Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease

Kartik K Venkatesh; Sadiya S Khan; Janet Catov; Jiqiang Wu; Rebecca McNeil; Philip Greenland; Jun Wu; Lisa D Levine; Lynn M Yee; Hyagriv N Simhan; David M Haas; Uma M Reddy; George Saade; Robert M Silver; C Noel Bairey Merz; William A Grobman

doi:10.1016/j.ajog.2024.05.007

Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease

Am J Obstet Gynecol. 2024 May 15:S0002-9378(24)00589-1. doi: 10.1016/j.ajog.2024.05.007. Online ahead of print.

Authors

Kartik K Venkatesh¹, Sadiya S Khan², Janet Catov³, Jiqiang Wu⁴, Rebecca McNeil⁵, Philip Greenland², Jun Wu⁶, Lisa D Levine⁷, Lynn M Yee⁸, Hyagriv N Simhan³, David M Haas⁹, Uma M Reddy¹⁰, George Saade¹¹, Robert M Silver¹², C Noel Bairey Merz¹³, William A Grobman⁴

Affiliations

¹ Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH. Electronic address: Kartik.venkatesh@osumc.edu.
² Departments of Preventive Medicine and Medicine, Northwestern University, Chicago, IL.
³ Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA.
⁴ Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH.
⁵ RTI International, Durham, NC.
⁶ Department of Environmental and Occupational Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Orange, CA.
⁷ Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
⁸ Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL.
⁹ Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN.
¹⁰ Department of Obstetrics and Gynecology, Columbia University, New York, NY.
¹¹ Department of Obstetrics and Gynecology, Eastern Virginia Medical College, Norfolk, VA.
¹² Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
¹³ Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA.

PMID: 38759711
DOI: 10.1016/j.ajog.2024.05.007

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.

Keywords: cardiovascular disease; cardiovascular health; pregnancy; social determinants of health; socioeconomic disadvantage; women.