Improving Cardiovascular Risk prediction in Women: The Role of Reproductive and Pregnancy Factors
Table of Contents
Cardiovascular disease (CVD) remains a leading cause of mortality for women globally. Customary cardiovascular risk prediction tools, though, frequently enough underestimate risk in women, especially those with a history of pregnancy complications. This is because thes tools were largely developed and validated using data from male populations and do not adequately incorporate the unique physiological changes and risk factors associated with reproduction. Recent research focuses on refining risk assessment by integrating female-specific factors, with varying degrees of success, highlighting the complexity of accurately predicting CVD risk in women.
The Limitations of Existing Risk Scores
Current widely-used CVD risk prediction scoring tools, such as QRISK®−3, were not designed with reproductive-age women in mind [6]. Consequently, they often fall short in accurately assessing the long-term cardiovascular health of this demographic. This is particularly true when estimating 30-year and lifetime risk, where the underestimation can be significant [7].
The issue stems from several factors:
lack of Female Representation in Development: The original datasets used to create and validate these scores largely excluded women of reproductive age.
Ignoring Reproductive History: Traditional scores don’t account for the impact of pregnancy-related conditions, which can considerably influence future CVD risk. Age Interaction: The impact of traditional risk factors like age interacts with reproductive and pregnancy-related conditions, increasing risk.
The Promise and Challenges of Incorporating Female-Specific Risk Factors
Researchers are actively exploring ways to improve risk prediction by adding female-specific risk factors, including those related to pregnancy. While some studies have shown improved discrimination (the ability to correctly identify those at risk) and calibration (the accuracy of predicted risk), the results have been mixed [4].
A study by Wambua et al. investigated adding reproductive and pregnancy-related conditions to the QRISK®−3 model. While the improvements were modest, sensitivity analysis within a subgroup of women with preeclampsia showed enhanced calibration, suggesting that focusing on specific conditions could be beneficial [4].
Several reasons may explain the limited benefit observed in some studies:
Parity Matters: The importance of reproductive factors likely differs based on whether a woman has been pregnant (parity). Developing separate models for nulliparous (never given birth) and parous (has given birth) women, or models that account for changes over time, may be necessary [8].
Correlation of Pregnancy Complications: Treating pregnancy complications as autonomous factors overlooks the fact that they often occur together or repeatedly, increasing overall risk. A woman with multiple complications across several pregnancies is at higher risk than someone with a single, isolated complication.
Short Follow-up Periods: Many studies have relatively short follow-up periods (e.g., a median of 3.7 years in the Wambua et al.study), leading to low event rates and possibly limiting the ability to detect significant improvements in model performance [4].
Current Recommendations and Future Directions
Recognizing the increased risk,postpartum cardiovascular risk (CVR) screening is now recommended globally for women who have experienced pregnancy complications [5]. This proactive approach aims to identify and manage risk factors early,potentially preventing future CVD events.
Future research should focus on:
Developing parity-specific risk models: Tailoring risk assessment to a woman’s reproductive history.
Modeling the interplay between reproductive factors and traditional risk factors: Understanding how age, cholesterol, and other factors interact with pregnancy complications.
Longer-term follow-up studies: Collecting data over extended periods to better capture the long-term impact of reproductive events on cardiovascular health.
Utilizing dynamic risk prediction: Incorporating how risk factors change over a woman’s lifespan.
Key Takeaways:
Traditional CVD risk scores underestimate risk in women, especially those with a history of pregnancy complications.
Incorporating female-specific risk factors into existing models shows promise, but improvements have been modest.
Parity, the correlation of pregnancy complications, and short follow-up periods are key factors influencing the effectiveness of these models.
Postpartum CVR screening is now recommended for women with pregnancy complications.
Sources:
4]wambua, et al.(2023). Adding reproductive and pregnancy-related conditions to cardiovascular risk prediction in women: a retrospective cohort study. European Heart Journal – Quality of Care and Clinical Outcomes, 9(6), 543-551.[https://doiorg/101093/ehjqcco/qcad064[https://doiorg/101093/ehjqcco/qcad064
[5] American Heart Association. (2023). Postpartum Cardiovascular Risk Assessment.[