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Pregnancy History Is Imperative for Cardiovascular Risk Assessment in Black Women

Originally publishedhttps://doi.org/10.1161/CIRCIMAGING.119.009439Circulation: Cardiovascular Imaging. 2019;12:e009439

See Article by Wichmann and Takx et al

Pregnancy complications are associated with cardiovascular disease later in life among women,1 specifically those with history of gestational diabetes mellitus, preeclampsia, gestational hypertension, and preterm birth.2–4 However, the extent to which these complications increase risk, especially among black women, remains poorly understood. Heart disease is the leading cause of death among black women,5 and disparities in cardiovascular outcomes among blacks persist.6 Therefore, further exploration of the prevalence and extent of risk from pregnancy complications among black women is pertinent.

In the current issue of Circulation: Cardiovascular Imaging, Wichmann et al7 present a multicenter, retrospective study assessing the association of history of pregnancy complications and subsequent coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) among black women. Four hundred thirty-nine black women with history of pregnancy complications were compared with 445 black women without history of pregnancy complications who were matched by age at time of CCTA, age at first delivery, number of pregnancies, body mass index, and smoking history. The time interval from pregnancy to CCTA ranged between 21 and 23 years and was not different among the subgroups.

Wichmann et al7 found that black women with history of gestational diabetes mellitus had a 3.26× increased likelihood of any coronary artery luminal narrowing ≥20% and 3× increased likelihood of obstructive coronary artery luminal narrowing ≥50% on CCTA as compared to controls when adjusting for confounders, such as body mass index, smoking status, type 2 diabetes mellitus, hypertension, hyperlipidemia, and age at CCTA. Importantly, those with history of gestational diabetes mellitus had higher prevalence of type 2 diabetes mellitus, but the association with gestational diabetes mellitus and CAD persisted when adjusting for type 2 diabetes mellitus. History of preterm delivery or preeclampsia trended towards increased CAD on CCTA, although those associations were not statistically significant. One could speculate that a study with more participants may have the power to detect a difference in those risk factors, albeit the associations would likely not to be as strong as in those with history of gestational diabetes mellitus.

The retrospective nature of this study is an inherent weakness; for instance, all patients had clinically indicated CCTA exams which may have inflated the overall CAD prevalence. Pregnancy complications were limited to chart interrogation for preterm delivery, preeclampsia, and gestational diabetes mellitus and did not include other relevant diagnoses, such as gestational hypertension. Extent of medical management of the pregnancy complications and the other comorbidities was not assessed. Furthermore, women with missing data, including those in whom relevant pregnancy history was not recorded, were excluded; we do not know whether or not such women were clinically similar to those included in the study. Finally, the primary study end point was CAD on CCTA instead of major adverse cardiovascular events (as those with major adverse cardiovascular event[s] or coronary revascularization[s] before CCTA were excluded) which could be considered a potential limitation.

However, knowledge of asymptomatic CAD before the clinical manifestations can affect preventative management strategies, including counseling, risk factor modification, recommended treatments, and follow-up. As not all patients evaluated in clinic will undergo a CCTA, these study findings support the routine collection of pregnancy history and integration of such history when determining risk. Although this study focused on preterm delivery, preeclampsia, and gestational diabetes mellitus, it also included number of pregnancies and age of delivery as these factors have been previously associated with cardiovascular risk.8,9 Additional relevant reproductive history to consider collecting in clinical care and future studies include placental abruption, infertility history and treatments, polycystic ovarian syndrome, exogenous hormone use, and early menopause/hysterectomy/oophorectomy.3,4,8–11

This valuable study addresses a current knowledge gap in an understudied population. It highlights the importance of inquiring black women about their pregnancy history and incorporating such history into risk assessment and medical care, especially for those with history of gestational diabetes mellitus. Continued research efforts and advancement in knowledge are necessary for better risk stratification, enhanced preventative strategies, including novel approaches,12 and ideally, improved cardiovascular health care and outcomes among black women.

Footnotes

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

Marysia S. Tweet, MD, FACC, Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905. Email

References

  • 1. Hauspurg A, Ying W, Hubel CA, Michos ED, Ouyang P. Adverse pregnancy outcomes and future maternal cardiovascular disease.Clin Cardiol. 2018; 41:239–246. doi: 10.1002/clc.22887CrossrefMedlineGoogle Scholar
  • 2. Mongraw-Chaffin ML, Cirillo PM, Cohn BA. Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort.Hypertension. 2010; 56:166–171. doi: 10.1161/HYPERTENSIONAHA.110.150078LinkGoogle Scholar
  • 3. Grandi SM, Filion KB, Yoon S, Ayele HT, Doyle CM, Hutcheon JA, Smith GN, Gore GC, Ray JG, Nerenberg K, Platt RW. Cardiovascular disease-related morbidity and mortality in women with a history of pregnancy complications.Circulation. 2019; 139:1069–1079. doi: 10.1161/CIRCULATIONAHA.118.036748LinkGoogle Scholar
  • 4. Brown HL, Warner JJ, Gianos E, Gulati M, Hill AJ, Hollier LM, Rosen SE, Rosser ML, Wenger NK; American Heart Association and the American College of Obstetricians and Gynecologists. Promoting risk identification and reduction of cardiovascular disease in women through collaboration with obstetricians and gynecologists: a presidential advisory from the American Heart Association and the American College of Obstetricians and Gynecologists.Circulation. 2018; 137:e843–e852. doi: 10.1161/CIR.0000000000000582LinkGoogle Scholar
  • 5. Centers for Disease Control and Prevention. Leading Causes of Death (LCOD) by race/ethnicity, all females-United States, 2015.https://www.cdc.gov/women/lcod/2015/race-ethnicity/index.htm. Accessed May 31, 2019.Google Scholar
  • 6. Van Dyke M, Greer S, Odom E, Schieb L, Vaughan A, Kramer M, Casper M. Heart disease death rates among blacks and whites aged ≥35 years - United States, 1968-2015.MMWR Surveill Summ. 2018; 67:1–11. doi: 10.15585/mmwr.ss6705a1CrossrefMedlineGoogle Scholar
  • 7. Wichmann JL, Takx RAP, Nunez JH, Vliegenthart R, Otani K, Litwin SE, Morris PB, De Cecco CN, Rosenberg RD, Bayer RR, Baumann S, Renker M, Vogl TJ, Wenger NK, Schoepf UJ. Relationship between pregnancy complications and subsequent coronary artery disease assessed by coronary CTA in black women.Circ Cardiovasc Imaging. 2019; 12:e008754. doi: 10.1161/CIRCIMAGING.118.008754LinkGoogle Scholar
  • 8. Oliver-Williams C, Vladutiu CJ, Loehr LR, Rosamond WD, Stuebe AM. The association between parity and subsequent cardiovascular disease in women: the atherosclerosis risk in communities study.J Womens Health (Larchmt). 2019; 28:721–727. doi: 10.1089/jwh.2018.7161CrossrefMedlineGoogle Scholar
  • 9. Sanghavi M, Kulinski J, Ayers CR, Nelson D, Stewart R, Parikh N, de Lemos JA, Khera A. Association between number of live births and markers of subclinical atherosclerosis: the Dallas heart study.Eur J Prev Cardiol. 2016; 23:391–399. doi: 10.1177/2047487315571891CrossrefMedlineGoogle Scholar
  • 10. Glintborg D, Rubin KH, Nybo M, Abrahamsen B, Andersen M. Cardiovascular disease in a nationwide population of Danish women with polycystic ovary syndrome.Cardiovasc Diabetol. 2018; 17:37. doi: 10.1186/s12933-018-0680-5CrossrefMedlineGoogle Scholar
  • 11. Laughlin-Tommaso SK, Khan Z, Weaver AL, Smith CY, Rocca WA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study.Menopause. 2018; 25:483–492. doi: 10.1097/GME.0000000000001043CrossrefMedlineGoogle Scholar
  • 12. Brewer LC, Hayes SN, Jenkins SM, Lackore KA, Breitkopf CR, Cooper LA, Patten CA. Improving cardiovascular health among African-Americans through mobile health: the FAITH! app pilot study [published online March 18, 2019].J Gen Intern Med. doi: 10.1007/s11606-019-04936-5CrossrefGoogle Scholar