Associations of Sociodemographic and Neighborhood Vulnerability With Cardiovascular Health in Midlife Women in the United States

BACKGROUND: Many women have suboptimal cardiovascular health (CVH), which declines during midlife. Few studies have characterized CVH across the menopausal transition or identified its sociodemographic and neighborhood determinants. METHODS: We analyzed a prospective cohort of women in eastern Massachusetts enrolled during pregnancy (1999-2002) and followed to midlife (2019-2024). Exposures included household income, education, race and ethnicity, and neighborhood Social Vulnerability Index (categorized from very low [<20th percentile] to very high [≥80th percentile]; higher categories=greater neighborhood vulnerability). Women self-reported their menopause status using questionnaires. Using Life's Essential 8, we derived CVH scores (0-100 points; higher score=better CVH) at 3-, 8-, 13-, 18-, and 23-year follow-up visits. Linear spline mixed-effect models examined associations of sociodemographics and neighborhood Social Vulnerability Index with differences in CVH across different menopause stages (premenopause, perimenopause, and postmenopause). RESULTS: Among 1200 women (mean enrollment age, 32.1 years; 67.5% Non-Hispanic White), 15.4% had household incomes ≤$40 000/y, 8.8% had ≤high school education, and 17.4% resided in very high Social Vulnerability Index neighborhoods. After covariate adjustment, women with lower income, lower education, or identifying as Non-Hispanic Black exhibited lower CVH across follow-up. Independent of individual sociodemographics, continued residence in vulnerable neighborhoods over time was associated with lower CVH and unfavorable CVH trajectories across follow-up. For example, residence in very high (versus very low) Social Vulnerability Index neighborhoods from enrollment to 3-year follow-up corresponded to mean CVH differences of -6.7 (95% CI, -12.3 to -1.2) at 3-year, -9.8 (95% CI, -15.6 to -4.0) at 8-year, -8.9 (95% CI, -13.9 to -3.9) at 13-year, -6.7 (95% CI, -12.9 to -0.5) at 18-year, and -7.2 (95% CI, -12.5 to -1.9) at 23-year follow-up, and with faster CVH score decline during premenopause (-0.62 points/y; 95% CI, -1.22 to -0.02). CONCLUSIONS: Women from disadvantaged sociodemographic backgrounds or residing in vulnerable neighborhoods exhibit poorer CVH across the menopausal transition, highlighting opportunities to optimize long-term CVH and mitigate cardiovascular disease risk.