OBSTETRICSTen-Year, Thirty-Year, and Lifetime Cardiovascular Disease Risk Estimates Following a Pregnancy Complicated by Preeclampsia
Abstract
Objectives
To calculate the cardiovascular disease (CVD) risk estimates for women following a pregnancy with or without preeclampsia.
Methods
We calculated 10-year, 30-year, and lifetime CVD risk estimates at one year postpartum for women recruited into the Pre-Eclampsia New Emerging Team’s prospective cohort.
Results
Complete CVD risk screening data were obtained from 118 control women and 99 preeclamptic women. A total of 18.2% of preeclamptic women and 1.7% of control women had a high 10-year risk (OR 13.08; 95% CI 3.38 to 85.5), 31.3% of preeclamptic women and 5.1% of control women had a high 30-year risk (OR 8.43; 95% CI 3.48 to 23.23), and 41.4% of preeclamptic women and 17.8% of control women had a high lifetime risk for CVD (OR 3.25; 95% CI 1.76 to 6.11).
Conclusion
The association of preeclampsia with the future development of CVD makes pregnancy an early window of opportunity for the preservation of health and prevention of CVD.
Résumé
Objectif
Calculer les estimations du risque de maladie cardiovasculaire (MCV) chez les femmes à la suite d’une grossesse s’étant accompagnée ou non d’une prééclampsie.
Méthodes
Nous avons calculé des estimations du risque de MCV sur 10 ans, sur 30 ans et à vie à un an postpartum pour ce qui est des femmes ayant participé à la cohorte prospective Pre-Eclampsia New Emerging Team.
Résultats
Des données complètes sur le dépistage du risque de MCV ont été obtenues auprès de 118 témoins et de 99 femmes prééclamptiques. Au total, 18,2 % des femmes prééclamptiques et 1,7 % des témoins étaient exposées à un risque élevé de MCV sur 10 ans (RC, 13,08; IC à 95 %, 3,38 - 85,5), 31,3 % des femmes prééclamptiques et 5,1 % des témoins étaient exposées à un risque élevé de MCV sur 30 ans (RC, 8,43; IC à 95 %, 3,48 - 23,23), et 41,4 % des femmes prééclamptiques et 17,8 % des témoins étaient exposées à un risque élevé de MCV à vie (RC, 3,25; IC à 95 %, 1,76 - 6,11).
Conclusions
L’association entre la prééclampsie et l’apparition future d’une MCV fait en sorte que la grossesse constitue une période précocement très propice à la mise en oeuvre de mesures visant le maintien de la santé et la prévention de la MCV.
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Cited by (84)
Understanding Patient Perspectives on Specialized, Longitudinal, Postpartum, Cardiovascular Risk-Reduction Clinics
2024, CJC OpenFemales who experience hypertensive disorders of pregnancy (HDP) have an increased lifelong risk of cardiovascular disease. Thus, Canadian clinical practice guidelines recommend cardiovascular risk reduction follow-up after a patient has HDP. This study examined the experiences of patients with HDP who attended a specialized, longitudinal general internal medicine postpartum cardiovascular risk reduction clinic called PreVASC. PreVASC focuses on comprehensive cardiovascular risk reduction through cardiovascular risk factor screening and management tailored specifically for female patients after they have HDP.
This multimethod study examined the experiences of female patients with HDP via the following: (i) a quantitative survey (summarized with descriptive statistics); (ii) semistructured qualitative patient phone interviews (results grouped thematically); and (iii) triangulation of qualitative themes with quantitative survey results.
Overall, 37% of eligible clinic patients (42 of 115) participated; 79% of participants (n = 33) reported being “very satisfied” with the PreVASC clinic’s specialized longitudinal model of care, and 95% (n = 40) reported making at least one preventive health behaviour change after receiving individualized counselling on cardiovascular risk reduction. Qualitative results found improvements in patient-reported cardiovascular health knowledge, health behaviours, and health-related anxiety. A preference for in-person vs phone clinic visits was reported by participants.
An in-person, general internal medicine specialist–led, longitudinal model of cardiovascular disease preventive care focused specifically on cardiovascular risk reduction after HDP had positive impacts on patient experience, health knowledge, and preventive health behaviours. This novel knowledge on patient preferences for a longitudinal, specialized model of care advances cardiovascular risk reduction tailored specifically for high-risk people after HDP.
Les femmes qui sont atteintes de troubles hypertensifs de la grossesse (THG) présentent un risque accru de maladie cardiovasculaire durant leur vie. Par conséquent, les lignes directrices canadiennes de pratique clinique recommandent un suivi pour la réduction du risque cardiovasculaire après la survenue d’un THG. Cette étude visait à examiner l’expérience des patientes qui ont été atteintes de THG et qui ont fréquenté l’une des cliniques de médecine interne spécialisées dans la réduction du risque cardiovasculaire post-partum et offrant une prise en charge longitudinale (PreVASC). Les cliniques PreVASC se concentrent sur la réduction des risques cardiovasculaires globaux par la détection des facteurs de risque cardiovasculaire et une prise en charge spécialement adaptée pour les femmes qui ont subi un THG.
Cette étude visait à examiner l’expérience des femmes atteintes d’un THG en faisant appel à diverses méthodes : i) sondage quantitatif (résumé par des statistiques descriptives); ii) entrevues téléphoniques semi-structurées de nature qualitative avec des patientes (résultats regroupés par thèmes); et iii) triangulation des thèmes qualitatifs et des résultats du sondage quantitatif.
Globalement, 37 % des patientes admissibles (42 sur 115) ont participé à l’étude; 79 % des participantes (n = 33) ont déclaré être « très satisfaites » du modèle de soins longitudinal spécialisé des cliniques PreVASC, et 95 % (n = 40) ont déclaré avoir adopté au moins un comportement préventif pour leur santé après avoir reçu des conseils personnalisés sur la réduction du risque cardiovasculaire. Les résultats qualitatifs obtenus auprès des patientes font état d’une amélioration des connaissances sur la santé cardiovasculaire, les comportements sains et l’anxiété liée à la santé. Les participantes ont dit préférer les visites cliniques en personne aux consultations par téléphone.
L'adoption d'un modèle longitudinal de médecine interne comprenant des rencontres avec des spécialistes pour prévenir les maladies cardiovasculaires, en particulier réduire le risque cardiovasculaire après un THG a eu des effets positifs chez les patientes en ce qui concerne l’expérience, les connaissances en matière de santé et les comportements à adopter pour prévenir les problèmes de santé. Ces nouvelles connaissances sur les préférences des patientes à l’égard de soins longitudinaux spécialisés représentent un pas en avant dans la mise en place d’une approche personnalisée de réduction du risque cardiovasculaire pour les personnes présentant un risque élevé après un THG.
Association between hypertensive disorders of pregnancy and cardiovascular diseases within 24 months after delivery
2023, American Journal of Obstetrics and GynecologyDespite the well-known association between hypertensive disorders of pregnancy and cardiovascular diseases, there are limited data on which specific cardiovascular diagnoses have the greatest risk profiles during the first 24 months after delivery. Most existing data on hypertensive disorders of pregnancy and short-term cardiovascular disease risks are limited to the immediate postpartum period; however, it is crucial to determine cardiovascular disease risk up to 24 months after delivery to inform cardiovascular disease screening protocols during the extended postpartum period.
This study aimed to delineate the risk of cardiovascular diagnoses in the first 24 months after delivery among patients with hypertensive disorders of pregnancy compared with patients without hypertensive disorders of pregnancy.
This longitudinal population-based study included pregnant individuals with deliveries during 2007 to 2019 in the Maine Health Data Organization’s All Payer Claims Data. This study excluded patients with preexisting cardiovascular disease, with multifetal pregnancies, or without continuous insurance during pregnancy. Hypertensive disorders of pregnancy and cardiovascular diseases (categorized by specific conditions: heart failure, ischemic heart disease, arrhythmia or cardiac arrest, cardiomyopathy, cerebrovascular disease or stroke, and new chronic hypertension) were identified using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, diagnosis codes. Cox proportional hazards models were used to estimate hazard ratios, adjusting for potential confounding factors.
Of the 119,422 pregnancies examined, the cumulative risk of cardiovascular disease within 24 months after delivery for those with hypertensive disorders of pregnancy vs those without hypertensive disorders of pregnancy was 0.6% vs 0.2% for heart failure, 0.3% vs 0.1% for ischemic heart disease, 0.2% vs 0.2% for arrhythmia or cardiac arrest, 0.6% vs 0.2% for cardiomyopathy, 0.8% vs 0.4% for cerebrovascular disease or stroke, 1.6% vs 0.7% for severe cardiac disease (composite outcome of heart failure, cerebrovascular disease or stroke, or cardiomyopathy), and 9.7% vs 1.5% for new chronic hypertension. After adjustment for potential confounders, those with hypertensive disorders of pregnancy had an increased risk of heart failure, cerebrovascular disease, cardiomyopathy, and severe cardiac disease within the first 24 months after delivery (adjusted hazard ratio, 2.81 [95% confidence interval, 1.90–4.15], 1.43 [95% confidence interval, 1.07–1.91], 2.90 [95% confidence interval, 1.96–4.27], and 1.90 [95% confidence interval, 1.54–2.30], respectively) compared with those without hypertensive disorders of pregnancy. In addition, those with hypertensive disorders of pregnancy had an increased risk for new chronic hypertension diagnosed after 42 days after delivery (adjusted hazard ratio, 7.29; 95% confidence interval, 6.57–8.09). There was no association between hypertensive disorders of pregnancy and ischemic heart disease (adjusted hazard ratio, 0.92; 95% confidence interval, 0.55–1.54) or cardiac arrest or arrhythmia (adjusted hazard ratio, 0.90; 95% confidence interval, 0.52–1.57). In addition, among women with hypertensive disorders of pregnancy, the highest proportion of first cardiovascular disease diagnoses occurred during the first month after delivery for cardiomyopathy (44%), heart failure (39%), cerebrovascular disease or stroke (39%), and severe cardiac disease (41%).
Patients with hypertensive disorders of pregnancy had an increased risk of developing new chronic hypertension, heart failure, cerebrovascular disease, and cardiomyopathy within 24 months after delivery. There was no association between hypertensive disorders of pregnancy and ischemic heart disease or cardiac arrest or arrhythmia. Patients with hypertensive disorders of pregnancy need targeted early postpartum interventions and increased monitoring in the first 24 months after delivery. This may preserve long-term health and improve maternal and neonatal outcomes in a subsequent pregnancy.
Sleep-disordered breathing in high-risk pregnancies is associated with elevated arterial stiffness and increased risk for preeclampsia
2022, American Journal of Obstetrics and GynecologyImpaired vascular function is a central feature of pathologic processes preceding the onset of preeclampsia. Arterial stiffness, a composite indicator of vascular health and an important vascular biomarker, has been found to be increased throughout pregnancy in those who develop preeclampsia and at the time of preeclampsia diagnosis. Although sleep-disordered breathing in pregnancy has been associated with increased risk for preeclampsia, it is unknown if sleep-disordered breathing is associated with elevated arterial stiffness in pregnancy.
This prospective observational cohort study aimed to evaluate arterial stiffness in pregnant women, with and without sleep-disordered breathing and assess the interaction between arterial stiffness, sleep-disordered breathing, and preeclampsia risk.
Women with high-risk singleton pregnancies were enrolled at 10 to 13 weeks’ gestation and completed the Epworth Sleepiness Score, Pittsburgh Sleep Quality Index, and Restless Legs Syndrome questionnaires at each trimester. Sleep-disordered breathing was defined as loud snoring or witnessed apneas (≥3 times per week). Central arterial stiffness (carotid-femoral pulse wave velocity, the gold standard measure of arterial stiffness), peripheral arterial stiffness (carotid-radial pulse wave velocity), wave reflection (augmentation index, time to wave reflection), and hemodynamics (central blood pressures, pulse pressure amplification) were assessed noninvasively using applanation tonometry at recruitment and every 4 weeks from recruitment until delivery.
High-risk pregnant women (n=181) were included in the study. Women with sleep-disordered breathing (n=41; 23%) had increased carotid-femoral pulse wave velocity throughout gestation independent of blood pressure and body mass index (P=.042). Differences observed in other vascular measures were not maintained after adjustment for confounders. Excessive daytime sleepiness, defined by Epworth Sleepiness Score >10, was associated with increased carotid-femoral pulse wave velocity only in women with sleep-disordered breathing (Pinteraction=.001). Midgestation (first or second trimester) sleep-disordered breathing was associated with an odds ratio of 3.4 (0.9–12.9) for preeclampsia, which increased to 5.7 (1.1–26.0) in women with sleep-disordered breathing and hypersomnolence, whereas late (third-trimester) sleep-disordered breathing was associated with an odds ratio of 8.2 (1.5–39.5) for preeclampsia.
High-risk pregnant women with midgestational sleep-disordered breathing had greater arterial stiffness throughout gestation than those without. Sleep-disordered breathing at any time during pregnancy was also associated with increased preeclampsia risk, and this effect was amplified by hypersomnolence.
Effects of pre-eclampsia on HDL-mediated cholesterol efflux capacity after pregnancy
2022, Atherosclerosis PlusCitation Excerpt :Women with a history of preeclampsia (PE) have a long-term increased risk of cardiovascular disease (CVD) compared to women who had a normotensive pregnancy [1–3]. Meta-analysis and cohort studies indicate that this risk is increased 2-fold and is evident within 10 years after pregnancy, i.e. still at an early stage in life, interacts with established risk factors, and lasts a lifetime [1,4–7]. Women who have experienced PE also show an increased incidence of hypertension, diabetes and dyslipidemia, all thought to contribute to the increased risk of CVD.
Preeclampsia (PE) is associated with life-long increased risk of cardiovascular disease. One of the main protective functions of high-density lipoprotein (HDL) is its role in reverse cholesterol transport. HDL-mediated cholesterol efflux capacity (CEC) is decreased during pregnancy in women with PE. Whether this persists postpartum is unknown.
Basal and transporter-specific CEC were determined 6 months postpartum in women who had a normotensive (n = 44) or a PE (n = 42) pregnancy. CEC was also measured in 23 normotensive and 20 PE women for whom samples were collected 24 months postpartum. Basal, ATP-binding cassette transporter-A1 (ABCA1)- and -G1 (ABCG1)-specific CEC were primarily determined using Chinese hamster ovary cells stably expressing human ABCA1 or ABCG1, and were also assessed using a J774 mouse macrophage cell line.
ABCA1-specific CEC was significantly lower in women who had PE 6 months postpartum (0.57 ± 0.1 vs 0.53 ± 0.08; p < 0.05), whilst basal and ABCG1-specific efflux were not significantly different. cAMP-specific CEC in J774 cells was also lower 6 months after PE (0.85 ± 0.21 vs 0.75 ± 0.25, p < 0.05). Although apoA-I, apoE, plasminogen and PON-1 levels were not significantly different in women who had PE compared with controls, ABCA1 efflux did correlate with apoA-l, HDL-C and apoE levels after a normal, and with apoA-l and HDL-C levels after a PE pregnancy. ABCA1-specific efflux decreased in all women between 6 and 24 months postpartum, by 11 ± 1.6% in women who had a normotensive pregnancy and 9 ± 1.3% in women who had PE. After adjustment for apoA-I levels, there was no significant difference in ABCA1-specific efflux between the groups at 6 months postpartum and in normotensive women over time, but remained significantly different between 6 and 24 months in women who had PE.
ABCA1-mediated CEC is impaired 6 months postpartum after a PE pregnancy and decreases thereafter in both normotensive and PE pregnancies. ABCA1-mediated efflux is dynamic after pregnancy but is unlikely to explain the long-term increased CVD risk in women with PE.
Arterial stiffness and pulsatile hemodynamics in pregnancy and pregnancy-related vascular complications
2022, Textbook of Arterial Stiffness and Pulsatile Hemodynamics in Health and DiseaseIn healthy pregnancies, maternal adaptations occur to accommodate both maternal and fetal metabolic demands. Systemic vasodilation and increased vascular compliance occur early in the first trimester, leading to decreased systemic vascular resistance that reaches a nadir in the second trimester. Consequently, increases in cardiac output, renin–angiotensin–aldosterone system activity, and plasma volume occur. The vascular and hematological changes result in a U-shaped curve in blood pressures, large artery stiffness (carotid-femoral pulse wave velocity, cfPWV), and wave reflection, reaching a nadir in the second trimester.
The demands of the developing fetus progressively increase with gestation; thus, vascular complications usually occur in the second-half of pregnancy. In this context, in preeclampsia, a potentially severe hypertensive disorder of pregnancy, impaired vascular responses are observed: blood pressures, cfPWV, and wave reflection exhibit a continuous increase from the first trimester to the end of pregnancy and beyond, rather than a U-shaped curve. Compared to normotensive pregnancies, arterial stiffness is significantly higher at the time of preeclampsia diagnosis, and its magnitude of increase is correlated with preeclampsia severity. Overall, vascular maladaptations in preeclampsia lead to failure to accommodate the increased demands of gestation, with devastating consequences for both the mother and fetus. This chapter reviews the vascular adaptations in pregnancy and the role of vascular dysfunction in the pathogenesis of hypertensive disorders of pregnancy.
Standardized Postpartum Follow-Up for Women with Pregnancy Complications: Barriers to Access and Perceptions of Maternal Cardiovascular Risk
2021, Journal of Obstetrics and Gynaecology CanadaCertain obstetrical complications are known to increase a woman's risk of future cardiovascular disease (CVD). The Maternal Health Clinic (MHC) provides postpartum cardiovascular risk counselling and follow-up; however, half of women referred do not attend. This study aimed to identify barriers to access, as well as whether attendance at the MHC improved the accuracy of patients’ CVD risk perception.
MHC patients completed a CVD risk perception questionnaire prior to being assessed and 3 months after their appointment (“attendees”). Calculated lifetime CVD risk scores were compared with perceived risk to assess accuracy of risk perception. Patients who did not attend their MHC appointment (“non-attendees”) were administered the questionnaire by phone and asked about perceived barriers to access.
Sixty-seven of 137 eligible attendees (48.9%) completed both the pre- and post-MHC questionnaires. Significantly more participants accurately estimated their absolute CVD risk after their MHC appointment, although the majority continued to underestimate their risk. Among non-attendees, 81 of 130 women (62.3%) completed the questionnaire. The most common barriers to access cited were being too busy with childcare, accessing follow-up with the patient's family doctor instead, and difficulty attending their appointment.
Lack of time and inconvenience were two common barriers to accessing the MHC. Improved collaboration with primary care providers and use of telemedicine may help to mitigate these issues. Both attendees and non-attendees appeared to have an inadequate perception of CVD risk. Standardized postpartum CVD risk screening and counselling may be an effective method of providing these women with risk education and improving the accuracy of their risk perception.
Certaines complications obstétricales sont reconnues pour augmenter le risque de maladie cardiovasculaire (MCV) future d'une femme. La Maternal Health Clinic (MHC) fournit des conseils et un suivi post-partum sur les risques cardiovasculaires; cependant, la moitié des femmes qui y sont orientées ne s'y présentent pas. Cette étude visait à définir les obstacles à l'accès et à déterminer si le fait de se présenter à la MHC améliorait la précision de la perception du risque de MCV des patientes.
Les patientes de la MHC ont rempli un questionnaire sur la perception du risque de MCV avant d’être évaluées et à 3 mois après leur rendez-vous (« participantes »). Les scores de risque de MCV à vie ont été comparés au risque perçu pour évaluer l'exactitude de la perception du risque. Les patientes qui ne se sont pas présentées au rendez-vous à la MHC (« non-participantes ») ont répondu à un questionnaire par téléphone et se sont fait demander quels étaient les obstacles perçus à l'accès.
Des 137 participantes admissibles, 67 (48,9 %) ont rempli les questionnaires avant et après le rendez-vous à la MHC. Comparativement aux non-participantes, les participantes étaient significativement plus nombreuses à estimer avec précision leur risque absolu de MCV après le rendez-vous à la MHC, bien que la majorité ait continué de sous-estimer leur risque. Parmi les non-participantes, 81 des 130 femmes (62,3 %) ont répondu au questionnaire. Les obstacles les plus fréquents à l'accès étaient le fait d’être trop occupée à s'occuper de son ou ses enfants, le suivi avec le médecin de famille plutôt qu’à la MHC et la difficulté à se présenter au rendez-vous.
Le manque de temps et le dérangement étaient les deux obstacles les plus fréquents à l'accès à la MHC. Une meilleure collaboration avec les fournisseurs de soins primaires et la télémédecine pourraient aider à atténuer ces problèmes. Les participantes et les non-participantes semblaient avoir une perception inadéquate du risque de MCV. Le dépistage normalisé post-partum des risques de MCV et les conseils peuvent constituer un moyen efficace d'informer ces femmes des risques et d'améliorer leur perception des risques.
Competing Interests: None declared.
Parts of this data were presented at the Society for Maternal–Fetal Medicine (2012) and Society for Gynecologic Investigation (2012).