Left Ventricular Remodeling Across the Menopausal Transition and Its Associations With Lifestyle Factors: Population-Based Cardiac MR Findings From the NAKO

Presenting Author(s)

• CS

  Christopher Schuppert, MD

  Attending Physician
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
  Freiburg, Baden-Wurttemberg, Germany

Primary Author(s)

• MF

  Martyna Flis, MSc

  PhD Student Imaging Epidemiology
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, Germany

Co-Author(s)

• PF

  Peter M. Full, MD

  Clinical Researcher
  German Cancer Research Center (DKFZ), Heidelberg, Germany, Germany
• JM

  Juliane Maushagen, MSc

  PhD Student Imaging Epidemiology
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, Germany
• RS

  Robin T. Schirrmeister, PhD

  Researcher
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, Germany
• MR

  Marco Reisert, PhD

  Researcher
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, Germany
• FB

  Fabian Bamberg, MD, MPH

  Clinical Director
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, Germany
• 

  Jeanette Schulz-Menger, MD

  Head Working Group Cardiac MRI
  Charité/ University Medicine Berlin and Helios
  Berlin, Berlin, Germany
• 

  Christopher L. Schlett, MD, MPH

  Deputy Director
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
  Freiburg, Baden-Wurttemberg, Germany
• SR

  Susanne Rospleszcz, PhD

  Principal Investigator
  Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, Germany

Background: Menopause is accompanied by changes in hormonal balance, metabolism, and vascular function, leading to increased cardiometabolic risk. It has also been associated with left ventricular (LV) remodeling, a process that may contribute to the development of heart failure with preserved ejection fraction (HFpEF). This study investigates LV remodeling before and after menopause and assesses whether the rate of age-related change or the associations with lifestyle factors differ by menopausal status.

Methods: We analyzed data from participants of the German National Cohort (NAKO) baseline examination who underwent whole-body magnetic resonance imaging (MRI). The sample included 4,104 premenopausal women (mean age 39 ± 10 years) and 3,038 postmenopausal women (mean age 58 ± 6 years) without clinical cardiovascular disease. Cardiac outcomes—left ventricular ejection fraction (LVEF), end-diastolic volume (LVEDV), stroke volume (LVSV), myocardial mass (LVM), wall thickness (LVWT), and concentricity index (LVCI)—were derived from cardiac magnetic resonance imaging (CMR). Lifestyle factors, including physical activity, smoking, alcohol consumption, sleep duration, and sleep quality, were obtained from standardized questionnaires. Associations of age and lifestyle with cardiac outcomes were assessed using generalized additive and confounder-adjusted linear regression models.

Results: Postmenopausal women had lower LV stroke volume (LVSV: 33 ± 6 mL) and higher LV concentricity index (LVCI: 0.77 ± 0.13) compared with premenopausal women (LVSV: 36 ± 6 mL; LVCI: 0.70 ± 0.10). In both groups, age was associated with higher LVEF, LVM, LVWT, and LVCI, and with lower LVEDV and LVSV (Figure 1). Age-related declines in LVEDV and LVSV were more pronounced in postmenopausal women (LVEDV: β = -0.257, 95% CI [-0.305, -0.209]; LVSV: β = -0.149, 95% CI [-0.183, -0.116]) than in premenopausal women (LVEDV: β = -0.093, 95% CI [-0.121, -0.066]; LVSV: β = -0.035, 95% CI [-0.055, -0.016]) (Figure 1).


Lifestyle factors showed notable differences by menopausal status (Figure 2). Unfavorable associations of smoking and alcohol consumption were generally stronger in postmenopausal women—for example, current smoking was significantly associated with lower LVSV in postmenopausal women (β = -0.853, 95% CI [-1.452, -0.254]) but not in premenopausal women (β = -0.012, 95% CI [-0.501, 0.477]). Short sleep duration (< 6.5 hours) was linked to higher LVWT and LVCI in postmenopausal women, but not in premenopausal women.

Conclusion: Associations of age and lifestyle factors with adverse cardiac remodeling were stronger in postmenopausal women, suggesting that this group may particularly benefit from lifestyle interventions.

Figure 1. Age-related cardiac remodeling in pre- and postmenopausal women: generalized additive model plots.
Figure 2. Associations of lifestyle factors with cardiac remodeling in pre- and postmenopausal women: forest plots of adjusted models.