Association of number of live births with left ventricular structure and function. The Multi-Ethnic Study of Atherosclerosis (MESA)

doi:10.1016/j.ahj.2011.12.011

American Heart Journal

Volume 163, Issue 3, March 2012, Pages 470-476

https://doi.org/10.1016/j.ahj.2011.12.011 Get rights and content

Background

Pregnancy is associated with marked maternal cardiovascular/hemodynamic changes. A greater number of pregnancies may be associated with long-term subclinical changes in left ventricular (LV) remodeling.

Methods

Among 2,234 white, black, Hispanic, and Chinese women (mean age 62 years) in the MESA, we used linear regression to relate live births and cardiac magnetic resonance imaging LV measures. Covariates included age, ethnicity, height, income, education, birth country, smoking, menopause, and oral contraceptive duration. Models were additionally adjusted for potential mediators: systolic blood pressure, antihypertensive use, total/high-density lipoprotein cholesterol, triglycerides, diabetes, and body mass index. We performed sensitivity analyses excluding 763 women in the lowest socioeconomic group: annual income <$25,000 and lower high school level of education.

Results

With each live birth, LV mass increased 1.26 g; LV end-diastolic volume, 0.74 mL; and LV end-systolic volume, 0.45 mL; LV ejection fraction decreased 0.18% (P trend <0.05). Changes were most notable for the category of women with ≥5 pregnancies. Upon adjustment for potential biologic mediators, live births remained positively associated with LV mass and end-systolic volume. Live births remained significantly associated with LV end-systolic, end-diastolic volumes, and LV mass (P trend ≤0.02) after excluding women in the lowest socioeconomic group.

Conclusions

Number of live births is associated with key LV structural and functional measures in middle to older ages, even after adjustment for sociodemographic factors and cardiovascular disease risk factors. Hemodynamic changes during pregnancy may be associated with cardiac structure/function beyond childbearing years.

Section snippets

Study population

The MESA, begun in July 2000, was designed to investigate the prevalence, correlates, and progression of CVD in individuals without clinically manifest or symptomatic CVD.⁹ This prospective cohort study enrolled 6,814 participants (including 3,601 women) aged 45 to 84 years from 6 US communities (Baltimore, MD; Chicago, IL; Forsyth County, NC; Los Angeles County, CA; Northern Manhattan, NY; and St Paul, MN). The recruitment of participants has been previously described.⁹ Cohort participants

Results

The characteristics of the 2,234 women (mean age 62 years) in our study sample are displayed in Table I, stratified by number of live births. The number of live births ranged from 0 to 18. The mean age was greater for women with increasing number of live births. Hispanic and Chinese women had more live births, whereas black and white women had fewer live births. Systolic and diastolic blood pressure and triglycerides were all higher with increasing numbers of live births. Prevalence of current

Summary of findings

Among 2,234 women free of CVD (mean age 62 years), number of live births was positively associated with subsequent LVEDV, LVESV, and LV mass and inversely associated with LVEF. Changes were most notable for women with 5 or more live births. After adjustment for potential biologic mediators, number of live births remained significantly associated with LV mass and LVESV and inversely associated with LVEF at a borderline level of statistical significance. The effects were similar across categories

Conclusions

Number of live births is associated with modest changes in key LV structural and functional measures in middle- to older-aged women, most notably among women reporting 5 or more live births during their lifetime. It is uncertain whether these changes are fully mediated through traditional CVD risk factors or reflect subclinical peripartum LV remodeling that persists postpartum.

Author Contributions

Drs Parikh and Lloyd-Jones had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Author Disclosures

None.

Acknowledgements

The authors thank the other investigators, the staff, and the participants of the MESA study for their valuable contributions. A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org.

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Systematic review of articles published in PubMed, Scopus, Embase, and Medline databases from inception to July 30, 2023. Patient demographics, obstetric, electrocardiographic, laboratory, echocardiographic characteristics, and prognosis were summarized descriptively.
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Among n = 3931 FHS participants (mean age 48 ± 13 years), higher numbers of live births were associated with worse left ventricular fractional shortening (multivariable β -1.11 (0.31); P = 0.0005 in ≥ 5 live births vs nulliparous women) and worse cardiac mechanics, including global circumferential strain and longitudinal and radial dyssynchrony (P < 0.01 for all comparing ≥ 5 live births vs nulliparity). When examining HF subtypes, women with ≥ 5 live births were at higher risk of developing future HFrEF compared with nulliparous women (HR 1.93, 95% CI 1.19–3.12; P = 0.008); by contrast, a lower risk of HFpEF was observed (HR 0.58, 95% CI 0.37–0.91; P = 0.02).
Greater numbers of live births are associated with worse cardiac structure and function. There was no association with overall HF, but a higher number of live births was associated with greater risk for incident HFrEF.
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Citation Excerpt :
The theory behind this increase risk for CVD related to parity is through the cardiometabolic changes of the cumulative number of pregnancies, including weight gain, increased waist circumference, hyperlipidemia, and subclinical atherosclerosis. Women with higher parity had a higher body mass index (BMI), lower high-density lipoprotein cholesterol, higher triglycerides, and higher low-density lipoprotein cholesterol at baseline than women with fewer births.17 Other pregnancy-related changes are likely also a factor.
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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.
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).
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Clinical InvestigationCoronary Artery DiseaseAssociation of number of live births with left ventricular structure and function. The Multi-Ethnic Study of Atherosclerosis (MESA)

Background

Methods

Results

Conclusions

Section snippets

Study population

Results

Summary of findings

Conclusions

Author Contributions

Author Disclosures

Acknowledgements

Am Heart J

Am J Cardiol

Int J Gynaecol Obstet

Atherosclerosis

J Card Fail

A prospective study of age at menarche, parity, age at first birth, and coronary heart disease in women

Am J Epidemiol

Number of pregnancies and the subsequent risk of cardiovascular disease

N Engl J Med

Parity and coronary heart disease among women in the American Cancer Society CPS II population

Epidemiology

Epidemiology of peripartum cardiomyopathy: incidence, predictors, and outcomes

Obstet Gynecol

Multi-ethnic study of atherosclerosis: objectives and design

Am J Epidemiol

Cardiovascular function in multi-ethnic study of atherosclerosis: normal values by age, sex, and ethnicity

AJR Am J Roentgenol

Control mechanisms for physiological hypertrophy of pregnancy

Circulation

Maternal blood volume and cardiac output during pregnancy: a hypothesis of endocrinologic control

Am J Physiol

The fuzzy logic of physiological cardiac hypertrophy

Hypertension

Left ventricular diastolic function in normal pregnancy. A prospective study using M-mode echocardiography and Doppler echocardiography

Dtsch Med Wochenschr

Left ventricular hypertrophy and diastolic dysfunction in healthy pregnant women

Cardiology

Maternal cardiovascular hemodynamic adaptation to pregnancy

Obstet Gynecol Surv

Impact of parity on anthropometric measures of obesity controlling by multiple confounders: a cross-sectional study in Chilean women

J Epidemiol Community Health

Clinical Investigation
Coronary Artery Disease
Association of number of live births with left ventricular structure and function. The Multi-Ethnic Study of Atherosclerosis (MESA)