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Original Investigation
September 16, 2020

Association of Adverse Pregnancy Outcomes With Risk of Atherosclerotic Cardiovascular Disease in Postmenopausal Women

Author Affiliations
  • 1Aalborg University School of Medicine and Health, Aalborg, Denmark
  • 2Stanford University School of Medicine, Stanford, California
  • 3UCSF School of Medicine, University of California, San Francisco
  • 4UC San Diego School of Medicine, University of California, San Diego
  • 5Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 6Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 7University of Florida School of Medicine, Gainesville
  • 8Brown University Alpert School of Medicine, Providence, Rhode Island
  • 9Ohio State University College of Public Health, Columbus
  • 10MedStar Health, Washington, DC
  • 11Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Cardiol. Published online September 16, 2020. doi:10.1001/jamacardio.2020.4097
Key Points

Question  Do adverse pregnancy outcomes represent independent risk factors for atherosclerotic cardiovascular disease in women?

Findings  In this cohort study including 46 805 Women’s Health Initiative participants, hypertensive disorders of pregnancy and low birth weight were independently associated with atherosclerotic cardiovascular disease after adjustment for standard risk factors and other adverse pregnancy outcomes.

Meaning  Adverse pregnancy outcomes are sex-specific risk factors for atherosclerotic cardiovascular disease in women.

Abstract

Importance  Atherosclerotic cardiovascular disease (ASCVD) may have unique risk factors in women. Most women have a history of pregnancy; common adverse pregnancy outcomes (APOs) appear to be associated with ASCVD, but prior studies have limitations.

Objective  To assess whether APOs are associated with increased ASCVD risk independently of traditional risk factors.

Design, Setting, and Participants  The APO history among participants in the Women’s Health Initiative, a large multiethnic cohort of postmenopausal women, was assessed. The associations of 5 self-reported APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight [ie, birth weight less than 2.49 kg], high birth weight [ie, birth weight greater than 4.08 kg], and preterm delivery by 3 weeks or more) with ASCVD were analyzed, adjusting for traditional ASCVD risk factors. Data were collected and analyzed in 2017.

Exposures  APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight, high birth weight, and preterm delivery).

Main Outcomes and Measures  Adjudicated ASCVD.

Results  A total of 48 113 Women’s Health Initiative participants responded to the survey; the median (interquartile range) age at time of enrollment was 60.0 (55.0-64.0) years. A total of 13 482 participants (28.8%) reported 1 or more APOs. Atherosclerotic cardiovascular disease was more frequent in women who reported an APO compared with those without APOs (1028 of 13 482 [7.6%] vs 1758 of 30 522 [5.8%]). Each APO, analyzed separately, was significantly associated with ASCVD, and gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and preterm delivery remained significant after adjustment for traditional ASCVD risk factors. When all APOs were analyzed together, hypertensive disorders of pregnancy (odds ratio, 1.27; 95% CI, 1.15-1.40) and low birth weight (odds ratio, 1.12; 95% CI, 1.00-1.26) remained independently associated with ASCVD. All findings were materially unchanged by additional adjustment for parity, body mass index, and socioeconomic factors.

Conclusions and Relevance  In this large multiethnic cohort of women, hypertensive disorders of pregnancy and low birth weight were independently associated with ASCVD after adjustment for risk factors and other APOs.

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