Pre-clinical atherosclerosis persists up to 10 years after preeclamptic pregnancy.

 Preeclampsia (PE) is a hypertensive disorder in pregnancy complicating up to 1-5% of pregnancies, and remains a major cause of maternal and fetal morbidity and mortality worldwide.

Pre-eclampsia (PE) is known to be associated with an increased cardiovascular risk later in life. The endothelial dysfunction persists even after the pregnancy is over.  Studies end-stage renal disease (ESRD) have shown that PE confers a subsequent risk of developing Hypertension in a short span of 8 years after delivery.[1] Women who are hypertensive after PE have twice the risk of developing CVD and 5-10-fold risk of developing end-stage renal disease (ESRD) as compared to healthy women.[2]

Identifying these young women with increased risk of CVD and ESRD is of considerable public health importance, since precautionary measures and lifestyle changes can be made to mitigate the risk to some extent.

Current guidelines advocate screening for CVD and renal disease in women with history of Preeclamptic pregnancy, but the evidence is very low.

Researchers have questioned the old dictum that ‘placenta is the cause of PE’ and a new paradigm is emerging that maternal cardiovascular dysfunction is the cause of PE especially the late onset variety. In fact, considerable atherosclerotic burden is already present during the preeclamptic pregnancy and 10 years thereafter. It is increased further by advanced age at first pregnancy, an increasing trend in recent years.

The carotid intima–media thickness (CIMT) is increasingly being used as a measure of preclinical atherosclerosis and can be evaluated by simple USG.

measuring CIMT 

Only a small number of studies have been conducted so far, that investigates the carotid Intima thickness and PE pregnancy.

A systematic review and meta-analysis of studies were conducted that reported CIMT in pregnant women with or without PE. The study was published online January 5, 2017 in Ultrasound in Obstetrics and Gynecology. [3]

A total of 14 studies conducted before March 2016 were identified and included in the meta-analysis. It was seen that women with PE had a significantly higher intima thickness as evident by Standardized mean difference (SMD, 1.10; P < 0.001). The difference persisted even a decade post-delivery.

The CIMT can be measured as a part of cardiovascular screening even before menopause when the CVD risks  rises  sharply for women.

Full Text of the article .

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[1] https://www.ncbi.nlm.nih.gov/pubmed/28001098

[2] https://www.ncbi.nlm.nih.gov/pubmed/25139045

[3] http://onlinelibrary.wiley.com/doi/10.1002/uog.17367/full

History of preeclampsia linked to coronary artery calcification 30 years later.

Preeclampsia (PE) is a hypertensive pregnancy disorder complicating 1-5% of all pregnancies, and is a major cause of maternal and fetal morbidity and mortality.

In-fact it is known as the modulator of the offspring health, as many studies have associated it with increased incidence of metabolic syndrome later in the life of the offspring. 

A substantial number of epidemiological studies in recent year have also documented it to be a risk factor for increased cardiovascular and renal diseases for mother later in life. 

Women who have history of preeclampsia have a 2 fold increase in CVD and 5-12 fold in end stage renal  diseases(ESRD).

A recent study by White WM et al in the forthcoming American journal of obstetrics & gynecology concluded that a history of preeclampsia is associated with an increased risk of coronary artery calcification more than 30 years after affected pregnancies, even after controlling individually for traditional risk factors.

This paper was also presented recently at the  Society for Maternal and fetal Medicine (SMFM) 36^th Annual pregnancy meeting at Atlanta Georgia in February, 2016.

This study by White WM et al is important because it is the first prospective cohort study with confirmation of preeclampsia by medical record review.

They recruited 40 women with history of preeclampsia and 40 women without such history were recruited from a large cohort of population in Olmsted County, MN and who delivered between 1976 and 1982.

They were matched for parity and age at the time of index birth. Cat scan was performed to measure the coronary artery calcification in Agatston Units. The mean age at imaging was 59.5 (± 4.6) years.

It was seen that the frequencies of being diagnosed with hypertension (60% v. 20%, p < 0.001) and higher BMI (29.8 vs. 25.3) were both greater in women with H/O preeclampsia.

The frequency of a CAC score > 50 Agatston units was also greater in the preeclampsia group (23% v. 0%, p=0.001). Compared to women without preeclampsia, the odds of having a higher coronary artery calcification score was 3.54 (1.39 - 9.02) times greater in women with prior preeclampsia without adjustment, and 2.61 (0.95 - 7.14) times greater after adjustment for current hypertension.

The presence of coronary artery calcifications may be able to identify those at a particularly high cardiovascular risk, since CAC is  a strong predictor of  CHD.

According to a recent Multi-Ethnic Study of Atherosclerosis (MESA) by Joshi PM et al in the Journal Atherosclerosis showed that a high burden of coronary artery calcium (CAC) is a strong predictor of coronary heart disease (CHD) among persons at low risk.

Recognition of PE as a risk factor for CVD allows identification of a young population of women at high risk of developing of cardiovascular disease.

Current guidelines recommend cardiovascular screening and treatment for formerly preeclamptic women. However, these recommendations are based on low levels of evidence due to a lack of studies on screening and prevention in formerly preeclamptic women.

The American Heart association guidelines have listed preeclampsia as an independent risk factor for CHD, as strong as a failed stress test— but larger studies are still needed to understand the underlying mechanism. 

The current study strongly advocates the need for research on mechanisms of late disease manifestations, and on effective screening and therapeutic strategies aimed at reducing the late disease burden in formerly preeclamptic women. Identification of women with CAC score > 50 carries significant potential therapeutic implications.

 References:

http://www.ncbi.nlm.nih.gov/pubmed/26841074

http://www.ajog.org/article/S0002-9378%2816%2900287-8/abstract

http://www.ncbi.nlm.nih.gov/pubmed/26792940