate the association between pregnancy loss with the risk of cardiometabolic multimorbidity in Chinese women.

METHOD

We analyzed the cross-sectional data of 299,582 female participants aged 30-79 years old from the China Kadoorie biobank. Cardiometabolic multimorbidity was defined as the coexistence of two or more CMDs, including coronary heart disease, stroke, hypertension, and diabetes. Multivariable logistic regression was used to evaluate the odds ratios (ORs) between the number and type of pregnancy loss with the risk of cardiometabolic multimorbidity, characterized by the number and type of CMD.

RESULTS

After adjusting for confounding factors, pregnancy loss was found to be significantly associated with increased cardiometabolic multimorbidity risk (OR, 1.13 95% CI 1.08-1.19). Specifically, pregnancy loss due to spontaneous and induced abortion (OR 1.10, 95% CI 1.03-1.18 and OR 1.13, 95% CI 1.08-1.19, respectively). In contrast, no significant association was found between stillbirth and cardiometabolic multimorbidity (OR 1.03, 95% CI 0.95-1.11). The risk of cardiometabolic multimorbidity increases as the number of pregnancy loss increases (one pregnancy loss: OR 1.10, 95% CI 1.05-1.16, two or more pregnancy loss: OR 1.16, 95% CI 1.10-1.22). Similarly, the diagnosis of multiple CMDs increases with increasing number of pregnancy loss. Pregnancy loss was related to higher risk of cardiometabolic multimorbidity across most CMD combinations of CMDs.

CONCLUSION

Pregnancy loss, in particular, spontaneous and induced abortion was significantly associated with greater risk of cardiometabolic multimorbidity. The associations were stronger among those with recurrent pregnancy loss.

Effects of prior reproductive losses on risk of cardiovascular diseases within six months of a first live birth

Objective

There is emerging evidence suggesting that pregnancy loss (induced or natural) is associated with an increased risk of cardiovascular diseases (CVD). This prospective longitudinal study investigates the effect of prior pregnancy losses on CVD risk during the first six months following a first live birth.

Methods

Medicaid claims of 1,002,556 low-income women were examined to identify history of pregnancy losses, CVD, diabetes, and hyperlipidemia prior to first live birth. The study population was categorized into five groups: A: women with no pregnancy loss or CVD history prior to first live birth; B: women with pregnancy loss and no CVD prior to first live birth. C: women with a first CVD diagnosis after a first pregnancy ending in a loss and before their first live birth. D: women with CVD prior to first live birth and no history of pregnancy loss. E: women with both CVD and pregnancy loss prior to their first live birth.

Results

After controlling for age, race, state of residence, and history of diabetes and hyperlipidemia, the risk of CVD in the six-month period following a first live birth were 15%, 214%, 79% and 129% more common for Groups B, C, D and E, respectively, compared to Group A.

Conclusions

Pregnancy loss is an independent risk factor for CVD risk following a first live birth, both for women with and without a prior history of CVD. The risk is highest when CVD is first diagnosed after a pregnancy loss and prior to a first live birth.

Miscarriage and stillbirth in relation to risk of cardiovascular diseases: A systematic review and meta-analysis

INTRODUCTION

The relationship between pregnancy loss and the risk of cardiovascular diseases (CVDs) remains a matter of debate. Our intention in conducting this meta-analysis was to analyze the relationship between miscarriage and stillbirth and risk of CVDs.

METHODS

PubMed, Embase, and Web of Science were systematically searched up to May 30, 2023 for all relevant studies. The random-effects model was applied to estimate the pooled relative risks (RRs) and 95% confidence intervals (95% CIs). We evaluated RR estimates for the risk of CVDs with each additional miscarriage and stillbirth through generalized least squares regression.

RESULTS

Twenty-three articles were incorporated into the meta-analysis. For women with a history of miscarriage, the pooled RRs for the risk of total CVDs, coronary heart disease (CHD), stroke, and total CVD deaths were 1.16 (95 % CI 1.10-1.22), 1.26 (1.12-1.41), 1.13 (1.03-1.24), and 1.20 (1.01-1.42), respectively. For women with a history of stillbirth, the pooled RRs for the risk of total CVDs, CHD, stroke, and total CVD deaths were 1.60 (1.34-1.89), 1.30 (1.12-1.50), 1.37 (1.06-1.78), and 1.95 (1.05-3.63), respectively. With each additional miscarriage, the risk increased for total CVDs (1.08, 1.04-1.13), CHD (1.08, 1.04-1.13), and stroke (1.05, 1.00-1.10). With each additional stillbirth, the risk increased for total CVDs (1.11, 1.03-1.21) and CHD (1.13, 1.07-1.19).

CONCLUSION

This meta-analysis indicates that both miscarriages and stillbirths are related to a higher risk of total CVDs, CHD, stroke, and total CVD deaths. The risk of total CVDs and CHD increased with the number of miscarriages or stillbirths.

Fetal loss and long-term maternal morbidity and mortality: A systematic review and meta-analysis

BACKGROUND

Evidence suggests common pathways between pregnancy losses and subsequent long-term maternal morbidity, rendering pregnancy complications an early chronic disease marker. There is a plethora of studies exploring associations between miscarriage and stillbirth with long-term adverse maternal health; however, these data are inconclusive.

METHODS AND FINDINGS

We systematically searched MEDLINE, EMBASE, AMED, BNI, CINAHL, and the Cochrane Library with relevant keywords and MeSH terms from inception to June 2023 (no language restrictions). We included studies exploring associations between stillbirth or miscarriage and incidence of cardiovascular, malignancy, mental health, other morbidities, and all-cause mortality in women without previous pregnancy loss. Studies reporting short-term morbidity (within a year of loss), case reports, letters, and animal studies were excluded. Study selection and data extraction were performed by 2 independent reviewers. Risk of bias was assessed using the Newcastle Ottawa Scale (NOS) and publication bias with funnel plots. Subgroup analysis explored the effect of recurrent losses on adverse outcomes. Statistical analysis was performed using an inverse variance random effects model and results are reported as risk ratios (RRs) with 95% confidence intervals (CIs) and prediction intervals (PIs) by combining the most adjusted RR, odds ratios (ORs) and hazard ratios (HRs) under the rare outcome assumption. We included 56 observational studies, including 45 in meta-analysis. There were 1,119,815 women who experienced pregnancy loss of whom 951,258 had a miscarriage and 168,557 stillbirth, compared with 11,965,574 women without previous loss. Women with a history of stillbirth had a greater risk of ischaemic heart disease (IHD) RR 1.56, 95% CI [1.30, 1.88]; p < 0.001, 95% PI [0.49 to 5.15]), cerebrovascular (RR 1.71, 95% CI [1.44, 2.03], p < 0.001, 95% PI [1.92, 2.42]), and any circulatory/cardiovascular disease (RR 1.86, 95% CI [1.01, 3.45], p = 0.05, 95% PI [0.74, 4.10]) compared with women without pregnancy loss. There was no evidence of increased risk of cardiovascular disease (IHD: RR 1.11, 95% CI [0.98, 1.27], 95% PI [0.46, 2.76] or cerebrovascular: RR 1.01, 95% CI [0.85, 1.21]) in women experiencing a miscarriage. Only women with a previous stillbirth were more likely to develop type 2 diabetes mellitus (T2DM) (RR: 1.16, 95% CI [1.07 to 2.26]; p < 0.001, 95% PI [1.05, 1.35]). Women with a stillbirth history had an increased risk of developing renal morbidities (RR 1.97, 95% CI [1.51, 2.57], p < 0.001, 95% [1.06, 4.72]) compared with controls. Women with a history of stillbirth had lower risk of breast cancer (RR: 0.80, 95% CI [0.67, 0.96], p-0.02, 95% PI [0.72, 0.93]). There was no evidence of altered risk of other malignancies in women experiencing pregnancy loss compared to controls. There was no evidence of long-term mental illness risk in women with previous pregnancy losses (stillbirth: RR 1.90, 95% CI [0.93, 3.88], 95% PI [0.34, 9.51], miscarriage: RR 1.78, 95% CI [0.88, 3.63], 95% PI [1.13, 4.16]). The main limitations include the potential for confounding due to use of aggregated data with variable degrees of adjustment.

CONCLUSIONS

Our results suggest that women with a history of stillbirth have a greater risk of future cardiovascular disease, T2DM, and renal morbidities. Women experiencing miscarriages, single or multiple, do not seem to have an altered risk.

The Role of Adverse Pregnancy Outcomes in Conventional Cardiovascular Risk Prediction

OBJECTIVE

Approximately one-third of women in the U.S. experience an adverse pregnancy outcome (APO), which are recognized as sex-specific cardiovascular disease (CVD) risk factors. We examine if APOs confer additional CVD risk beyond that of traditional CVD risk factors.

METHODS

Women, age 40-79, with a pregnancy history and no pre-existing CVD were identified in the electronic health record of one health system (n = 2306). APOs included any APO, hypertensive disease of pregnancy (HDP), and gestational diabetes (GDM). Hazard ratios of time to CVD event were estimated from survival models using Cox proportional hazard regression. Discrimination, calibration, and net reclassification of re-estimated CVD risk prediction models including APOs were examined.

RESULTS

There was no significant association between any APO, HDP, or GDM and time to CVD outcome in survival models (95% confidence intervals all include 1). Including any APO, HDP, GDM in the CVD risk prediction model did not significantly improve discrimination and there were no clinically relevant changes in net reclassification of cases and non-cases. The strongest predictor of time to CVD event in the survival models was Black race, with hazard ratios ranging from 1.59 to 1.62, statistically significant for all three models.

CONCLUSION

Women with APOs did not have an additional risk of CVD, controlling for traditional risk factors in the PCE and this sex-specific factor did not improve risk prediction. Black race was consistently a strong predictor of CVD even with data limitations. Further study of APOs can help determine how to best use this information for CVD prevention in women.

Pregnancy loss and risk of incident CVD within 5 years: Findings from the Women's Health Initiative

Background

Previous studies have demonstrated an increased risk of cardiovascular disease (CVD) in women with a history of pregnancy loss. Less is known about whether pregnancy loss is associated with age at the onset of CVD, but this is a question of interest, as a demonstrated association of pregnancy loss with early-onset CVD may provide clues to the biological basis of the association, as well as having implications for clinical care. We conducted an age-stratified analysis of pregnancy loss history and incident CVD in a large cohort of postmenopausal women aged 50-79 years old.

Methods

Associations between a history of pregnancy loss and incident CVD were examined among participants in the Women's Health Initiative Observational Study. Exposures were any history of pregnancy loss (miscarriage and/or stillbirth), recurrent (2+) loss, and a history of stillbirth. Logistic regression analyses were used to examine associations between pregnancy loss and incident CVD within 5 years of study entry in three age strata (50-59, 69-69, and 70-79). Outcomes of interest were total CVD, coronary heart disease (CHD), congestive heart failure, and stroke. To assess the risk of early onset CVD, Cox proportional hazard regression was used to examine incident CVD before the age of 60 in a subset of subjects aged 50-59 at study entry.

Results

After adjustment for cardiovascular risk factors, a history of stillbirth was associated with an elevated risk of all cardiovascular outcomes in the study cohort within 5 years of study entry. Interactions between age and pregnancy loss exposures were not significant for any cardiovascular outcome; however, age-stratified analyses demonstrated an association between a history of stillbirth and risk of incident CVD within 5 years in all age groups, with the highest point estimate seen in women aged 50-59 (OR 1.99; 95% CI, 1.16-3.43). Additionally, stillbirth was associated with incident CHD among women aged 50-59 (OR 3.12; 95% CI, 1.33-7.29) and 60-69 (OR 2.06; 95% CI, 1.24-3.43) and with incident heart failure and stroke among women aged 70-79. Among women aged 50-59 with a history of stillbirth, a non-significantly elevated hazard ratio was observed for heart failure before the age of 60 (HR 2.93, 95% CI, 0.96-6.64).

Conclusions

History of stillbirth was strongly associated with a risk of cardiovascular outcomes within 5 years of baseline in a cohort of postmenopausal women aged 50-79. History of pregnancy loss, and of stillbirth in particular, might be a clinically useful marker of cardiovascular disease risk in women.

Intergenerational trends in reproduction: Infertility and pregnancy loss

This review article summarises the evidence for intergenerational trends observed to date within infertility and pregnancy loss. There appears to be evidence of intergenerational trends between mothers and daughters for the age at menopause, endometriosis, polycystic ovarian syndrome (PCOS), male factor infertility and miscarriage. At present, there is no evidence for a predisposition to stillbirth between mothers and daughters. One study found an association with familial predisposition for ectopic pregnancy. Very few studies have considered the potential for paternal transmission of risk of infertility or pregnancy loss. The majority of studies to date have significant limitations because of their observational design, risk of recall bias and risk of confounding. Therefore, high-quality well-designed research, with multi-centre collaboration and utilisation of registry-based data sources and individual patient data, is needed to understand whether infertility and pregnancy loss may have heritable factors. Epidemiological findings need to be followed up and investigated with translational research to determine the possible causalities as well as any implications for clinical practice.

Pregnancy loss is related to body mass index and prediabetes in early adulthood: Findings from Add Health

Pregnancy loss, including miscarriage and stillbirth, affects 15-20% of pregnancies in the United States (US) annually. Accumulating evidence suggests that pregnancy loss is associated with a greater cardiovascular disease (CVD) burden later in life. However, few studies have evaluated the impact of pregnancy loss on CVD risk factors in early adulthood (age <35 years). The aim of this study was to examine associations between pregnancy loss and CVD risk factors (body mass index, blood pressure, hyperlipidemia, diabetes status) in early adulthood. We conducted a cross-sectional analysis using the public-use dataset for Wave IV (2007-2009) of the National Longitudinal Study of Adolescent to Adult Health (Add Health). Our sample consisted of women, ages 24-32 years, with a previous pregnancy who completed biological data collection (n = 2,968). Pregnancy loss was assessed as any history of miscarriage or stillbirth; and quantified as none, one, or recurrent (≥2) pregnancy loss. Associations between pregnancy loss and each CVD risk factor were tested using linear and logistic regression adjusting for sociodemographic factors, parity, health behaviors during pregnancy, and depression. We tested for interactions with race/ethnicity. A total of 670 women reported a pregnancy loss, of which 28% reported recurrent pregnancy loss. A prior pregnancy loss was related to a 3.79 (kg/mm2) higher BMI in non-Hispanic Black women, but not white women. Women with recurrent pregnancy loss were more likely to have prediabetes (AOR, 1.93; 95% CI, 1.10-3.37, p<0.05) than women with all live births. Findings suggest that pregnancy loss may be associated with a more adverse CVD risk profile in early adulthood, particularly for women who experience recurrent pregnancy loss. This highlights the need for CVD risk assessment in young women with a prior pregnancy loss. Further research is necessary to identify underlying risk factors of pregnancy loss that may predispose women to CVD.

The risk of cardiovascular diseases after miscarriage, stillbirth, and induced abortion: a systematic review and meta-analysis

Aims

Miscarriage and stillbirth have been included in cardiovascular disease (CVD) risk guidelines, however heterogeneity in exposures and outcomes and the absence of reviews assessing induced abortion, prevented comprehensive assessment. We aimed to perform a systematic review and meta-analysis of the risk of cardiovascular diseases for women with prior pregnancy loss (miscarriage, stillbirth, and induced abortion).

Methods and results

Observational studies reporting risk of CVD, coronary heart disease (CHD), and stroke in women with pregnancy loss were selected after searching MEDLINE, Scopus, CINAHL, Web of Knowledge, and Cochrane Library (to January 2020). Data were extracted, and study quality were assessed using the Newcastle-Ottawa Scale. Pooled relative risk (RR) and 95% confidence intervals (CIs) were calculated using inverse variance weighted random-effects meta-analysis.Twenty-two studies involving 4 337 683 women were identified. Seven studies were good quality, seven were fair and eight were poor. Recurrent miscarriage was associated with a higher CHD risk (RR = 1.37, 95% CI: 1.12-1.66). One or more stillbirths was associated with a higher CVD (RR = 1.41, 95% CI: 1.09-1.82), CHD (RR = 1.51, 95% CI: 1.04-1.29), and stroke risk (RR = 1.33, 95% CI: 1.03-1.71). Recurrent stillbirth was associated with a higher CHD risk (RR = 1.28, 95% CI: 1.18-1.39). One or more abortions was associated with a higher CVD (RR = 1.04, 95% CI: 1.02-1.07), as was recurrent abortion (RR = 1.09, 95% CI: 1.05-1.13).

Conclusion

Women with previous pregnancy loss are at a higher CVD, CHD, and stroke risk. Early identification and risk factor management is recommended. Further research is needed to understand CVD risk after abortion.

Infertility, recurrent pregnancy loss, and risk of stroke: pooled analysis of individual patient data of 618 851 women

OBJECTIVE

To examine the associations of infertility, recurrent miscarriage, and stillbirth with the risk of first non-fatal and fatal stroke, further stratified by stroke subtypes.

DESIGN

Individual participant pooled analysis of eight prospective cohort studies.

SETTING

Cohort studies across seven countries (Australia, China, Japan, Netherlands, Sweden, the United Kingdom, and the United States) participating in the InterLACE (International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events) consortium, which was established in June 2012.

PARTICIPANTS

618 851 women aged 32.0-73.0 years at baseline with data on infertility, miscarriage, or stillbirth, at least one outcome event (non-fatal or fatal stroke), and information on covariates were included; 93 119 women were excluded. Of the participants, 275 863 had data on non-fatal and fatal stroke, 54 716 only had data on non-fatal stroke, and 288 272 only had data on fatal stroke.

MAIN OUTCOME AND MEASURES

Non-fatal strokes were identified through self-reported questionnaires, linked hospital data, or national patient registers. Fatal strokes were identified through death registry data.

RESULTS

The median follow-up for non-fatal stroke and fatal stroke was 13.0 years (interquartile range 12.0-14.0) and 9.4 years (7.6-13.0), respectively. A first non-fatal stroke was experienced by 9265 (2.8%) women and 4003 (0.7%) experienced a fatal stroke. Hazard ratios for non-fatal or fatal stroke were stratified by hypertension and adjusted for race or ethnicity, body mass index, smoking status, education level, and study. Infertility was associated with an increased risk of non-fatal stroke (hazard ratio 1.14, 95% confidence interval 1.08 to 1.20). Recurrent miscarriage (at least three) was associated with higher risk of non-fatal and fatal stroke (1.35, 1.27 to 1.44, and 1.82, 1.58 to 2.10, respectively). Women with stillbirth were at 31% higher risk of non-fatal stroke (1.31, 1.10 to 1.57) and women with recurrent stillbirth were at 26% higher risk of fatal stroke (1.26, 1.15 to 1.39). The increased risk of stroke (non-fatal or fatal) associated with infertility or recurrent stillbirths was mainly driven by a single stroke subtype (non-fatal ischaemic stroke and fatal haemorrhagic stroke), while the increased risk of stroke (non-fatal or fatal) associated with recurrent miscarriages was driven by both subtypes.

CONCLUSION

A history of recurrent miscarriages and death or loss of a baby before or during birth could be considered a female specific risk factor for stroke, with differences in risk according to stroke subtypes. These findings could contribute to improved monitoring and stroke prevention for women with such a history.

Elevated cardiovascular disease risk in low-income women with a history of pregnancy loss

OBJECTIVE

Pregnancy is associated with elevated risk of cardiovascular diseases (CVD), but little is known regarding the association between CVD and specific types of pregnancy losses. The aim of this study is to investigate the effects of pregnancy loss on the risk of subsequent CVD of any type.

METHODS

This prospective longitudinal study examines medical records between 1999 and 2014 for Medicaid beneficiaries born after 1982 who lived in a state that funds all reproductive health services, including induced abortion. Unique pregnancy outcomes, history of diabetes, hyperlipidaemia or CVD (International Classification of Diseases, Ninth Revision (ICD-9): 401-459) prior to their first pregnancy outcome for each woman. Cumulative incidence rates of a first CVD diagnosis following a first pregnancy were calculated for the observed period, exceeding 12 years.

RESULTS

A history of pregnancy loss was associated with 38% (OR=1.38; 95% CI=1.37 to 1.40) higher risk of a CVD diagnosis in the period observed. After controlling for history of diabetes, hyperlipidaemia, age, year of first pregnancy, race, state of residence, months of eligibility, number of pregnancies, births, number of losses before and after the first live birth, exposure to any pregnancy loss was associated with an 18% (adjusted OR=1.18; 95% CI=1.15 to 1.21) increased risk of CVD. Our analyses also reveal an important temporal relationship between the CVD and pregnancy loss. Immediate and short-term increased CVD risk is more characteristic for women whose first pregnancy ended in live birth while a delayed and more prolonged increased risk of CVD is associated with a first pregnancy loss.

CONCLUSIONS

Our findings corroborate previous research showing that pregnancy loss is an independent risk factor for CVD, especially for diseases more chronic in nature. Our research contributes to understanding the specific needs for cardiovascular health monitoring for pregnant women and developing a consistent, evidence-based screening tools for both short-term and long-term follow-up.

Pregnancy loss and risk of cardiovascular disease: the Nurses' Health Study II

AIMS

The aim of this study was to explore the association of pregnancy loss (PL) with the incidence of cardiovascular disease (CVD) and examine the extent to which this relation is mediated by subsequent metabolic disorders.

METHODS AND RESULTS

We followed 95 465 ever-gravid women participating in the Nurses' Health Study II between 1993 and 2017. Cox proportional hazards models were used to estimate the hazard ratios (HRs) of CVD, including coronary heart disease (CHD), and stroke, according to the occurrence of PL. A mediation analysis was conducted to explore the intermediating effect of subsequent type 2 diabetes, hypertension, or hypercholesterolaemia. During 2 205 392 person-years of follow-up (mean 23.10 years), 2225 (2.3%) incident CVD cases were documented. After adjusting for confounding factors, PL was associated with an HR of 1.21 [95% confidence interval (CI) 1.10-1.33] for CVD during follow-up. A similar association was observed for CHD (HR 1.20; 95% CI 1.07-1.35) and stroke (HR 1.23; 95% CI 1.04-1.44). The risk of CVD increased with the number of PLs [HR 1.18 (95% CI 1.06-1.31) for 1 and 1.34 (95% CI 1.13-1.59) for ≥2 times] and was greater for PL occurring early in reproductive lifespan [HR 1.40 (95% CI 1.21-1.62) for age ≤23 years, 1.25 (95% CI 1.09-1.43) for age 24-29 years, and 1.03 (95% CI 0.88-1.19) for age ≥30 years]. Hypertension, hypercholesterolaemia, and type 2 diabetes all explained <1.80% of the association between PL and CVD.

CONCLUSION

PL was associated with a greater CVD risk, independently of subsequent development of metabolic disorders.

Does Adding Adverse Pregnancy Outcomes Improve the Framingham Cardiovascular Risk Score in Women? Data from the Tehran Lipid and Glucose Study

Background Limited and conflicting evidence is available regarding the predictive value of adding adverse pregnancy outcomes (APOs) to established cardiovascular disease (CVD) risk factors. Hence, the objective of this study was to determine whether adding APOs to the Framingham risk score improves the prediction of CVD events in women. Methods and Results Out of 5413 women who participated in the Tehran Lipid and Glucose Study, 4013 women met the eligibility criteria included for the present study. The exposure and the outcome variables were collected based on the standard protocol. Cox proportional hazard model was used to evaluate the association of APOs and CVDs. The variant of C-statistic for survivals and reclassification of subjects into Framingham risk score categories after adding APOs was reported. Out of the 4013 eligible subjects, a total of 1484 (36.98%) women reported 1 APO, while 395 (9.84%) of the cases reported multiple APOs. Univariate proportional hazard Cox models showed the significant relations between CVD events and APOs. The enhanced model had a higher C-statistic indicating more acceptable discrimination as well as a slight improvement in discrimination (C-statistic differences: 0.0053). Moreover, we observed a greater risk of experiencing a CVD event in women with a history of multiple APOs compared with cases with only 1 APO (1 APO: hazard ratio [HR] = 1.22; 2 APOs: HR; 1.94; ≥3 APOs: HR = 2.48). Conclusions Beyond the established risk factors, re-estimated CVDs risk by adding APOs to the Framingham risk score may improve the accurate risk estimation of CVD. Further observational studies are needed to confirm our findings.

Pregnancy Complications and Risk of Cardiovascular Disease Later in Life: A Nationwide Cohort Study

Background

The aim of this study was to investigate the associations between pregnancy complications and cardiovascular mortality and hospitalizations of cardiovascular disease (CVD) after adjustment for major confounding.

Methods and Results

In a nationwide register‐based cohort study, women with singleton births between 1973 and 2014 were included from the Swedish Medical Birth Register. Outcomes of mortality and hospitalizations of CVD were collected from the Cause of Death Register and the National Inpatient Register. The cohort was followed from the date of the first delivery until death or end of follow‐up, whichever occurred first. The pregnancy complications studied were preeclampsia or eclampsia, gestational hypertension, gestational diabetes, preterm birth, small for gestational age, and stillbirth. Among the 2 134 239 women (mean age at first pregnancy, 27.0 [SD, 5.1] and mean parity 1.96 [SD, 0.9]), 19.1% (N=407 597) had 1 of the studied pregnancy complications. All pregnancy complications were associated with all‐cause and cardiovascular mortality and hospitalization for CVD (ischemic heart disease, ischemic stroke, and peripheral artery disease) after adjustment for major confounding in a Cox proportional hazard regression model. The adjusted hazard ratio for cardiovascular mortality was 1.84 (95% CI, 1.38–2.44) for preterm birth and 3.14 (95% CI, 1.81–5.44) for stillbirth.

Conclusions

In this large cohort study, pregnancy complications were associated with all‐cause mortality, cardiovascular mortality, and hospitalizations for CVD, also after adjusting for confounding, including overweight, smoking, and comorbidities. The study highlights that less established pregnancy complications such as preterm birth and stillbirth are also associated with cardiovascular mortality and CVD.

Infertility, Miscarriage, Stillbirth, and the Risk of Stroke Among Women: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Stroke is one of the leading causes of mortality, and women are impacted more from stroke than men in terms of their absolute number and in having worse outcomes. A growing number of studies have explored the association between pregnancy complications, pregnancy outcomes, and stroke. Limited studies, however, have investigated links involving infertility, miscarriage, and stillbirth, which could plausibly be associated via a background of endocrine conditions, endothelial dysfunction, and chronic systematic inflammation. This review aims to summarize current evidence and provide up-to-date information on the associations of infertility, miscarriage, and stillbirth, with stroke incidence.

METHODS

A comprehensive literature search was conducted for cohort and case-control studies on associations between infertility, miscarriage, stillbirth, and stroke up to September 26, 2020. Seven databases were searched: PubMed, Embase, Cochrane, CINIHL, PsyclNFO, Wanfang, and CNKI. Random-effects models were used to estimate the pooled hazard ratios (HRs) and 95% CIs.

RESULTS

Sixteen cohort studies and 2 case-control studies enrolling 7 808 521 women were included in this meta-analysis. Women who had experienced miscarriage or stillbirth were at higher risk of stroke (miscarriage: HR, 1.07 [95% CI, 1.00-1.14]; stillbirth: HR, 1.38 [95% CI, 1.11-1.71]) than other women. The HRs of stroke for each additional miscarriage and stillbirth were 1.13 (95% CI, 0.96-1.33) and 1.25 (95% CI, 1.06-1.49), respectively. In subgroup analysis, increased risk of stroke was associated with repeated miscarriages and stillbirths (miscarriage ≥3: HR, 1.42 [95% CI, 1.05-1.90]; stillbirth ≥2: HR, 1.14 [95% CI, 1.04-1.26]). Associations between infertility and stroke were inconsistent and inconclusive (HR, 1.07 [95% CI, 0.87-1.32]).

CONCLUSIONS

Miscarriage and stillbirth are associated with increased risk of stroke among women, which could be used as a contributing risk factor to help identify women at higher risk of stroke.

Predicting Incident Heart Failure in Women With Machine Learning: The Women's Health Initiative Cohort

BACKGROUND

Heart failure (HF) is a leading cause of cardiac morbidity among women, whose risk factors differ from those in men. We used machine-learning approaches to develop risk- prediction models for incident HF in a cohort of postmenopausal women from the Women's Health Initiative (WHI).

METHODS

We used 2 machine-learning methods-Least Absolute Shrinkage and Selection Operator (LASSO) and Classification and Regression Trees (CART)-to perform variable selection on 1227 baseline WHI variables for the primary outcome of incident HF. These variables were then used to construct separate Cox proportional hazard models, and we compared these results, using receiver-operating characteristic (ROC) curve analysis, against a comparator model built using variables from the Atherosclerosis Risk in Communities (ARIC) HF prediction model. We analyzed 43,709 women who had 2222 incident HF events; median follow-up was 14.3 years.

RESULTS

LASSO selected 10 predictors, and CART selected 11 predictors. The highest correlation between selected variables was 0.46. In addition to selecting well-established predictors such as age, myocardial infarction, and smoking, novel predictors included physical function, number of pregnancies, number of previous live births and age at menopause. In ROC analysis, the CART-derived model had the highest C-statistic of 0.83 (95% confidence interval [CI], 0.81-0.85), followed by LASSO 0.82 (95% CI, 0.81-0.84) and ARIC 0.73 (95% CI, 0.70-0.76).

CONCLUSIONS

Machine-learning approaches can be used to develop HF risk-prediction models that can have better discrimination compared with an established HF risk model and may provide a basis for investigating novel HF predictors.

Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association

This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman's risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD. Adopting a heart-healthy diet and increasing physical activity among women with APOs, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk. Lactation and breastfeeding may lower a woman's later cardiometabolic risk. Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs and CVD in non-White women are needed to better understand and address these health disparities. Future studies of aspirin, statins, and metformin may better inform our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.

Recurrent pregnancy loss

Recurrent pregnancy loss is a distressing pregnancy disorder experienced by ~2.5% of women trying to conceive. Recurrent pregnancy loss is defined as the failure of two or more clinically recognized pregnancies before 20-24 weeks of gestation and includes embryonic and fetal losses. The diagnosis of an early pregnancy loss is relatively straightforward, although progress in predicting and preventing recurrent pregnancy loss has been hampered by a lack of standardized definitions, the uncertainties surrounding the pathogenesis and the highly variable clinical presentation. The prognosis for couples with recurrent pregnancy loss is generally good, although the likelihood of a successful pregnancy depends on maternal age and the number of previous losses. Recurrent pregnancy loss can be caused by chromosomal errors, anatomical uterine defects, autoimmune disorders and endometrial dysfunction. Available treatments target the putative risk factors of pregnancy loss, although the effectiveness of many medical interventions is controversial. Regardless of the underlying aetiology, couples require accurate information on their chances of having a baby and appropriate support should be offered to reduce the psychological burden associated with multiple miscarriages. Future research must investigate the pathogenesis of recurrent pregnancy loss and evaluate novel diagnostic tests and treatments in adequately powered clinical trials.

Stillbirth is associated with increased risk of long-term maternal renal disease: a nationwide cohort study

Background

Stillbirth is a devastating adverse pregnancy outcome that may occur without any obvious reason or may occur in the context of fetal growth restriction, preeclampsia, or other obstetric complications. There is increasing evidence that women who experience stillbirths are at greater risk of long-term cardiovascular disease, but little is known about their risk of chronic kidney disease and end-stage renal disease. We conducted the largest study to date to investigate the subsequent risk of maternal chronic kidney disease and end-stage renal disease following stillbirth.

Objective

To identify whether pregnancy complicated by stillbirth is associated with subsequent risk of maternal chronic kidney disease and end-stage renal disease, independent of underlying medical or obstetric comorbidities.

Study Design/Methods

We conducted a population-based cohort study using nationwide data from the Swedish Medical Birth Register, National Patient Register, and Swedish Renal Register. We included all women who had live births and stillbirths from 1973 to 2012, with follow-up to 2013. Women with preexisting renal disease were excluded. Cox proportional hazard regression models were used to estimate adjusted hazard ratios and 95% confidence intervals for associations between stillbirth and maternal chronic kidney disease and end-stage renal disease respectively. We controlled for maternal age, year of delivery, country of origin, parity, body mass index, smoking, gestational diabetes, preeclampsia, and small for gestational age deliveries. Women who had a history of medical comorbidities, which may predispose to renal disease (prepregnancy cardiovascular disease, hypertension, diabetes, lupus, systemic sclerosis, hemoglobinopathy, or coagulopathy), were excluded from the main analysis and examined separately.

Results

There were 1,941,057 unique women who had 3,755,444 singleton pregnancies, followed up over 42,313,758 person-years. The median follow-up time was 20.7 years (interquartile range, 9.9–30.0 years). 13,032 women (0.7%) had at least 1 stillbirth. Women who had experienced at least 1 stillbirth had a greater risk of developing chronic kidney disease (adjusted hazard ratio, 1.26; 95% confidence interval, 1.09–1.45) and end-stage renal disease (adjusted hazard ratio, 2.25; 95% confidence interval, 1.55–3.25) compared with women who only had live births. These associations persisted after removing all stillbirths that occurred in the context of preeclampsia, and small for gestational age or congenital malformations (for chronic kidney disease, adjusted hazard ratio, 1.33; 95% confidence interval, 1.13–1.57; for end-stage renal disease, adjusted hazard ratio, 2.95; 95% confidence interval, CI 1.86–4.68). There was no significant association observed between stillbirth and either chronic kidney disease or end-stage renal disease in women who had preexisting medical comorbidities (chronic kidney disease, adjusted hazard ratio, 1.13; 95% confidence interval, 0.73–1.75 or end-stage renal disease, adjusted hazard ratio, 1.49; 95% confidence interval, 0.78–2.85).

Conclusion

Women who have a history of stillbirth may be at increased risk of chronic kidney disease and end-stage renal disease compared with women who have only had live births. This association persists independently of preeclampsia, and small for gestational age, maternal smoking, obesity, and medical comorbidities. Further research is required to determine whether affected women would benefit from closer surveillance and follow-up for future renal disease.

Adverse pregnancy outcomes and subsequent development of connective tissue disease in the UK: an epidemiological study

OBJECTIVE

This study assessed prevalence of connective tissue disease (CTDs), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS) and antiphospholipid antibodies (aPL) in women with previous adverse pregnancy outcome compared with uncomplicated livebirths.

DESIGN

Retrospective case-control study.

SETTING

UK Primary Care.

POPULATION OR SAMPLE

Records of women, 18 years and older, within the Clinical Practice Research Datalink (CPRD) (1 January 2000-31 December 2013).

METHODS

Clinical Practice Research Datalink was searched for pregnancy terms to identify adverse pregnancy outcome. Each identified case was matched to five livebirths.

MAIN OUTCOME MEASURES

Diagnosis of SLE, CTD, APS or autoimmune antibodies. Poisson regression was performed to calculate relative risk ratios (RR), comparing adverse pregnancy outcome with livebirth cohorts.

RESULTS

Clinical Practice Research Datalink identified 20 123 adverse pregnancy outcomes matched to 97 323 livebirths, with a total of 875 590 person-years follow up. Median follow up from study entry was 7.29 years (SD 4.39). Compared with women with an uncomplicated livebirth, women with adverse pregnancy outcome had an increased risk of developing CTD or autoimmune antibodies (RR 3.20, 95% CI 2.90-3.51). Risk was greatest following a stillbirth (RR 5.82, 95% CI 4.97-6.81). For CTD and SLE, the risk was greatest within the first 5 years of adverse pregnancy outcome. Risk for aPL and APS diagnosis was highest ≥5 years from adverse pregnancy outcome.

CONCLUSIONS

Adverse pregnancy outcome is associated with increased risk of developing maternal CTD, including SLE. Either immunological factors predispose women to adverse pregnancy outcome and subsequent CTD diagnosis or, alternatively, adverse pregnancy outcome initiates autoimmune events which culminate in CTD in later life.

TWEETABLE ABSTRACT

Stillbirth is associated with increased maternal risk of developing systemic lupus erythematosus (SLE).

Inherited susceptibility to miscarriage: a nested case-control study of 31,565 women from an intergenerational cohort

BACKGROUND

Miscarriage can be a devastating outcome for couples, and most miscarriages are unexplained. Many adverse obstetric outcomes (such as preeclampsia, preterm birth, and growth restriction) are thought to be inherited. It is possible that these conditions could share similar pathophysiologic mechanisms (such as endothelial dysfunction) with miscarriage. Therefore, it was hypothesized that there could be a susceptibility to miscarriage transmitted from mother to daughter.

OBJECTIVE

This study aimed to investigate the association between a maternal history of miscarriage and the risk of miscarriage in daughters.

STUDY DESIGN

A case-control study nested within an intergenerational cohort was conducted. Mother-daughter pairs were identified from the intergenerational cohort within the Aberdeen Maternity and Neonatal Databank, United Kingdom. A mother's history of miscarriage was the exposure. The primary outcome was miscarriage in daughters. There were 31,565 mother-daughter pairs who were eligible for inclusion. A population average model that used generalized estimating equations with robust standard errors was used to estimate the odds of a mother's history of miscarriage in daughters with a miscarriage compared with daughters with only livebirths. This method accounted for clustering of daughters within mothers, and multiadjusted analyses were performed to include confounders at the daughter's pregnancy level.

RESULTS

Daughters who miscarried had 11% greater odds of being born to mothers with a history of miscarriage (adjusted odds ratio, 1.11; 95% confidence interval, 1.01-1.22). Daughters with recurrent miscarriage (≥2) were also more likely to be born to a mother with a history of miscarriage (adjusted odds ratio, 1.25; 95% confidence interval, 1.04-1.49).

CONCLUSION

There may be an inherited predisposition to miscarriage transmitted from mother to daughter. Future research should investigate genetic or familial environmental factors that may predispose women to miscarriage.

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

BACKGROUND

Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD.

METHODS

We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI).

RESULTS

Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage.

CONCLUSIONS

Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

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.

Relation of Pregnancy Loss to Risk of Cardiovascular Disease in Parous Postmenopausal Women (From the Women's Health Initiative)

Women with history of pregnancy loss (PL) have higher burden of cardiovascular disease (CVD) later in life, yet it is unclear whether this is attributable to an association with established CVD risk factors (RFs). We examined whether PL is associated with CVD RFs and biomarkers in parous postmenopausal women in the Women's Health Initiative, and whether the association between PL and CVD RFs accounted for the association between PL and incident CVD. Linear and logistic regressions were used to estimate associations between baseline history of PL and CVD RFs. Cox proportional hazards regression models were used to estimate the associations between baseline history of PL and incident CVD after adjustment for baseline RFs. Of 79,121 women, 27,272 (35%) had experienced PL. History of PL was associated with higher body mass index (p < 0.0001), hypertension (p < 0.0001), diabetes (p = 0.003), depression (p < 0.0001), and lower income (p < 0.0001), physical activity (p = 0.01), poorer diet (p < 0.0001), smoking (p < 0.0001), and alcohol use (p < 0.0001). After adjustment for CVD RFs, PL was significantly associated with incident CVD over mean follow up of 16 years (hazard ratio 1.11, 95% confidence interval 1.06 to 1.16). In conclusion, several CVD RFs are associated with PL, but they do not entirely account for the association between PL and incident CVD.

Association between reproductive factors and carotid atherosclerosis in post-menopausal women

OBJECTIVES

Assessment of cardiovascular risk in women is specific and hormonal factors should be considered to avoid its underestimation. So far, studies on this issue are lacking and the impact of reproductive factors on cardiovascular risk has yet to be determined. We study the association between reproductive factors and carotid atherosclerosis, a non-invasive marker of cardiovascular diseases, in post-menopause.

STUDY DESIGN

In this cross-sectional study, data were analyzed from post-menopausal women with at least one cardiovascular risk factor followed through a dedicated healthcare pathway at the Lille University Hospital between January 1st, 2013 and December 31st, 2016.

MAIN OUTCOME AND MEASURES

The primary outcome was the presence of plaque or stenosis at carotid ultrasound.

RESULTS

We included 370 post-menopausal women with a mean age of 63.4 ± 0.5 years. Carotid atherosclerosis was found in 161 (43,3%) women. Women with 3 or more children had higher odds of having carotid atherosclerosis than women with fewer than 3 children after adjustment for age, OR 1,69 [CI 95% 1,09-2,61], p = 0,019, and after further adjustment for anthropometric measures, traditional cardiovascular risk factors and pregnancy-related complications: OR 1,65 [CI 95% 1,05-2,62], p = 0,031. No other reproductive factor was significantly associated with carotid atherosclerosis.

CONCLUSIONS

A higher parity was associated with higher odds of carotid atherosclerosis independently of age, traditional risk factors, anthropometric measures and gestational diseases among post-menopausal women at risk of cardiovascular diseases. This suggests the importance of considering the number of children when assessing cardiovascular risk in women.

Pregnancy loss and risk of later dementia: A nationwide cohort study, Denmark, 1977-2017

INTRODUCTION

Pregnancy losses may be associated with increased risks of dementia.

METHODS

We conducted a register-based cohort study in 1,243,957 women with ≥1 pregnancy in Denmark in the period 1977-2015. Using Cox regression, we estimated hazard ratios (HRs) comparing risks of dementia in women with and without pregnancy losses.

RESULTS

During 21,672,433 person-years of follow-up, 261,279 women experienced a pregnancy loss, and 2188 women were diagnosed with dementia. Stillbirth was associated with an 86% increased risk of dementia overall (HR 1.86, 95% confidence interval [CI] 1.28-2.71). By contrast, miscarriage was not associated with later risk of dementia overall (single miscarriage, HR 0.99, 95% CI 0.87-1.12; recurrent miscarriages, HR 1.06, 95% CI 0.84-1.35). Adjustment for cardiovascular disease, hypertension, and diabetes did not meaningfully alter the association magnitudes.

DISCUSSION

Stillbirth and dementia may share underlying mechanisms, suggesting that a history of stillbirth should be considered when assessing dementia risk in women.

Pregnancy Complications as a Window to Future Cardiovascular Disease

Pregnancy is a time of significant hemodynamic, metabolic, and hormonal stress that can unmask underlying subclinical cardiovascular abnormalities, and pregnancy-related complications may serve as early warning signs for future risk of cardiovascular disease. The increased recognition of these sex-specific risk factors could identify women who may benefit from more intensive risk factor modification to reduce morbidity and mortality later in life. In this review, we describe several pregnancy-related complications that have been associated with the risk of cardiovascular disease, including hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm delivery, and pregnancy loss. Pregnancy-associated risk factors must be identified to fully assess a woman's future cardiovascular risk and may influence strategies for risk reduction.

Protein signatures linking history of miscarriages and metabolic syndrome: a proteomic study among North Indian women

Background

Metabolic syndrome (MeS), a constellation of metabolic adversities, and history of miscarriage make women at a higher risk for cardiovascular diseases (CVDs). However, molecular evidence indicating a link between the two phenotypes (history of miscarriage and MeS) among women would offer an opportunity to predict the risk factor for CVDs at an early stage. Thus, the present retrospective study attempts to identify the proteins signatures (if any) to understand the connection between the history of miscarriage and MeS.

Methods

Age-matched 80 pre-menopausal women who were not on any medical intervention or drugs were recruited from a Mendelian population of the same gene pool. Recruited women were classified into four groups—(a) Group A—absolute cases with history of miscarriage and MeS, (b) Group B—absolute controls without any history of miscarriage and MeS, (c) Group C—cases with MeS but lack any history of miscarriage, (d) Group D—cases with history of miscarriage but lack MeS. Differentially expressed proteins in plasma samples of women from four groups were identified using 2-D gel electrophoresis and mass spectrometry.

Results

Three case groups (A, C, and D) showed 18 differentially expressed proteins. Nearly 60% of proteins (11/18) were commonly dysregulated in Group C (only with MeS) and Group D (only with miscarriage history). Nearly 40% of proteins (7/18) were commonly dysregulated in the three case groups (Groups A, C, and D), indicating a shared pathophysiology. Four proteins were exclusive but shared by case groups C and D indicating the independent routes for CVDs through MeS or miscarriages. In absolute cases, transthyretin (TTR) showed exclusive upregulation, which was further validated by Western blotting and ELISA. Networking analyses showed the strong association of TTR with haptoglobin, transferrin and ApoA1 hinting toward a cross-talk among these proteins which could be a cause or an effect of TTR upregulation.

Conclusion

The study provides evidence for molecular link between the history of miscarriage and MeS through a putative role of TTR. However, longitudinal follow-up studies with larger sample size would further help to demonstrate the significance of TTR and other targeted proteins in risk stratification and the onset of CVDs.

Mechanisms of Sex Disparities in Cardiovascular Function and Remodeling

Epidemiological studies demonstrate disparities between men and women in cardiovascular disease prevalence, clinical symptoms, treatments, and outcomes. Enrollment of women in clinical trials is lower than men, and experimental studies investigating molecular mechanisms and efficacy of certain therapeutics in cardiovascular disease have been primarily conducted in male animals. These practices bias data interpretation and limit the implication of research findings in female clinical populations. This review will focus on the biological origins of sex differences in cardiovascular physiology, health, and disease, with an emphasis on the sex hormones, estrogen and testosterone. First, we will briefly discuss epidemiological evidence of sex disparities in cardiovascular disease prevalence and clinical manifestation. Second, we will describe studies suggesting sexual dimorphism in normal cardiovascular function from fetal life to older age. Third, we will summarize and critically discuss the current literature regarding the molecular mechanisms underlying the effects of estrogens and androgens on cardiac and vascular physiology and the contribution of these hormones to sex differences in cardiovascular disease. Fourth, we will present cardiovascular disease risk factors that are positively associated with the female sex, and thus, contributing to increased cardiovascular risk in women. We conclude that inclusion of both men and women in the investigation of the role of estrogens and androgens in cardiovascular physiology will advance our understanding of the mechanisms underlying sex differences in cardiovascular disease. In addition, investigating the role of sex-specific factors in the development of cardiovascular disease will reduce sex and gender disparities in the treatment and diagnosis of cardiovascular disease. © 2019 American Physiological Society. Compr Physiol 9:375-411, 2019.

Cardiovascular disease risk unmasked by pregnancy complications

Pregnancy related complications indicate a propensity for atherosclerotic disease. Epidemiologic data demonstrate early onset cardiovascular disease in women with a history of pregnancy loss, preterm pregnancy or pregnancy complicated by intrauterine growth restriction. Early onset diabetes, increased rates of MI and increased rates of stroke are more prevalent after gestational diabetes. In addition, hypertensive disorders of pregnancy mark significant pathophysiologic changes, including vascular dysfunction and immunologic changes, which induce atherogenesis and result in a substantial increase in rates of stroke, ischemic heart disease and cardiac mortality. Metabolic, endothelial and inflammatory changes are responsible for either the early onset or early recognition of cardiovascular disease propensity in patients who experience a complicated pregnancy. Therefore, the American Heart Association guidelines recognize pregnancy related complications as an independent risk factor for heart disease. This review informs physicians of epidemiologic data and, guideline recommendations and is meant to guide physicians in early interventions including provider education, routine post-partum multidisciplinary (primary care, obstetrics, cardiology) evaluation, risk factor monitoring and control after a complicated pregnancy.

Early or late pregnancy loss and development of clinical cardiovascular disease risk factors: a prospective cohort study

OBJECTIVE

To assess the association between the outcome of a woman's first pregnancy and risk of clinical cardiovascular disease risk factors.

DESIGN

Prospective cohort study.

SETTING AND POPULATION

Nurses' Health Study II.

METHODS

Multivariable-adjusted Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between first pregnancy outcome and hypertension, type 2 diabetes, and hypercholesterolemia.

MAIN OUTCOME MEASURES

Hypertension, type 2 diabetes, and hypercholesterolemia.

RESULTS

Compared to women who reported a singleton live first birth, women with early spontaneous abortion (<12 weeks) had a greater rate of type 2 diabetes (HR: 1.20; 95% CI: 1.07-1.34) and hypercholesterolemia (HR: 1.06; 95% CI: 1.02-1.10), and a marginally increased rate of hypertension (HR: 1.05, 95% CI: 1.00-1.11). Late spontaneous abortion (12-19 weeks) was associated with an increased rate of type 2 diabetes (HR: 1.38; 95% CI: 1.14-1.65), hypercholesterolemia (HR: 1.11; 95% CI: 1.03-1.19), and hypertension (HR: 1.15; 95% CI: 1.05-1.25). The rates of type 2 diabetes (HR: 1.45; 95% CI: 1.13-1.87) and hypertension (HR: 1.15; 95% CI: 1.01-1.30) were higher in women who delivered stillbirth. In contrast, women whose first pregnancy ended in an induced abortion had lower rates of hypertension (HR: 0.87; 95% CI: 0.84-0.91) and type 2 diabetes (HR: 0.89; 95% CI: 0.79-0.99) than women with a singleton live birth.

CONCLUSIONS

Several types of pregnancy loss were associated with an increased rate of hypertension, type 2 diabetes, and hypercholesterolemia, which may provide novel insight into the pathways through which pregnancy outcomes and CVD are linked.

TWEETABLE ABSTRACT

Pregnancy loss is associated with later maternal risk of hypertension, type 2 diabetes, and hypercholesterolemia.

Pregnancy-Related Risk Factors Are Associated With a Significant Burden of Treated Hypertension Within 10 Years of Delivery: Findings From a Population-Based Norwegian Cohort

BACKGROUND

The association between pregnancy complications and women's later cardiovascular disease has, primarily, been evaluated in studies lacking information on important covariates. This report evaluates the prospective associations between pregnancy-related risk factors (preeclampsia/eclampsia, gestational hypertension, pregestational and gestational diabetes mellitus, preterm delivery, and fetal growth restriction) and pharmacologically treated hypertension within 10 years after pregnancy, while adjusting for a wide range of covariates.

METHODS AND RESULTS

Prepregnancy normotensive women participating in the MoBa (Norwegian Mother and Child Cohort Study) from January 2004 through July 2009 were linked to the Norwegian Prescription Database to identify women with pharmacologically treated hypertension beyond the postpartum period of 3 months. The burden of hypertension associated with pregnancy-related risk factors was evaluated using an attributable fraction method. A total of 1480 women developed pharmacologically treated hypertension within the follow-up among 60 027 women (rate of hypertension, 3.6/1000 person-years). The proportion of hypertension associated with a history of preeclampsia/eclampsia, gestational hypertension, preterm delivery, and pregestational or gestational diabetes mellitus was 28.6% (95% confidence interval, 25.5%-31.6%) on the basis of multivariable analyses adjusting for numerous covariates. The proportion was similar for women with a healthy prepregnancy body mass index (18.5-24.9 kg/m2; attributable fraction (AF)% 25.9%; 95% confidence interval, 21.3%-30.3%), but considerably higher for nulliparous women at baseline within the first 5 years of follow-up. Small-for-gestational age, however, did not increase subsequent hypertension risk in multivariable analyses.

CONCLUSIONS

A structured postpartum follow-up of high-risk women identified through pregnancy-related risk factors would facilitate personalized preventive strategies to postpone or avoid onset of premature cardiovascular events.

Preconception Blood Pressure Levels and Reproductive Outcomes in a Prospective Cohort of Women Attempting Pregnancy

Elevated blood pressure in young adulthood is an early risk marker for cardiovascular disease. Despite a strong biological rationale, little research has evaluated whether incremental increases in preconception blood pressure have early consequences for reproductive health. We evaluated preconception blood pressure and fecundability, pregnancy loss, and live birth in the EAGeR trial (Effects of Aspirin on Gestational and Reproduction; 2007-2011), a randomized clinical trial of aspirin and reproductive outcomes among 1228 women attempting pregnancy with a history of pregnancy loss. Systolic and diastolic blood pressure were measured during preconception in the first observed menstrual cycle and in early pregnancy and used to derive mean arterial pressure. Fecundability was assessed as number of menstrual cycles until pregnancy, determined through human chorionic gonadotropin testing. Pregnancy loss included both human chorionic gonadotropin-detected and clinical losses. Analyses adjusted for treatment assignment, age, body mass index, race, marital status, smoking, parity, and time since last loss. Mean preconception systolic and diastolic blood pressure were 111.6 mm Hg (SD, 12.1) and 72.5 (SD, 9.4) mm Hg. Risk of pregnancy loss increased 18% per 10 mm Hg increase in diastolic blood pressure (95% confidence interval, 1.03-1.36) and 17% per 10 mm Hg increase in mean arterial pressure (95% confidence interval, 1.02-1.35) in adjusted analyses. Findings were similar for early pregnancy blood pressure. Preconception blood pressure was not related to fecundability or live birth in adjusted analyses. Findings suggest that preconception blood pressure among healthy women is associated with pregnancy loss, and lifestyle interventions targeting blood pressure among young women may favorably impact reproductive health.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00467363.

Pregnancy Loss and Carotid Intima-Media Thickness in Mexican Women

BACKGROUND

Cardiovascular disease in women often develops without conventional risk factors. Prenatal loss is a common pregnancy outcome that may result in physiological changes can increase the potential future risk of cardiovascular disease. Insufficient information exists regarding the impact of pregnancy loss on early markers of cardiovascular disease risk.

METHODS AND RESULTS

Cross-sectional analysis of 1767 disease-free women from the MTC (Mexican Teachers' Cohort) who had been pregnant was used to evaluate the relationship between pregnancy loss and carotid intima-media thickness (IMT). Participants responded to a questionnaire regarding their reproductive history, risk factors, and medical conditions. We defined pregnancy loss as history of miscarriage and/or stillbirth. Trained neurologists measured IMT using ultrasound. We log-transformed IMT and defined subclinical carotid atherosclerosis (SCA) as IMT ≥0.8 mm and/or plaque. We used multivariable linear and logistic regression models to assess the relation of pregnancy loss, IMT, and SCA. The mean age of participants was 49.8±5.1 years. The prevalence of pregnancy loss was 22%, and we observed SCA in 23% of participants. Comparing participants who reported a pregnancy loss and those who did not, the multivariable-adjusted odds ratio for SCA was 1.52 (95% confidence interval, 1.12-2.06). Women who experienced a stillbirth had 2.32 higher odds (95% confidence interval, 1.03-5.21) of SCA than those who did not. Mean IMT appeared to be higher in women who reported a pregnancy loss relative to those who did not; nevertheless, this was not statistically significant.

CONCLUSIONS

Pregnancy loss could be linked to cardiovascular disease later in life. The key findings of our study await confirmation and further investigation of the potential underlying mechanisms for this association is required.

History of Adverse Pregnancy Outcomes, Blood Pressure, and Subclinical Vascular Measures in Late Midlife: SWAN (Study of Women's Health Across the Nation)

BACKGROUND

Adverse pregnancy outcomes, such as preterm birth (PTB), have been associated with elevated risk of maternal cardiovascular disease, but their effect on late midlife blood pressure (BP) and subclinical vascular measures remains understudied.

METHODS AND RESULTS

We conducted a cross-sectional analysis with 1220 multiethnic parous women enrolled in SWAN (Study of Women's Health Across the Nation) to evaluate the impact of self-reported history of adverse pregnancy outcomes (PTB, small-for-gestational-age, stillbirth), on maternal BP, mean arterial pressure, and subclinical vascular measures (carotid intima-media thickness, plaque, and pulse wave velocity) in late midlife. We also examined whether these associations were modified by race/ethnicity. Associations were tested in linear and logistic regression models adjusting for sociodemographics, reproductive factors, cardiovascular risk factors, and medications. Women were on average aged 60 years and 255 women reported a history of an adverse pregnancy outcome. In fully adjusted models, history of PTB was associated with higher BP (systolic: β=6.40; SE, 1.62 [P<0.0001] and diastolic: β=3.18; SE, 0.98 [P=0.001]) and mean arterial pressure (β=4.55; SE 1.13 [P<0.0001]). PTB was associated with lower intima-media thickness, but not after excluding women with prevalent hypertension. There were no significant associations with other subclinical vascular measures.

CONCLUSIONS

Findings suggest that history of PTB is associated with higher BP and mean arterial pressure in late midlife. Adverse pregnancy outcomes were not significantly related to subclinical cardiovascular disease when excluding women with prevalent hypertension. Future studies across the menopause transition may be important to assess the impact of adverse pregnancy outcomes on midlife progression of BP.

Coronary microvascular dysfunction is not associated with a history of reproductive risk factors in women with angina pectoris-An iPOWER substudy

BACKGROUND

Reproductive risk factors such as preeclampsia and recurrent miscarriages have been associated with adverse cardiovascular (CV) events. Underlying coronary microvascular dysfunction (CMD) may be a common denominator.

PURPOSE

We investigated whether a history of reproductive risk factors was associated with CMD in women with angina pectoris and no obstructive coronary artery disease (CAD).

METHODS

Participants from the iPOWER study, including women with angina pectoris and no obstructive CAD (<50% stenosis), were invited to complete an electronic survey regarding reproductive risk factors: recurrent miscarriages, gestational diabetes, preeclampsia, rhesus immunity, polycystic ovary syndrome and menopausal status as well as migraine and Raynaud phenomenon. CMD was assessed by transthoracic Doppler echocardiography with measurement of coronary flow velocity reserve (CFVR) during high-dose dipyridamole infusion, and analyzed in three categories with cut-off points at 2.0 and 2.5. Associations between CFVR and a history of reproductive risk factors were examined by age-adjusted trend test.

RESULTS

The questionnaire was completed by 613 women (73% of those invited), of whom 550 had a successful CFVR measurement. There was no significant difference in baseline characteristics between participants and non-participants. Median (interquartile range (IQR)) age was 62.8 (54.8; 68.7) years, median (IQR) BMI 26.2 (23.2; 29.8) kg/m², and 81.5% were postmenopausal. We did not find any significant associations between any of the reproductive risk factors, Raynaud's phenomenon or migraine and CFVR.

CONCLUSION

The lack of association between coronary microvascular function and a history of reproductive risk factors, migraine and Raynaud's phenomenon suggests that a common vascular pathophysiological mechanism underlying these conditions is unlikely.

Pregnancy, pregnancy loss, and the risk of cardiovascular disease in Chinese women: findings from the China Kadoorie Biobank

BACKGROUND

Pregnancy and pregnancy loss may be linked to cardiovascular disease (CVD). However, the evidence is still inconsistent, especially in East Asians, whose reproductive patterns differ importantly from those in the West. We examined the associations of pregnancy, miscarriage, induced abortion, and stillbirth with CVD incidence among Chinese women.

METHODS

In 2004-2008, the nationwide China Kadoorie Biobank recruited 302,669 women aged 30-79 years from ten diverse localities. During 7 years of follow-up, 43,968 incident cases of circulatory disease, 14,440 of coronary heart disease, and 19,925 of stroke (including 11,430 ischaemic and 2170 haemorrhagic strokes), were recorded among 289,573 women without prior CVD at baseline. Cox regression yielded multiple adjusted hazard ratios (HRs) for CVD risks associated with pregnancy outcomes.

RESULTS

Overall, 99% of women had been pregnant, and among them 10%, 53%, and 7% reported having a history of miscarriage, induced abortion, and stillbirth, respectively. Each additional pregnancy was associated with an adjusted HR of 1.03 (95% confidence interval, CI: 1.02; 1.04) for circulatory disease. A history of miscarriage, induced abortion, and stillbirth, respectively, were associated with adjusted HRs of 1.04 (1.01; 1.07), 1.04 (1.02; 1.07), and 1.07 (1.03; 1.11) for circulatory disease. The relationship was stronger with recurrent pregnancy loss; adjusted HRs for each additional loss being 1.04 (1.00; 1.09) for miscarriage, 1.02 (1.01; 1.04) for induced abortion, and 1.04 (1.00; 1.08) for stillbirth.

CONCLUSIONS

Among Chinese women, increases in pregnancy, and a history and recurrence of miscarriage, induced abortion, and stillbirth are each associated with a higher risk of CVD.

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.

Reproductive Factors and Incidence of Heart Failure Hospitalization in the Women's Health Initiative

BACKGROUND

Reproductive factors reflective of endogenous sex hormone exposure might have an effect on cardiac remodeling and the development of heart failure (HF).

OBJECTIVES

This study examined the association between key reproductive factors and the incidence of HF.

METHODS

Women from a cohort of the Women's Health Initiative were systematically evaluated for the incidence of HF hospitalization from study enrollment through 2014. Reproductive factors (number of live births, age at first pregnancy, and total reproductive duration [time from menarche to menopause]) were self-reported at study baseline in 1993 to 1998. We employed Cox proportional hazards regression analysis in age- and multivariable-adjusted models.

RESULTS

Among 28,516 women, with an average age of 62.7 ± 7.1 years at baseline, 1,494 (5.2%) had an adjudicated incident HF hospitalization during an average follow-up of 13.1 years. After adjusting for covariates, total reproductive duration in years was inversely associated with incident HF: hazard ratios (HRs) of 0.99 per year (95% confidence interval [CI]: 0.98 to 0.99 per year) and 0.95 per 5 years (95% CI: 0.91 to 0.99 per 5 years). Conversely, early age at first pregnancy and nulliparity were significantly associated with incident HF in age-adjusted models, but not after multivariable adjustment. Notably, nulliparity was associated with incident HF with preserved ejection fraction in the fully adjusted model (HR: 2.75; 95% CI: 1.16 to 6.52).

CONCLUSIONS

In post-menopausal women, shorter total reproductive duration was associated with higher risk of incident HF, and nulliparity was associated with higher risk for incident HF with preserved ejection fraction. Whether exposure to endogenous sex hormones underlies this relationship should be investigated in future studies.