Risk and Trajectory of Premature CVD in Women With a History of Pre-Eclampsia
abstract
This abstract is available on the publisher's site.
Access this abstract nowAIMS
Pre-eclampsia increases women's lifetime risk of cardiovascular disease (CVD). Little is known about the trajectory of CVD after pre-eclampsia, limiting the usefulness of this knowledge for informing screening, prevention, and interventions. We investigated when the risk of CVD increases after pre-eclampsia and how the risk changes over time since pregnancy.
METHODS AND RESULTS
This register-based study included 1 157 666 women with >1 pregnancy between 1978 and 2017. Cumulative incidences of acute myocardial infarction (AMI) and ischaemic stroke were estimated, as well as hazard ratios (HRs) by attained age and time since delivery. Up to 2% [95% confidence interval (CI): 1.46-2.82%] of women with pre-eclampsia in their first pregnancy had an AMI or stroke within two decades of delivery, compared with up to 1.2% (95% CI: 1.08-1.30%) of pre-eclampsia-free women; differences in cumulative incidences were evident 7 years after delivery. Ten years after delivery, women with pre-eclampsia had four- and three-fold higher rates of AMI (HR = 4.16, 95% CI: 3.16-5.49) and stroke (HR = 2.59, 95% CI 2.04-3.28) than women without pre-eclampsia; rates remained doubled >20 years later. Women with pre-eclampsia aged 30-39 years had five-fold and three-fold higher rates of AMI (HR = 4.88, 95% CI 3.55-6.71) and stroke (HR = 2.56, 95% CI 1.95-3.36) than women of similar age without pre-eclampsia.
CONCLUSIONS
Women with a history of pre-eclampsia have high rates of AMI and stroke at early ages and within a decade after delivery. The findings suggest that pre-eclampsia history could be useful in identifying women at increased risk of CVD and that targeted interventions should be initiated soon after delivery.
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Additional Info
Risk and trajectory of premature ischaemic cardiovascular disease in women with a history of pre-eclampsia: a nationwide register-based study
Eur J Prev Cardiol 2023 Jan 26;[EPub Ahead of Print], S Hallum, S Basit, M Kamper-Jørgensen, TSG Sehested, HA BoydFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The American College of Cardiology/American Heart Association 2018 Guideline on the Management of Blood Cholesterol lists pre-eclampsia as a risk-enhancing factor for physician–patient risk discussion for cholesterol management. The current study of premature ischemic cardiovascular disease in women with a history of pre-eclampsia escalates the concern of the adverse predictive impact of pre-eclampsia on premature ischemic cardiovascular disease. This register-based study from Denmark included over one million women with at least one pregnancy between 1978 and 2017 and examined the cumulative indices of acute myocardial infarction and ischemic stroke. Up to 2% of women with pre-eclampsia in a first pregnancy incur acute myocardial infarction or stroke within 2 decades of delivery. After delivery, women with pre-eclampsia had threefold and fourfold higher rates of myocardial infarction and stroke, respectively. Women with pre-eclampsia aged 30 to 39 years had fivefold and threefold higher rates of acute myocardial infarction and stroke, respectively, than women of comparable age without pre-eclampsia. The authors suggest that pre-eclampsia history can be useful in identifying women at increased risk of cardiovascular disease and that targeted interventions should be initiated soon after delivery.
Pre-eclampsia in the US is a major cause of maternal and perinatal morbidity and mortality; it occurs in up to 10% of pregnancies. Pre-eclampsia has increased by about 25% in the past 2 decades, disproportionately affecting African American women, and is more prevalent both at the extremes of reproductive age and with underlying cardiovascular risk factors. The US Preventive Services Task Force recommends screening for pre-eclampsia by blood pressure measurement at each pregnancy visit. In addition, the US Preventive Services Task Force recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in women at high risk for pre-eclampsia.1
The Chronic Hypertension and Pregnancy trial demonstrated that a treatment strategy targeting a blood pressure of less than 140/90 mm Hg for pregnant women with chronic hypertension improved outcomes compared with a regimen that initiated treatment only for blood pressure at or above 160/105 mm Hg.2 Whether this regimen will decrease the occurrence of pre-eclampsia is unknown, but it offers promise of benefit for women who have hypertensive disorders of pregnancy.
Recommendations after pre-eclampsia include extended lactation (which decreases the risk of maternal hypertension), achieving an optimal BMI, smoking cessation, a healthy diet, regular exercise, and planned long-term surveillance.
A further concern is identified in a cohort study involving almost 8.5 million participants in Nordic countries which identified that offspring exposed to maternal pre-eclampsia had a 33% increased risk of ischemic heart disease and a 34% increased risk of stroke in childhood and young adulthood and that the associated risk of stroke was higher with severe forms of pre-eclampsia.3
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