Measures of cardiovascular risk and subclinical atherosclerosis in a cohort of women with a remote history of preeclampsia
Introduction
Preeclampsia, defined as hypertension with albuminuria arising after 20 weeks of gestation [1], complicates 3–5% of all pregnancies [2]. Women with a history of preeclampsia are twice as likely to experience long term cardiovascular disease (CVD) compared to women with an unaffected pregnancy; those with a history of severe preeclampsia are five times more likely to develop CVD [3]. The degree to which premature onset of CVD is marked by overt or sub-clinical atherosclerosis is less known, however [4].
Carotid intima-media thickness (CIMT) independently predicts future CVD both in those with established coronary artery disease (CAD) [5], [6] and those free of CAD [7]. Not only does higher CIMT correlate with various classical CVD risk factors [8], [9] but it independently predicts myocardial infarction and stroke [7], [10]. Similarly, the presence of non-occlusive carotid artery plaque is an independent predictor of myocardial infarction and stroke [5]. The American Heart Association's Prevention Conference on Noninvasive Tests of Atherosclerotic Burden concluded that CIMT enhances CVD risk assessment beyond traditional risk factors [11]. The American heart Association also endorses the use of CIMT for the detection of subclinical atherosclerosis in “intermediate risk” asymptomatic individuals, such as women with a history of preeclampsia.
Given that women with a history of preeclampsia are at increased risk for early onset CVD, including coronary artery, cerebrovascular and peripheral vascular disease [3], and that CIMT is an accepted measure of subclinical atherosclerosis, we sought to determine if women with a remote history of preeclampsia have greater CIMT than women with unaffected pregnancies. Secondarily, we compared CVD risk factors between women with and without a history of preeclampsia, as well as electrocardiogram findings.
Section snippets
Study population
We performed a nested cohort study of women with and without a remote history of preeclampsia. We included women who had preeclampsia diagnosed at delivery between January 1986 and December 1995. These women were previously assembled as a cohort in the McMaster Outcome Study of Hypertension in Pregnancy [12]. McMaster Outcome Study of Hypertension in Pregnancy comprised all consecutive pregnant women whose sitting systolic blood pressure was ≥140 mmHg and/or whose diastolic blood pressures was
Results
Baseline characteristics between the women with a remote history of preeclampsia and women with uncomplicated pregnancies were similar in terms of current age, age of their oldest child, ethnicity, education, income, marital status, smoking history and family history apart from a trend towards a history of hypertension in the families of previously preeclamptic women (85.2% versus 66.5%, p 0.059, Table 1). Women with a history of preeclampsia had a higher prevalence of chronic hypertension
Discussion
Two decades after delivery, women with a history of preeclampsia have increased risks of a number of cardiovascular risk factors and an abnormal electrocardiogram but not CIMT, relative to women with uncomplicated pregnancies. This lack of a difference in CIMT may be due to the fact that women with a history of preeclampsia had higher use of ACE inhibitors and anti-platelet agents, and while their blood pressure was higher, it was generally well controlled, without an increased risk of
Funding
This work was supported by an operating grant from the Heart and Stroke Foundation (HSF), Ontario, Canada (operating grant # NA6337). Dr McDonald's salary is supported by a Canadian Institutes of Health Research (CIHR) New Investigator salary award, Ottawa, Canada. Dr. Yusuf holds a Heart and Stroke Foundation (HSF) Chair in Cardiovascular Research, Ontario, Canada. None of the funding agencies had any role in the idea, design, analyses, interpretation of data, writing of the manuscript or
Conflicts of interest
The authors do not have any personal or financial or other conflicts of interest.
Acknowledgments
We thank all of the women who participated in this study, the research personnel, and Dr. Robert Burrows for gathering together the initial cohort and his support of this study.
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