Why hypertension in midlife women? Impact of Prior Preterm or Term Small for Gestational Age Birth Extent of awareness, treatment, and control of high BP • Cardiovascular disease among women ≥ 40 years in the U.S (%) on Maternal Blood Pressure (CVD) is leading cause of During the Menopausal Transition: death in women. 90 87 85 82 82 80 77 • High blood pressure (BP) Study of Women’s Health Across the Nation 71 is a major risk factor for 59 55 54 CVD and stroke. 50 • Elimination could reduce Yamn Ya mnia I. I. Corté tés, , Ph PhD, , MPH MPH, , FNP-BC BC CVD mortality by 38%. • Synchronous effect of NH WHITE NH BLACK HISPANIC NH ASIAN Assistant Professor chronologic and Awareness Treatment Control School of Nursing reproductive aging University of North Carolina at Chapel Hill References: Chobanian et al., Hypertension 2003; Patel et al., Ann Intern Med 2015; Zhang and Moran et al., Hypertension 2014 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 2 Preterm and small for gestational Pregnancy: a “stress test” age (SGA) delivery • Preterm delivery associated with more rapid increases in BP even with normotensive pregnancy. § Higher BP à coronary artery calcification. • Preterm and SGA delivery associated with hypertension at age ≤ 45 years. • Preterm birth à BP at late midlife • Whether preterm or SGA delivery is associated with increases in BP across the menopausal transition is unknown. Sattar and Greer, BMJ 2002; 325; Catov et al., J Women’s Health 2015. References: Catov et al., Hypertension 2013 ; Catov et al., Hypertension 2018; Xu et al., PLos One 2014. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 4 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Study of Women’s Health Across the Nation (SWAN) Study purpose Boston,M ,MA Detroit, , MI • To characterize the relationship between history of Newark, , NJ preterm and term SGA birth with longitudinal Chicago, , IL Oakland, CA Oa measures of BP during the menopausal transition. Pittsburgh,P ,PA • To examine whether self-reported history of preterm Lo Los s Angeles, s, CA and term SGA birth is associated with prevalent and incident hypertension. Multi Mu ti-si site, e, mul ulti-et ethnic, c, longitudinal st study = Black = Hispanic = Chinese = Japanese THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 5 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING Study of Women’s Health Across the Nation Study of Women’s Health Across the Nation (SWAN) (SWAN) Boston,M ,MA Boston,M ,MA Detroit, , MI Detroit, , MI Newark, , NJ Newark, , NJ Chicago, , IL Chicago, , IL Oakland, CA Oa Oakland, CA Oa Pittsburgh,P ,PA Pittsburgh,P ,PA Lo Los s Angeles, s, CA Los Lo s Angeles, s, CA Age 42-52 years Pre or early perimenopausal Intact uterus and at least one ovary Wo Women enrolled 1996-1997 1997 Menstrual bleeding in past 3 months No hormone therapy in past 3 months = Black = Hispanic = Chinese = Japanese = Black = Hispanic = Chinese = Japanese THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
SWAN procedures Research Design and Variables • Analysis includes baseline and up to 13 follow-up • Pr Pregnancy histo tory (Vi Visit t 13): visits over approx. 16 years § Preterm birth (delivery <37 weeks gestation) • At each visit: § Term SGA (birth weight ≤ 10th percentile for gestational age) § Term appropriate for gestational age was referent § Socio-demographics and lifestyle factors § Medical/medication history • Ou Outcome (baseline thru Visit 13): § Systolic BP, diastolic BP § Menopause status, hormone therapy § Prevalent hypertension (normal, elevated, stage 1, stage 2) § Physical measures (e.g., waist, BMI, BP) § Incident hypertension (systolic BP ≥ 140 or diastolic BP ≥ 90 or med) § Blood draw (e.g. sex hormones, lipids) References: World Health Organization, Weight Percentile Calculator ; Flack et al., Am J Hypertens. 2018 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING Table 1. Participant characteristics at baseline (n=1772) Statistical Analyses Mean ± SD Me SD, Me Media ian [IQR], n No A No Adv dver erse e PTB PT Term-SG Te SGA P (% (%) Pregnancy Pr (n (n= 197) (n (n=164) ) (n (n= 1411) • Participant characteristics Age, Mean ± SD 46.5 ± 2.7 46.1 ± 2.7 46.8 ± 2.6 0. 0.03 03 Race/Ethnicity <0.0001 <0 § ANOVA or Kruskal-Wallis and Chi-Square or Fisher’s Exact White 668 (47.4) 93 (47.2) 35 (21.3) • Change in BP over time – linear mixed models Black 361 (25.6) 57 (28.9) 91 (55.5) Hispanic 82 (5.8) 20 (10.2) 10 (6.1) § years since baseline, years since final menstrual period Chinese 297 (21.1) 27 (13.7) 28 (17.1) College degree 606 (43.5) 75 (38.1) 63 (38.9) 0.39 • Prevalence of hypertension - generalized estimating equation Hard to pay for basics 344 (26.0) 62 (33.0) 62 (42.2) <0.0001 <0 Age at first birth, Mean ± SD 25.9 ± 6.0 24.9 ± 6.0 23.4 ± 6.0 • Incident hypertension - cox regression <0.0001 <0 Parity ≥ 4 175 (12.4) 47 (23.9) 41 (25.0) <0 <0.0001 • Sensitivity analyses – excluding history of hypertensive pregnancy Gestational diabetes 64 (4.5) 14 (7.3) 16 (9.8) <0 <0.0001 • Interactions with race/ethnicity Hypertensive pregnancy 115 (8.2) 32 (16.7) 23 (14.1) <0.0001 <0 Current smoker 192 (13.7) 32 (16.3) 32 (19.5) 0.11 Model 3 Physical activity 7.8 ± 1.8 7.6 ± 1.6 7.3 ± 1.7 † Model 2 0. 0.04 04 Model 1 Reproductive BMI (kg/m 2 ) 27.9 ± 7.1 28.2 ± 7.5 28.8 ± 7.3 0.31 CVD risk factors Demographics factors Total cholesterol 193.3 ± 33.1 198.2 ± 37.6 194.0 ± 33.9 0.17 (smoking, BMI, (parity, age at 1 st birth, (age, site, Diabetes 34 (2.4) 17 (8.6) 12 (7.3) 0. 0.0006 0006 physical activity, race/ethnicity) hypertensive/diabetes Systolic BP (mm/Hg) 115.8 ± 16.0 119.6 ± 15.9 ‡ 121.6 ± 16.8 ψ <0.0001 <0 medications) pregnancy) Diastolic BP (mm/Hg) 74.6 ± 10.1 76.3 ± 10.5 † 77.5 ± 10.1 ‡ 0. 0.0004 0004 Antihypertensive treatment 119 (8.4) 23 (11.7) 23 (14.0) 0. 0.03 03 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING Note: BP= blood pressure; PTB = preterm birth; SGA= small for gestational age
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