Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease - 11/07/24

Doi : 10.1016/j.ajog.2024.05.007

Kartik K. Venkatesh, MD, PhD ^a,^⁎ , Sadiya S. Khan, MD, MSc ^b, Janet Catov, PhD ^c, Jiqiang Wu, MSc ^a, Rebecca McNeil, PhD ^d, Philip Greenland, MD ^b, Jun Wu, PhD ^e, Lisa D. Levine, MD ^f, Lynn M. Yee, MD, MPH ^g, Hyagriv N. Simhan, MD ^c, David M. Haas, MD ^h, Uma M. Reddy, MD, MPH ⁱ, George Saade, MD ^j, Robert M. Silver, MD ^k, C. Noel Bairey Merz, MD ^l, William A. Grobman, MD, MBA ^a
^a Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH
^b Departments of Preventive Medicine and Medicine, Northwestern University, Chicago, IL
^c Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA
^d RTI International, Durham, NC
^e Department of Environmental and Occupational Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Orange, CA
^f Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
^g Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
^h Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN
ⁱ Department of Obstetrics and Gynecology, Columbia University, New York, NY
^j Department of Obstetrics and Gynecology, Eastern Virginia Medical College, Norfolk, VA
^k Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
^l Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA

^∗Corresponding author: Kartik K. Venkatesh, MD, PhD.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 11 July 2024

Abstract

Background

Pregnancy is an educable and actionable life stage to address social determinants of health (SDOH) and lifelong cardiovascular disease (CVD) prevention. However, the link between a risk score that combines multiple neighborhood-level social determinants in pregnancy and the risk of long-term CVD remains to be evaluated.

Objective

To examine whether neighborhood-level socioeconomic disadvantage measured by the Area Deprivation Index (ADI) in early pregnancy is associated with a higher 30-year predicted risk of CVD postpartum, as measured by the Framingham Risk Score.

Study Design

An analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be Heart Health Study longitudinal cohort. Participant home addresses during early pregnancy were geocoded at the Census-block level. The exposure was neighborhood-level socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]) measured in the first trimester. Outcomes were the predicted 30-year risks of atherosclerotic cardiovascular disease (ASCVD, composite of fatal and nonfatal coronary heart disease and stroke) and total CVD (composite of ASCVD plus coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication, and heart failure) using the Framingham Risk Score measured 2 to 7 years after delivery. These outcomes were assessed as continuous measures of absolute estimated risk in increments of 1%, and, secondarily, as categorical measures with high-risk defined as an estimated probability of CVD ≥10%. Multivariable linear regression and modified Poisson regression models adjusted for baseline age and individual-level social determinants, including health insurance, educational attainment, and household poverty.

Results

Among 4309 nulliparous individuals at baseline, the median age was 27 years (interquartile range [IQR]: 23–31) and the median ADI was 43 (IQR: 22–74). At 2 to 7 years postpartum (median: 3.1 years, IQR: 2.5, 3.7), the median 30-year risk of ASCVD was 2.3% (IQR: 1.5, 3.5) and of total CVD was 5.5% (IQR: 3.7, 7.9); 2.2% and 14.3% of individuals had predicted 30-year risk ≥10%, respectively. Individuals living in the highest ADI tertile had a higher predicted risk of 30-year ASCVD % (adjusted ß: 0.41; 95% confidence interval [CI]: 0.19, 0.63) compared with those in the lowest tertile; and those living in the top 2 ADI tertiles had higher absolute risks of 30-year total CVD % (T2: adj. ß: 0.37; 95% CI: 0.03, 0.72; T3: adj. ß: 0.74; 95% CI: 0.36, 1.13). Similarly, individuals living in neighborhoods in the highest ADI tertile were more likely to have a high 30-year predicted risk of ASCVD (adjusted risk ratio [aRR]: 2.21; 95% CI: 1.21, 4.02) and total CVD ≥10% (aRR: 1.35; 95% CI: 1.08, 1.69).

Conclusion

Neighborhood-level socioeconomic disadvantage in early pregnancy was associated with a higher estimated long-term risk of CVD postpartum. Incorporating aggregated SDOH into existing clinical workflows and future research in pregnancy could reduce disparities in maternal cardiovascular health across the lifespan, and requires further study.

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Key words : cardiovascular disease, cardiovascular health, pregnancy, social determinants of health, socioeconomic disadvantage, women

Plan

Introduction

Materials and methods

Results in the context of what is known

Clinical implications

Research implications

Strengths and limitations

Conclusions

	K.K.V. reports receiving research support from the Care Innovation and Community Improvement Program at The Ohio State University. S.S.K., J.C., J.W., R.M., P.G., J.W., L.D.L., L.M.Y., H.N.S., D.M.H., U.M.R., G.S., R.M.S., C.N.B.M., and W.A.G. report no conflict of interest.
	This study was supported by grant funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; U10 HD063036; U10 HD063072; U10 HD063047; U10 HD063037; U10 HD063041; U10 HD063020; U10 HD063046; U10 HD063048; and U10 HD063053). In addition, support was provided by the Clinical and Translational Science Institutes (UL1TR001108 and UL1TR000153). This study was also supported by a cooperative agreement funding from the National Heart, Lung, and Blood Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (U10-HL119991; U10-HL119989; U10-HL120034; U10-HL119990; U10-HL120006; U10-HL119992; U10-HL120019; U10-HL119993; U10-HL120018, and U01HL145358), the National Center for Advancing Translational Sciences through UL-1-TR000124, UL-1-TR000153, UL-1-TR000439, and UL-1-TR001108; and U54AG065141, the Barbra Streisand Women's Cardiovascular Research and Education Program, and the Erika J. Glazer Women's Heart Research Initiative, Cedars-Sinai Medical Center, Los Angeles; with supplemental support to U10-HL119991 from the Office of Research on Women's Health, the Office of Disease Prevention, and the Office of Behavioral and Social Sciences Research.
	Presented orally at the American Heart Association, Philadelphia, PA, Nov. 11, 2023.
	Cite this article as: Venkatesh KK, Khan SS, Catov J, et al. Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease. Am J Obstet Gynecol 2024;XXX:XX–XX.