Association Between History of Adverse Pregnancy Outcomes and Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography

Abstract

ImportanceAdverse pregnancy outcomes are recognized risk enhancers for cardiovascular disease, but the prevalence of subclinical coronary atherosclerosis after these conditions is unknown.ObjectiveTo assess associations between history of adverse pregnancy outcomes and coronary artery disease assessed by coronary computed tomography angiography screening.Design, Setting, and ParticipantsCross-sectional study of a population-based cohort of women in Sweden (n = 10 528) with 1 or more deliveries in 1973 or later, ascertained via the Swedish National Medical Birth Register, who subsequently participated in the Swedish Cardiopulmonary Bioimage Study at age 50 to 65 (median, 57.3) years in 2013-2018. Delivery data were prospectively collected.ExposuresAdverse pregnancy outcomes, including preeclampsia, gestational hypertension, preterm delivery, small-for-gestational-age infant, and gestational diabetes. The reference category included women with no history of these exposures.Main Outcomes and MeasuresCoronary computed tomography angiography indexes, including any coronary atherosclerosis, significant stenosis, noncalcified plaque, segment involvement score of 4 or greater, and coronary artery calcium score greater than 100.ResultsA median 29.6 (IQR, 25.0-34.9) years after first registered delivery, 18.9% of women had a history of adverse pregnancy outcomes, with specific pregnancy histories ranging from 1.4% (gestational diabetes) to 9.5% (preterm delivery). The prevalence of any coronary atherosclerosis in women with a history of any adverse pregnancy outcome was 32.1% (95% CI, 30.0%-34.2%), which was significantly higher (prevalence difference, 3.8% [95% CI, 1.6%-6.1%]; prevalence ratio, 1.14 [95% CI, 1.06-1.22]) compared with reference women. History of gestational hypertension and preeclampsia were both significantly associated with higher and similar prevalence of all outcome indexes. For preeclampsia, the highest prevalence difference was observed for any coronary atherosclerosis (prevalence difference, 8.0% [95% CI, 3.7%-12.3%]; prevalence ratio, 1.28 [95% CI, 1.14-1.45]), and the highest prevalence ratio was observed for significant stenosis (prevalence difference, 3.1% [95% CI, 1.1%-5.1%]; prevalence ratio, 2.46 [95% CI, 1.65-3.67]). In adjusted models, odds ratios for preeclampsia ranged from 1.31 (95% CI, 1.07-1.61) for any coronary atherosclerosis to 2.21 (95% CI, 1.42-3.44) for significant stenosis. Similar associations were observed for history of preeclampsia or gestational hypertension among women with low predicted cardiovascular risk.Conclusions and RelevanceAmong Swedish women undergoing coronary computed tomography angiography screening, there was a statistically significant association between history of adverse pregnancy outcomes and image-identified coronary artery disease, including among women estimated to be at low cardiovascular disease risk. Further research is needed to understand the clinical importance of these associations.

Pregnancy as an Early Cardiovascular Moment: Peripartum Cardiovascular Health

“…In the Cardiovascular Risk profile: Imaging and Gender-Specific Disorders (CREw-IMAGO), coronary artery calcium was significantly more prevalent in women with a history of preeclampsia, but only in those ≥45 years; however, coronary artery calcium was not significantly different in women <45 years. 169 In a population-based analysis from Sweden, coronary CT angiography demonstrated a significant association between APOs and any coronary atherosclerosis, suggesting that subclinical and noncalcified plaques may be detectable earlier in the disease course among young women. 170 Pregnancy is further associated with substantial physiological cardiac remodeling.…”

Sex, Racial, and Ethnic Disparities in Acute Coronary Syndrome: Novel Risk Factors and Recommendations for Earlier Diagnosis to Improve Outcomes

“…78,79 In a population-based cross-sectional analysis of 10 528 women aged 50 to 65 years in Sweden undergoing screening coronary computed tomographic angiography, women who had a history of preeclampsia or gestational hypertension had a prevalence of atherosclerosis of 36.3% and 40.9%, respectively, compared with 28.3% and 28.3% in those without. 80 The adjusted OR for any coronary atherosclerosis or a stenosis >50% with preeclampsia was 1.31 (95% CI, 1.07–1.61) and 2.21 (95% CI, 1.42–3.44), respectively; 1.33 (95% CI, 1.01–1.74) and 1.83 (95% CI, 1.00–3.33), respectively, for gestational hypertension and 1.80 (95% CI, 1.13–2.87) for a stenosis >50% for a small-for-gestational-age infant. 80 Preeclampsia and gestational hypertension were linked to a greater prevalence of a stenosis > 50% with prevalence ratios of 3.15 (1.90–5.21) and 1.58 (0.59–4.24), respectively, and coronary artery calcium (CAC) >100 with prevalence ratios of 1.81 (1.21–2.72) and 2.74 (1.71–4.37), respectively.…”

Prediction of future chronic hypertension from maternal characteristics in early pregnancy

“…These shared risk factors may be known health conditions (such as obesity), or pre-existing but subclinical abnormalities in cardiac and vascular health (such as increased peripheral vascular resistance or endothelial dysfunction). It is theoretically possible that PE or GH may themselves damage the maternal CV system, but there is little evidence to support this concern First, adjusting for conventional CV risk factors eliminates entirely or almost entirely any association observed between PE or GH and CV disease, although this was not the case in a recent Swedish registry study examining coronary atherosclerosis by computed tomograph 22 Second, prolonging maternal exposure to PE through its expectant care has yielded inconsistent estimates of the effect on CV disease. 23 Third, adding a history of PE or GH to traditional 10-year CV risk estimate algorithms has changed their performance little or not at all 24…”