Pregnancy, stress, sleep issues, physiology among women's unique cardiovascular concerns

February 23, 2021

DALLAS, Feb. 23, 2021 — Women face many female-specific risks for heart disease and stroke, including pregnancy, physical and emotional stress, sleep patterns and many physiological factors, according to multiple studies highlighted in this year’s Go Red for Women® special issue of the Journal of the American Heart Association, published online today.

“Although cardiovascular disease is the leading cause of death in men and women, women are less likely to be diagnosed and receive preventive care and aggressive treatment compared to men,” said Journal of the American Heart Association Editor-in-Chief Barry London, M.D., Ph.D., Ph.D., the Potter Lambert Chair in Internal Medicine, director of the division of cardiovascular medicine, director of the Abboud Cardiovascular Research Center, professor of cardiovascular medicine and professor of molecular physiology and biophysics at the University of Iowa’s Carver College of Medicine in Iowa City, Iowa. “Identifying and addressing the unique ways cardiovascular disease affects women is critical to improving outcomes and saving lives, and we’re pleased to highlight this very important and impactful research.”

Of note in this issue is a report from the American Heart Association’s Go Red for Women Strategically Focused Research Network. Launched in Spring 2016, this initiative funded five research centers to extensively study cardiovascular (CVD) risk in women: This report highlights the findings of the centers, showing how insufficient sleep, sedentariness and pregnancy-related complications may increase CVD risk in women. It also details the presentation and factors associated with myocardial infarction with non-obstructive coronary arteries and heart failure with preserved ejection fraction in women. Additional collaborative studies assessed the relations among CVD risks and various lifestyle behaviors including nightly fasting duration, mindfulness and behavioral and physical risk factors. Other research focused on metabolomic profiling of heart failure with preserved ejection fraction in women.

Among the many findings: Many of the studies in the Association’s Strategically Focused Research Network have been published in scientific journals and presented at scientific meeting, and significant research continues. The findings generated by the initiative and the new investigators trained in multi-disciplinary research, will further promote awareness among the public and in the medical field about the female-specific factors that influence CVD.

Below are highlights of additional manuscripts focused on cardiovascular disease in women in this special issue of the Journal of the American Heart Association. The complete manuscripts can be here.

Early pregnancy atherogenic profile in a first pregnancy and hypertension risk 2-7 years after delivery – Janet Cotav, et al.

In the nuMoM2b-Heart Health Study, researchers evaluated whether cardiometabolic risk factors identified early in a first pregnancy were related to adverse pregnancy outcomes (APO) and/or gestational diabetes (GDM), as well as subsequent maternal hypertension 2-7 years after giving birth.

The multicenter cohort of 4,471 women were tracked for adverse pregnancy outcomes including hypertensive disorders of pregnancy, preterm delivery, low birthweight for gestational age and gestational diabetes and for their risk of hypertension (130/80 mmHg or antihypertensive use) 2-7 years after giving birth.

Among all participants, 24.6% of the women (1,102) experienced an adverse pregnancy outcome or gestational diabetes during a first birth. Women with at least one of these complications were, on average, more likely to be older than 35, to smoke, and to be of non-Hispanic Black race/ethnicity.

Women with an APO or GDM were more likely to have an elevated cardiovascular risk profile in the first trimester: they were more likely to have obesity (34.2% vs. 19.5%); had a higher mean blood pressure (SBP 112.2 mm Hg vs. 108.4 mm Hg; DBP 69.2 mm Hg vs. 66.6 mm Hg); had higher mean concentrations of glucose (5.0 vs. 4.8 mmol/L); had a higher median level of insulin (77.6 pmol/L vs. 27 60.1 pmol/L); high triglycerides (1.4 mmol/L  vs. 1.3 mmol/L) and hsCRP, high sensitivity c-reactive protein, a marker for inflammation (5.6 nmol/L vs. 4.0 nmol/L); or had lower HDL-C or good cholesterol (1.8 mmol/L vs. 1.9 mmol/L).

A total of 32.8% of women with APOs or GDM had hypertension (blood pressure ≥130/80 mmHg or took blood pressure medication) within 2-7 years after delivery, compared to 18.1% of women with no APO or GDM. Compared to women with no complications, those who had an APO or GDM had higher rates of elevated blood pressure (7.6% vs. 6.3%) and stage 1 (19.9% vs. 13.3%) and stage 2 hypertension (12.9% vs. 4.8%). After accounting for confounders (age, race/ethnicity, insurance status and smoking), early pregnancy BMI, total cholesterol, HDL-C, LDL-C, glucose, insulin, hsCRP, triglycerides, blood pressure, diet quality and physical activity were all related to increased risk of hypertension 2-7 years after giving birth.

The researchers said because women typically have access to health care during pregnancy and postpartum, assessment of cardiometabolic health early in pregnancy may help to identify risk for APO and GDM and to identify opportunities to improve cardiovascular health later in life.

The Associations of Job Strain, Life Events and Social Strain with Coronary Heart Disease in the Women's Health Initiative Observational Study - Yvonne Michael, et al

Researchers analyzed long-term health data for 80,825 women in the Women’s Health Initiative Observational Study, who had a mean age of 63.4 years when they enrolled in the study, and they were followed for an average of 14.7 years. They aimed to determine the independent and synergistic effect of different stress domains, including work, stressful life events and social relationships, on women’s coronary heart disease (CHD) risk.

Job strain was determined by factoring job control (whether workers can exert influence over tasks) and job demand (the workload and intensity of the job). Stressful life events and social strain were assessed through self-reported questionnaires. Cox proportional hazard models were used to evaluate associations of each stressor with CHD separately and together.

A total of 3,841 women (4.8%) developed coronary heart disease during an average of 14.7 years of follow-up. After adjustment for age, other stressors, job tenure and socioeconomic factors, highly stressful life events were associated with a 12% increased risk of CHD, and high social strain was associated with a 9% increased risk of CHD. While job strain was not independently associated with CHD risk, researchers observed a statistically significant interaction between job strain and social strain. Women who had high social strain but low job control and low job demand had a 21% increased risk of CHD.

Researchers concluded that stressful life events and social strain were each associated with increased risk of CHD among women. For job strain, the increased CHD risk was confounded by socioeconomic factors. Exposure to job strain and social strain interacted synergistically, resulting in a higher risk of CHD than expected from exposure to either stressor alone.

This study is accompanied by an editorial, Pearls and Purple: The Dawn of a Modern Age - Melissa Tracy, et al.

Sexual Assault and Carotid Plaque among Midlife Women – Rebecca Thurston, et al.

Researchers in this study examined whether women who reported being the victim of sexual assault had higher carotid artery plaque build-up levels and if those levels continued to rise during midlife. Study participants included 160 non-smoking, CVD-free women ages 40-60 years, 28% of whom reported being the victim of sexual violence. The women were assessed twice between 2012 and 2020, and at both evaluations, they completed questionnaires, physical measures, blood tests and ultrasounds to measure plaque build-up in the carotid artery.

Compared to women who did not report a history of sexual assault, the women who were victims of sexual violence were four times more likely to have plaque build-up of more than 30% of the carotid artery at baseline and three times more likely to have that extent of plaque build-up at follow-up.

Researchers said their findings indicate sexual assault is associated with a higher level of carotid atherosclerosis, and the levels appear to increase over midlife. The associations were not explained by standard CVD risk factors, depression or symptoms of post-traumatic stress.

Other studies in this special issue include:
Authors’ disclosures and funding sources for all studies in the special issue are listed in the individual manuscripts.

To raise awareness about how participation in research could advance scientific understanding of cardiovascular health, the American Heart Association and Verily, Alphabet’s life sciences and health care arm, are collaborating on Research Goes Red™. Research Goes Red aims to empower women to contribute to health research. Learn more at

Additional Resources: Statements and conclusions of studies published in the American Heart Association’s scientific journals are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers are available here, and the Association’s overall financial information is available here

About the American Heart Association

The American Heart Association is a relentless force for a world of longer, healthier lives. We are dedicated to ensuring equitable health in all communities. Through collaboration with numerous organizations, and powered by millions of volunteers, we fund innovative research, advocate for the public's health and share lifesaving resources. The Dallas-based organization has been a leading source of health information for nearly a century. Connect with us on heart.orgFacebookTwitter or by calling 1-800-AHA-USA1.  

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