背景:怀孕是解决健康(SDOH)和终身心血管疾病(CVD)预防的社会决定因素的可教育和可操作的生命阶段。但是,结合了怀孕期间多个邻里水平社会决定因素的风险评分与长期CVD风险之间的联系仍有待评估。
目的:研究妊娠早期区域剥夺指数(ADI)测量的社区水平的社会经济劣势是否与产后30年预测的CVD风险较高有关,由弗雷明汉风险评分衡量。
方法:对前瞻性未产妊娠结局研究-监测准妈妈心脏健康研究(nuMoM2b)纵向队列数据的分析。怀孕初期的参与者家庭住址在人口普查区级别进行了地理编码。使用2015年ADI的三分地(最少被剥夺[T1],参考;最剥夺[T3])在孕早期测量。结果是动脉粥样硬化性CVD的预测30年风险(ASCVD,致命和非致命冠心病和中风的复合)和总CVD(ASCVD加冠状动脉功能不全的复合,心绞痛,短暂性脑缺血发作,间歇性跛行,和心力衰竭)使用分娩后2至7年的Framingham风险评分进行测量。这些结果被评估为绝对估计风险的连续测量,增量为1%,and,其次,将高风险定义为CVD>10%的估计概率。多变量线性回归和修正的泊松回归模型调整基线年龄和个人水平的社会决定因素,包括医疗保险,教育程度,家庭贫困。
结果:在基线时的4,309个未产个体中,中位年龄为27岁(IQR:23~31),中位ADI为43岁(IQR:22~74).产后2至7年(中位数:3.1年,IQR:2.5,3.7),ASCVD的中位30年风险为2.3%(IQR:1.5,3.5),总CVD的中位30年风险为5.5%(IQR:3.7,7.9);2.2%和14.3%的个体预测30年风险>10%,分别。生活在ADI最高的人群中的个体具有较高的30年ASCVD%的预测风险(调整。β:0.41;95%CI:0.19,0.63)与最低三分位数相比;生活在前两个ADI三分位数的人30年总CVD%的绝对风险较高(T2:调整。β:0.37;95%CI:0.03,0.72;T3:调整。β:0.74;95%CI:0.36,1.13)。同样,生活在ADI最高人群社区的个体更有可能具有较高的30年ASCVD预测风险(aRR:2.21;95%CI:1.21,4.02)和总CVD≥10%(aRR:1.35;95%CI:1.08,1.69).
结论:妊娠早期社区水平的社会经济劣势与估计的产后CVD长期风险较高相关。将聚合的SDOH纳入现有的临床工作流程和未来的妊娠研究可以减少整个生命周期中产妇心血管健康的差异。需要进一步研究。
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.
METHODS: 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).
CONCLUSIONS: 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.