Cardiovascular risk in under-represented minority women with PCOS: evidence for subclinical cardiac remodeling and HFpEF predisposition

Background/Introduction Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in reproductive-aged Hispanic and South Asian women. PCOS is associated with higher rates of morbid obesity and insulin resistance which may lead to cardiovascular disease (CVD). The most recent JACC Scientific Statement on HFpEF does not identify PCOS as a risk factor (RF)1. The lack of studies on HFpEF risk and adverse CV outcomes in PCOS populations needs to be evaluated as incidence of these diseases increase. This study attempts to evaluate PCOS as a RF for HFpEF in reproductive aged female patients. Purpose To evaluate reproductive aged female patients with PCOS and assess risk for HFpEF and adverse CV outcomes. Methods We conducted a single center retrospective cohort study with the TriNetX research tool in our network. Around 150,000 female patients from ages 18-45 years old were documented from 2015-2025. Propensity score matching was performed to balance demographics and comorbidities. The index event was the diagnosis of PCOS. Exposure group included 23,000 females with PCOS and exclusion criteria included no history of heart failure, peripartum cardiomyopathy and coronary artery disease. The control group included 122,000 females undergoing routine gynecological exam and excluded history of PCOS. Patients were observed for primary outcomes of cardiac arrest and all-cause mortality and secondary outcomes. Risk ratios (RR), odds ratios (OR) were calculated for binary outcomes. Statistical significance was defined as two-tailed p<0.05 Results Among 23,000 PCOS patients, patients with a mean age of 27 years old were affected. In terms of race-specific results in percentages: Caucasian (38%), Latino (16%), African American (10%) and Asian (8%) patients were observed with PCOS. Compared with control, the PCOS group was more likely to endorse dyspnea with exertion (RR 1.697, OR 1.706, P<0.0001). Also, had higher risk of hypertension (RR 2.285, OR 2.347, p<0.0001). Main findings included: PCOS patients had increased risk for left ventricular hypertrophy (LVH) (RR 1.911, OR 1.912, p=0.0081), increased left atrial size (RR 2.111, OR 2.078, p= 0.0007) and non-rheumatic mitral regurgitation (MR) (RR 1.323, OR 1.324, p=0.0496). All cause-mortality and cardiac arrest were similar among groups and not significant. Secondary outcomes of NT-proBNP, CAD, and cardiac arrhythmia were similar among groups and not significant. Conclusion PCOS patients were found to have structural markers that are well-recognized precursors to HFpEF. These findings suggest that PCOS may represent an underrecognized RF for HFpEF development, particularly in Hispanic and South Asian women who bear a disproportionate burden of both PCOS and cardio metabolic disease. Future prospective studies and larger multicenter analyses should focus on early cardiovascular risk stratification and longitudinal follow-up in this at-risk population.