Socioeconomic status and adverse pregnancy outcome increase the risk of long-term cardiovascular disease: an analysis using the UK Biobank.

To estimate whether breastfeeding is associated with the estimated risk of long-term atherosclerotic cardiovascular disease (ASCVD) and whether this association varies with prior gestational diabetes mellitus (GDM). We conducted a secondary analysis from the prospective HAPO (Hyperglycemia and Adverse Pregnancy Outcome) Follow-Up Study. The exposure was any breastfeeding (yes or no). The primary outcomes, measured 10-14 years after delivery with the Framingham Risk Score, were estimated ASCVD risk (composite of fatal and nonfatal coronary heart disease and stroke) over the subsequent 10- and 30-year time periods. Multivariable linear regression models were used and adjusted for baseline pregnancy covariates: field center, age, body mass index (BMI), height, smoking and alcohol use, parity, and time from delivery to ASCVD risk assessment. Secondarily, we examined whether the association between breastfeeding and ASCVD varied by GDM status (effect modification). Of 4,540 individuals, the median age was 30.6 years at baseline. More than three-fourths (79.7%) reported breastfeeding, which did not vary by GDM status (79.5% vs 81.0%). At 10-14 years after delivery (median 11.6 years), individuals who breastfed had a lower estimated risk of ASCVD over the subsequent 10 years (2.3% vs 2.5%, adjusted β -0.13, 95% CI, -0.25 to -0.02) and 30 years (6.2% vs 6.9%, adjusted β -0.36, 95% CI, -0.66 and -0.05). The association between breastfeeding and estimated ASCVD risk varied significantly by GDM status: The protective effect of breastfeeding was greater for individuals with GDM for estimated 10-year ASCVD risk (GDM: adjusted β -0.52, 95% CI, -0.98 and -0.05; no GDM: adjusted β -0.09, 95% CI, -0.20 and -0.02; interaction P =.004) and 30-year ASCVD risk (GDM: adjusted β -1.33, 95% CI, -2.53 and -0.14; no GDM: adjusted β -0.25, 95% CI, -0.54 and 0.03; interaction P =.003). Breastfeeding, particularly after an individual had GDM, was associated with a lower estimated risk of long-term ASCVD. These findings indicate the potential benefit of breastfeeding for long-term cardiovascular health, especially among those with GDM.

Background: Adverse pregnancy outcomes (APOs) occur in up to 15% of all pregnancies, and are associated with an increased risk of long-term atherosclerotic cardiovascular disease (ASCVD) in the mother. However, it is unclear if this association is independent of standard ASCVD risk factors or is present in multiethnic populations with adjudicated CVD events. Methods: Participants in the Women’s Health Initiative were asked to complete a retrospective survey in 2017 about APOs, [gestational diabetes, birthweight < 5 pounds, birth weight > 9 pounds, delivery > 3 weeks pre-term, and hypertensive disorder of pregnancy (gestational hypertension or preeclampsia)]. Cox models were used to assess the hazard for developing incident ASCVD (defined as adjudicated stroke, myocardial infarction, peripheral artery disease, coronary revascularization). Follow up began at the baseline study exam. Hazard ratios were assessed using the Cox model. Two primary models were employed for each individual APO: 1) univariate, and 2) adjusted for the baseline ASCVD risk factors of age, smoking, use of cholesterol lowering drugs, hypertension and diabetes. Results: The 50,679 respondents were 89.1% White, 5.2% Black, 2.4% Hispanic, 2.1% Asian-Pacific Islander, and 1.2% Other race. There were 12,499 (25%) women who reported an APO: 1041 (2.1%) had gestational diabetes, 6282 (12.4%) had low birth weight, 2970 (5.9%) had high birth weight, 7365 (14.5%) had a premature birth, and 3238 (6.4%) had preeclampsia or gestational hypertension. Over 1,020,899 person-years of follow up, 3569 (7.0%) adjudicated CVD events occurred. In univariate models, each APO was associated with ASCVD (Figure). In multivariable models adjusting for standard risk factors, all APOs were associated with a significantly increased risk of CVD (Figure), with the exception of high birth weight. There was no significant effect modification by race on these associations. Conclusion: Adverse pregnancy outcomes were associated with increased risk of late ASCVD in a multiethnic population of post-menopausal women, independent of ASCVD risk factors. Associations between APO and ASCVD were consistent across racial groups. APOs should be considered in CVD risk assessment in women.

Genome-wide polygenic risk scores for hypertensive disease during pregnancy can also predict the risk for long-term cardiovascular disease

Background: Women with a history of adverse pregnancy outcomes (APOs) are at increased risk of developing cardiovascular disease (CVD). Whether maintaining higher cardiovascular health is associated with a lower risk of CVD in this population is not known. Aims: To evaluate the association between Life’s Essential 8 (LE8) and incident CVD in women with a history of APOs. Methods: We included 2,263 participants with a prior diagnosis of APOs (including hypertensive disorders of pregnancy, gestational diabetes, placental abruption, small for gestational age, or preterm birth) and 107,260 parous participants without a history of APOs from the UK Biobank, all of whom were free of CVD at baseline. LE8 was calculated at baseline (range 0-100). Multivariable-adjusted Cox models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI) between LE8 score and incident total and subtypes of CVD. We also examined the interaction between LE8 score and incident CVD among individuals with and without a history of APOs. Results: Over a mean 13.5 years of follow-up, 197 incident CVD events were documented in women with a history of APOs. Compared to women in the bottom tertile of LE8 score (<67), those in the top tertile (>76) had a lower incidence of total CVD, HR (95% CI) of 0.43 (0.29, 0.65), CHD [0.31 (0.17, 0.56)] and AF [0.46 (0.23, 0.91)]. We observed a significant interaction between history of APOs, LE8 score, and incident CVD ( Table 1 ). Women with a history of APO who maintained high LE8 score were at similar risk as those without APO with a high LE8 score, 0.95 (0.63-1.43), whereas there was an excess risk observed for those with an intermediate (HR with vs. without APO: 1.73 vs 1.25) and low LE8 scores (HR with vs. without APO: 2.48 vs 1.81). Conclusion: Among women with a history of APOs, better cardiovascular health as assessed using the LE8 score was associated with a significantly lower incidence of incident CVD. Additionally, women with a history of APOs who maintained high LE8 scores had similar risk of CVD as women without a history of APOs.

Pregnancy identifies women who may be at a greater risk of cardiovascular disease (CVD), based on the development of adverse pregnancy outcomes (APOs), and may identify women who may benefit from atherosclerotic CVD (ASCVD) risk reduction efforts. APOs are common and although they are separate diagnoses, all these disorders seem to share an underlying pathogenesis. What is not clear is whether the APO itself initiates a pathway that results in CVD or whether the APO uncovers a woman’s predisposition to CVD. Regardless, APOs have immediate risks to maternal and foetal health, in addition to longer-term CVD consequences. CVD risk assessment and stratification in women remains complex and, historically, has underestimated risk, especially in young women. Further research is needed into the role of ASCVD risk assessment and the effect of aggressive ASCVD risk modification on CVD outcomes in women with a history of APOs.

Introduction: Lifetime risk for cardiovascular disease (CVD) is higher in women who experience adverse pregnancy outcomes (APOs) including pre-eclampsia, preterm birth, gestational hypertension, and gestational diabetes. APOs are risk-enhancing factors for atherosclerotic cardiovascular disease (ASCVD) in contemporary cholesterol guidelines. Hypothesis: History of APOs impacts consideration for lipid therapy in a significant proportion of women with borderline to intermediate CVD risk . Methods: A single center retrospective chart review of new patients who presented to the University of Florida Women’s Heart Health Clinic between July 2017 - July 2019 was performed. New female patients were routinely screened for pregnancy history with an obstetrics questionnaire, and cardiovascular history and lipid profiles were collected where available. Patients were stratified by age and calculated 10-yr risk of a cardiovascular event using the ACC/AHA Pooled Cohort Equation. APO history within age and risk categories in addition to pregnancy history documentation in electronic health records were then assessed. Results: Of the 182 new patients who presented to the University of Florida Women’s Heart Health Clinic between July 2017 - July 2019, average age was 49 years old and 71.3% were Caucasian. 25% of the study population had history of APO, and of patients with history of APO, only 55% had documented lipid profiles, 46% had pregnancy history documented in the obstetrics section of the electronic health record, and 17% had pregnancy history documented in their past medical history section. For patients aged 40-75 y/o with borderline-intermediate 10-yr CV event risk, risk-enhancing factors influenced consideration of potential statin therapy, with 20% of patients in the intermediate risk group having history of APO. Conclusions: Pregnancy history impacts potential statin therapy in a significant percentage of women aged 40-75 y/o with borderline-intermediate 10-yr ASCVD risk. However, APOs are often under-recognized and poorly documented as non-traditional CVD risk factors in women. Efforts to improve recognition of APOs in clinical practice should be promoted to improve CVD risk reduction efforts, particularly in young women.

Introduction Age is the dominant driver of atherosclerotic cardiovascular disease (ASCVD) risk, and the estimated 10-year ASCVD risk of almost all individuals ≥70 years exceeds conventional risk thresholds. Treatment of risk factors should be considered taking ASCVD risk modifiers, including frailty, lifetime treatment benefit, comorbidities, polypharmacy, socio-economic status, and patient preferences into account. Aim Because of problems with risk prediction in the elderly most ASCVD risk scores do not function well, so there is limited ability to quantify ASCVD risk in persons 70 years of age or older. Therefore, we sought out to estimate ASCVD risk in apparently healthy elderly persons. Methods We enrolled 253 apparently healthy elderly persons ≥70 years without established ASCVD. The Systemic Coronary Risk Estimation 2 - Older Persons (SCORE2-OP) score was used to estimate the 10-year risk of ASCVD. A 10-year risk ≥15% was generally considered ‘very high risk’, and 7.5% to <15% was considered ‘high risk’. Based on age study population was divided into four groups: (1) 70–74 years (N=61), (2) 75–79 years (N=73), 80–84 (N=76), and (4) 85-89 years (N=43). Results The median 10-year ASCVD risk in the entire cohort was 23% (17%–32%). There was no person with low ASCVD risk (<7.5%). 41 out of 253 persons (16.2%) were high-risk and 212 (83.8%) were very high-risk. The number of persons at very high risk of ASCVD increased dramatically with age. Roughly, almost all persons aged ≥75 years were deemed very high risk (Table 1). Multimorbidity defined as the presence of two or more chronic conditions and polypharmacy defined as the use of at least 5 medications were highly prevalent in all four study groups. Hypertension was the most prevalent condition – roughly eight in 10 persons had hypertension. The rate of overweight/obese patients was higher in younger persons. This fact was further reflected by the body composition of study participants and the rate of malnutrition (Table 1). Age ≥75 years was highly predictive for identifying persons at very high risk for ASCVD with a C-statistics of 0.92 (positive predictive value 99%, negative predictive value 53%; P<0.001) (Figure 1). Conclusions Older people without established ASCVD are a heterogeneous group. Most of them were found to be at very high risk of ASCVD. Age and high blood pressure were the dominant drivers of that risk. In addition, ASCVD risk modifiers such as multimorbidity, polypharmacy, and malnutrition were highly prevalent. These findings have important clinical and public health and individualized decisions regarding preventative and therapeutic strategies for elderly persons are needed.Table 1Baseline characteristicsFigure 1.ROC analysis

Background: Hypertension is a significant risk factor for cardiovascular disease. According to the Centers for Disease Control and Prevention (CDC) half of all United States citizens with hypertension (HTN) do not have their blood pressure under control. As such, HTN remains a large public health challenge, especially in patients with other comorbidities such as diabetes or poor nutritional status. Our goal was to assess the correlation between various vitamin levels with both HTN and atherosclerotic cardiovascular disease (ASCVD) risk in diabetic patients in order to identify potential targets for intervention to further decrease ASCVD and HTN risk. Methods: We obtained data from the medical record data warehouse of a primary care outpatient clinic predominantly run by internal medicine residents within a large safety-net hospital from January to December 2015. Patients with a diagnosis of diabetes mellitus (both type 1 and 2) were identified and electronic medical records were reviewed. ASCVD risk scores were calculated using the American College of Cardiology ASCVD risk estimator. Linear and logistical regression analyses were performed using SPSS software to assess the correlation between Vitamin B12, Vitamin D, and folic acid levels with both HTN and ASCVD risk. Results: Our patient population was predominantly African American (93%, 1633 of 1750). ASCVD scores could be calculated for 883 patients (60% female) and 94% (829 of 883) of these patients had elevated ASCVD risk scores ≥7.5. 86% (760 of 883) of patients had a diagnosis of hypertension or were on anti-hypertensive treatment. However, analyses of Vitamin D (14%, 126 of 883), Vitamin B12 (31%, 273 of 883), and folic acid (18%, 159 of 883) levels did not reveal any statistically significant correlation with HTN or ASCVD risk, even when stratified for different levels of a1c, ASCVD, or categories of HTN. There was however, a non-statistically significant correlation between vitamin D deficiency and HTN across all a1c levels (a1c <7, r=0.767, p=0.08; a1c ≥7 & <10, r=0.703, p=0.11; a1c ≥7, r=0.543, p=0.09) Conclusion: Our mathematical model cannot be used to explain any statistically significant correlation between Vitamin D, Vitamin B12, or folic acid levels with HTN or ASCVD risk in diabetic patients despite the fact that some studies have noted a potential association. This may reflect an inherent difference in our population (predominantly African American) or may be due to the low baseline monitoring rates of these vitamins. Future aims include initiating a targeted educational intervention for residents in the continuity clinic to not only actively monitor these vitamin levels in high risk populations, but to also demonstrate that resident driven intervention is an effective way to modify both HTN and ASCVD risk factors. Further studies are necessary to elucidate the long term relationship between vitamin levels and CVD risk.

BackgroundMexican Americans (MA) experience cognitive decline at younger ages and have higher rates of cardiovascular disease (CVD) than Non‐Hispanic whites (NHW). Persons who are depressed are more likely to have one or more risk factors for cardiovascular disease. The purpose of this study was to examine the impact of depression and Atherosclerotic Cardiovascular Disease (ASCVD) on cognitive function in MA and NHW.MethodData was collected from the Health and Aging Brain Study: Health Disparities (HABS‐HD) study. A total of 1094 participants who were classified as normal controls were stratified into 4 groups: no depression and low risk ASCVD (N= 684), no depression and high risk ASCVD (N= 222), depression and low risk ASCVD (N=140), and depression and high risk ASCVD (N=48). Depressive symptoms were assessed via Geriatric Depression Scale (GDS). ASCVD risk was calculated using a risk calculator. One‐way ANOVAs were conducted to examine differences in cognitive performance based on ASCVD risk and depression.ResultThe results showed that depressed NHW and MA males with a low ASCVD risk had significantly lower mean scores on Trail Making Test A than the non‐depressed with low ASCVD risk group (p < 0.006), (p < 0.017). Depressed MA males with high ASCVD risk had significantly lower mean scores on the MMSE than the non‐depressed low ASCVD risk group (p < 0.00). Depressed NHW females with low ASCVD risk had significantly lower mean scores on delayed memory than the non‐depressed low ASCVD risk group (p < 0.008). Depressed MA females with a high ASCVD risk demonstrated significantly lower mean scores on the COWA and SEVLT Trials 1‐5 and the non‐depressed low ASCVD risk group (p < 0.002), (p < 0.046).ConclusionThe results of this study indicated that depression and risk of ASCVD can impact cognitive functioning in different ways. In men depression impacted scores on Trails A. In MA women comorbid depression and high risk for ASCVD affect scores on the COWA and SEVLT. These findings support that medical comorbidities influence cognitive function. Future research directions include exploring the relationships between other CVD risk factors and depression.

Introduction: The American Heart Association (AHA) pooled cohort equations provide sex and race specific estimates of 10-year atherosclerotic cardiovascular disease (ASCVD) risk based on traditional risk factors, but not physical activity (PA) or fitness. The effect of exercise training on estimated ASCVD risk has not been previously evaluated, which is clinically relevant to individuals with type 2 diabetes (T2D) who have increased risk of ASCVD. The purpose of the present study is to determine the effect of aerobic (AER), resistance (RES) or combination (COMB) exercise training on 10-year ASCVD risk in individuals with T2D. Methods: The present study is an ancillary analysis of the Health Benefits of Aerobic and Resistance Training Study (HART-D). Adults with T2D (n=148) were randomized to 9 months of AER, RES, COMB exercise training or a control group (CON); 10-year ASCVD risk was calculated using the AHA pooled cohort equations based on each participants’ demographic (age, sex, race) and clinical data (high density lipoprotein, total cholesterol, systolic blood pressure/history of hypertension) and known T2D status at baseline and follow-up. Change in ASCVD risk was evaluated with an analysis of covariance with adjustment for baseline ASCVD risk. Results: Participants in the present analysis had a mean (SD) 10-year ASCVD risk of 12.2% (9.4). Baseline ASCVD risk was associated with body fat (r=-0.22, p< 0.001) and duration of T2D (r=0.18, p=0.03), but not with peak VO 2 , hemoglobin A 1C , or other cardiometabolic variables (p>0.05). No significant change in ASCVD risk was observed in the AERO (-0.36%, CI: -1.44 to 0.71), RES (-0.43%, CI: -1.49 to 0.63) and the COMB groups (-0.54%, CI: -1.57 to 0.49) compared to the CON (0.02%, CI: -1.26 to 1.31) group. However, in exercisers only, the change in diastolic blood pressure was associated with change in ASCVD (r=0.34, p<0.001), but not change in hemoglobin A 1C , peak VO 2 , body fat mass, or other cardiometabolic risk factors (p>0.05). Conclusions: The present study suggests that 9 months of exercise training did not reduce ASCVD risk predicted by the pooled cohort equations. Since exercise training is recommended by the AHA to reduce ASCVD risk especially in adults with T2D, future studies should evaluate if adding a variable that represents physical activity and/or fitness provides additional discrimination in the prediction of ASCVD.

BackgroundTrimethylamine N‐oxide (TMAO) is a gut microbiota‐dependent metabolite of dietary choline, L‐carnitine, and phosphatidylcholine‐rich foods. On the basis of experimental studies and patients with prevalent disease, elevated plasma TMAO may increase risk of atherosclerotic cardiovascular disease (ASCVD). TMAO is also renally cleared and may interact with and causally contribute to renal dysfunction. Yet, how serial TMAO levels relate to incident and recurrent ASCVD in community‐based populations and the potential mediating or modifying role of renal function are not established.Methods and ResultsWe investigated associations of serial measures of plasma TMAO, assessed at baseline and 7 years, with incident and recurrent ASCVD in a community‐based cohort of 4131 (incident) and 1449 (recurrent) older US adults. TMAO was measured using stable isotope dilution liquid chromatography–tandem mass spectrometry (laboratory coefficient of variation, <6%). Incident ASCVD (myocardial infarction, fatal coronary heart disease, stroke, sudden cardiac death, or other atherosclerotic death) was centrally adjudicated using medical records. Risk was assessed by multivariable Cox proportional hazards regression, including time‐varying demographics, lifestyle factors, medical history, laboratory measures, and dietary habits. Potential mediating effects and interaction by estimated glomerular filtration rate (eGFR) were assessed. During prospective follow‐up, 1766 incident and 897 recurrent ASCVD events occurred. After multivariable adjustment, higher levels of TMAO were associated with a higher risk of incident ASCVD, with extreme quintile hazard ratio (HR) compared with the lowest quintile=1.21 (95% CI, 1.02–1.42; P‐trend=0.029). This relationship appeared mediated or confounded by eGFR (eGFR‐adjusted HR, 1.07; 95% CI, 0.90–1.27), as well as modified by eGFR (P‐interaction <0.001). High levels of TMAO were associated with higher incidence of ASCVD in the presence of impaired renal function (eGFR <60 mL/min per 1.73 m2: HR, 1.56 [95% CI, 1.13–2.14]; P‐trend=0.007), but not normal or mildly reduced renal function (eGFR ≥60 mL/min per 1.73 m2: HR, 1.03 [95% CI, 0.85–1.25]; P‐trend=0.668). Among individuals with prior ASCVD, TMAO associated with higher risk of recurrent ASCVD (HR, 1.25 [95% CI, 1.01–1.56]; P‐trend=0.009), without significant modification by eGFR.ConclusionsIn this large community‐based cohort of older US adults, serial measures of TMAO were associated with higher risk of incident ASCVD, with apparent modification by presence of impaired renal function and with higher risk of recurrent ASCVD.

Atherosclerotic cardiovascular disease (ASCVD) may have unique risk factors in women. Most women have a history of pregnancy; common adverse pregnancy outcomes (APOs) appear to be associated with ASCVD, but prior studies have limitations. To assess whether APOs are associated with increased ASCVD risk independently of traditional risk factors. The APO history among participants in the Women's Health Initiative, a large multiethnic cohort of postmenopausal women, was assessed. The associations of 5 self-reported APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight [ie, birth weight less than 2.49 kg], high birth weight [ie, birth weight greater than 4.08 kg], and preterm delivery by 3 weeks or more) with ASCVD were analyzed, adjusting for traditional ASCVD risk factors. Data were collected and analyzed in 2017. APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight, high birth weight, and preterm delivery). Adjudicated ASCVD. A total of 48 113 Women's Health Initiative participants responded to the survey; the median (interquartile range) age at time of enrollment was 60.0 (55.0-64.0) years. A total of 13 482 participants (28.8%) reported 1 or more APOs. Atherosclerotic cardiovascular disease was more frequent in women who reported an APO compared with those without APOs (1028 of 13 482 [7.6%] vs 1758 of 30 522 [5.8%]). Each APO, analyzed separately, was significantly associated with ASCVD, and gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and preterm delivery remained significant after adjustment for traditional ASCVD risk factors. When all APOs were analyzed together, hypertensive disorders of pregnancy (odds ratio, 1.27; 95% CI, 1.15-1.40) and low birth weight (odds ratio, 1.12; 95% CI, 1.00-1.26) remained independently associated with ASCVD. All findings were materially unchanged by additional adjustment for parity, body mass index, and socioeconomic factors. In this large multiethnic cohort of women, hypertensive disorders of pregnancy and low birth weight were independently associated with ASCVD after adjustment for risk factors and other APOs.

Low bone mineral density (BMD) is associated with higher risk of atherosclerotic cardiovascular disease (ASCVD) in women. We investigated whether the association between low BMD and ASCVD differs according to the age at ASCVD occurrence. We retrospectively analyzed 7932 women aged 50–65 years who underwent dual-energy X-ray absorptiometry. ASCVD was defined as a composite of ASCVD death, myocardial infarction, and ischemic stroke. When we classified participants into no event (n = 7803), early ASCVD (< 70 years) (n = 97), and late ASCVD (≥ 70 years) (n = 32) groups, age gradually increased across groups (median, 58, 60, and 63 years, respectively). However, the estimated BMD T-score at the age of 65 years was lowest in the early ASCVD group (median − 0.9, − 1.1, and − 0.5, respectively). Lower BMD was an independent predictor for early ASCVD (adjusted hazard ratio [95% confidence interval]: 1.34 [1.08–1.67] per 1-SD decrease in T-score), but not for late ASCVD (0.88 [0.60–1.30]). The inverse trend between early ASCVD risk and BMD T-score was consistent regardless of the number of accompanied clinical risk factors. Thus, low BMD is an independent predictor for early ASCVD in women. BMD evaluation can provide prognostic benefit for risk stratification for early ASCVD.

ObjectiveExamine whether the relationship between the pooled cohort equations (PCE) predicted 10-year risk for atherosclerotic cardiovascular disease (ASCVD) and absolute risk for ASCVD is modified by socioeconomic status (SES).DesignPopulation-based longitudinal...

Background and Aims: Emerging evidence suggests adverse pregnancy outcomes (APOs) may increase future cardiovascular risk. This study aimed to assess in a Spanish cohort the long-term risk of cardiovascular disease in women with APOs compared to those without such complications. Methods: A retrospective longitudinal cohort study was conducted at Hospital Vall d'Hebron (Barcelona, Spain), including pregnant women delivering between January 2010 and December 2015. Women with pre-existing medical conditions were excluded. APOs included preeclampsia, gestational diabetes, preterm birth, late miscarriage, and stillbirth. Cardiovascular events were defined as acute myocardial infarction or stroke. Both APO and non-APO groups were compared for their risk of cardiovascular events in the years following delivery, using unadjusted and adjusted models. Results: Out of 12,071 pregnant women delivered at Hospital Vall d'Hebron during the study period. 10,734 met the inclusion criteria (8234 in the non-APO group and 2500 in the APO group). The adjusted model revealed a significant association between APOs and cardiovascular events post-delivery (HR 2.5; 95% CI 1.4-4.4). Furthermore, an increased number of APOs (≥2) correlated with a higher risk of post-delivery cardiovascular events (HR 8.6; 95% CI 2.8-26.8). Conclusions: Women with adverse pregnancy outcomes (APOs), particularly those experiencing preeclampsia, preterm birth, and late miscarriage, exhibit an elevated long-term risk of cardiovascular events. Our findings highlight that these associations persist even after adjusting for traditional cardiovascular risk factors, indicating that APOs may independently influence long-term cardiovascular health. This underscores the importance of recognizing pregnancy as a critical window for early cardiovascular health interventions and counseling. Addressing these risks proactively could improve long-term health outcomes for women with a history of APOs.