Elsevier

Pregnancy Hypertension

Volume 28, June 2022, Pages 28-34
Pregnancy Hypertension

Association between aspirin use during pregnancy and cardiovascular risk factors 2–7 years after delivery: The nuMoM2b Heart Health Study

https://doi.org/10.1016/j.preghy.2022.01.012Get rights and content

Highlights

  • First pregnancy aspirin use was not associated with later cardiovascular outcomes.

  • Propensity scores for aspirin use during first pregnancy were included as covariates.

  • Few women in this cohort were exposed to aspirin, so power is limited.

Abstract

Objectives

To evaluate the association between aspirin use during first pregnancy and later maternal cardiovascular risk.

Study design

In this secondary analysis of a prospective cohort, we included participants who carried their first pregnancy to 20 + weeks, had data regarding aspirin use, and attended a study visit 2–7 years following delivery. The exposure was aspirin use during the first pregnancy. We calculated aspirin use propensity scores from logistic regression models including baseline variables associated with aspirin use in pregnancy and cardiovascular risk. Outcomes of interest were incident cardiovascular-related diagnoses 2–7 years following delivery. Robust Poisson regression calculated the risk of outcomes by aspirin exposure, adjusting for the aspirin use propensity score.

Main outcome measures

The primary outcome was a composite of incident cardiovascular diagnoses at the time of the study visit: cardiovascular events, chronic hypertension, metabolic syndrome, prediabetes or type 2 diabetes, dyslipidemia, and chronic kidney disease.

Results

Of 4,480 women included, 84 (1.9%) reported taking aspirin during their first pregnancy. 52.6% of participants in the aspirin-exposed group and 43.0% in the unexposed group had the primary outcome. After adjusting for the aspirin use propensity scores, aspirin use during the first pregnancy was not associated with any of the outcomes.

Conclusion

We did not detect an association between aspirin use during the first pregnancy and cardiovascular-related diagnoses 2–7 years later. Our study was only powered to detect a large difference in relative risk, so we cannot rule out a smaller difference that may be clinically meaningful.

Introduction

Women with adverse pregnancy outcomes, including hypertensive disorders of pregnancy, stillbirth, preterm birth, and delivery of a small-for-gestational age neonate, have higher risk for the subsequent development of cardiovascular disease compared to women with normal pregnancy outcomes [1], [2], [3], [4], [5], [6], [7]. While the pathophysiologic mechanisms underlying this association remain poorly understood, low-dose aspirin has been investigated as a preventive therapy for both placenta-mediated pregnancy complications (mostly hypertensive disorders of pregnancy) [8], [9] and cardiovascular disease outside of pregnancy [10]. Even at low doses, aspirin achieves irreversible inhibition of cyclooxygenase enzymes, reducing platelet activation, production of thromboxane A2, and subsequent platelet aggregation [11], [12]. These processes have been implicated in the pathogenesis of both abnormal placentation [13] and cardiovascular events such as myocardial infarction and stroke [14].

Large multinational randomized trials of low-dose aspirin during pregnancy have demonstrated meaningful reductions in the risk for preeclampsia among women assigned to aspirin therapy [8], [9]. In addition, low-dose aspirin has been associated with a decreased risk for perinatal death, preterm birth, and delivery of a small-for-gestational age neonate [15], [16], [17], [18]. The United States Preventive Services Task Force (USPSTF) now recommends daily low-dose (81 mg) aspirin for the prevention of preeclampsia among women with risk factors [19]. Numerous studies have assessed the effect of aspirin on pregnancy outcomes, and other studies have assessed the association between pregnancy outcomes and later cardiovascular health. However, the relationship between aspirin use in pregnancy and subsequent cardiovascular risk trajectory is unknown.

We hypothesize that aspirin use during the first pregnancy confers cardiovascular protection beyond the first pregnancy. We aimed to determine whether women who took aspirin during their first pregnancy have more favorable cardiovascular risk profiles several years after delivery compared to women who did not take aspirin, adjusting for propensity for aspirin use.

Section snippets

Methods

This is a secondary analysis of the Nulliparous Pregnancy Outcomes Study – Monitoring Mothers-to-be (nuMoM2b) Heart Health Study (HHS). The nuMoM2b-HHS is a prospective observational cohort that followed participants for 2–7 years following their first pregnancy to investigate relationships between adverse pregnancy outcomes and cardiovascular health [20]. Participants were enrolled in nuMoM2b during the first trimester of their first pregnancy and completed an in-person nuMoM2b-HHS study visit

Results

After excluding 4 participants with missing data regarding aspirin exposure, we included 4,480 women who had completed medication forms during their first pregnancy and subsequently attended an in-person nuMoM2b-HHS study visit (Fig. 1). Eighty-four women (1.9% of the study population) reported taking aspirin during their first pregnancy. Compared with women who did not take aspirin during their first pregnancy, women who reported taking aspirin were older, had higher education levels, private

Discussion

In this secondary analysis of the nuMoM2b-HHS prospective cohort, exposure to aspirin during the first pregnancy was not associated with cardiovascular events or diagnoses 2–7 years after delivery. Although not statistically significant, it is worth noting that the point estimate for the association between aspirin exposure and incident chronic kidney disease 2–7 years later was in the positive direction (toward aspirin exposure being associated with chronic kidney disease). This may reflect

Funding sources

This work was supported by cooperative agreement funding from the National Heart, Lung, and Blood Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U10‐HL119991; U10‐HL119989; U10‐HL120034; U10‐HL119990; U10‐HL120006; U10‐HL119992; U10‐HL120019; U10‐HL119993; U10‐HL120018, and U01HL145358. The study was also supported by grant funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U10 HD063036; U10

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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